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Based on observation, interview and record review the facility failed provide adequate nursing services on the behavioral unit.

The facility failed to ensure adequate numbers of staff to provide nursing care to patients on the behavioral unit. The facility failed to provide adequate staffing to provide incontinence care and activities of daily living for 5 of 10 patients sampled (refer to A-392). This lack of care resulted in one patient having skin breakdown. One patient may have fallen as a result of inadequate staffing.

The facility failed to adequately assess and provide nursing care to 3 of 10 patients sampled. This lack of care resulted in 1 patient having an increase in wound size. The facility failed to provide nursing care plans for medical conditions for 7 of 8 patients' records reviewed on the behavioral unit (refer to A-396). The lack of care planning contributed to Patient #1 and #4 not receiving appropriate wound care and Patient #3 not receiving adequate nursing care for end-stage liver disease. The lack of care planning puts patients at risk for inadequate nursing care.

The overall effect of these failures resulted in the facility's inability to ensure the safe and effective provision of nursing care on the behavioral unit.
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Based on observation, interview and record review, the facility failed to ensure adequate numbers of staff to provide nursing care to patients on the behavioral unit. The facility failed to provide adequate staffing to provide incontinence care and activities of daily living for 5 (Patients #1, #3, #4, #5, and #8) of 10 patients sampled. This lack of care resulted in 1 (Patient #1) having skin breakdown. One patient (#8) may have fallen as a result of inadequate staffing. The facility failed to adequately assess and provide nursing care to 3 (Patients #1, #3, and #4) of 10 patients sampled. This lack of care resulted in 1 (Patient #4) having an increase in wound size.

Findings include:

1. During the initial visit, upon entering the geriatric unit of the behavioral unit on 7/9/14 at 9:40 a.m., there was a strong odor of urine throughout the unit. Observations in the family room noted 6 patients and 2 members folding clothing. Patient #4 was sleeping in a recliner. She was disheveled and her hair appeared dirty and uncombed. There was no sock on her left foot. She was wearing a hospital gown. Patient #5 was seated in a regular chair. He was slid down so far in his chair that his neck was bent on the back of the chair. He was dressed in a hospital gown. He was unshaven and hair appeared unwashed.

Upon returning to the geriatric unit at 11:15 a.m., the odor of urine presented as soon as we passed through the locked doors.
In an interview at that time the director stated, "We are constantly battling the odor of urine on this unit." When asked about chemicals to control the odor, he stated, "We can't use a lot of those in mental health."

On 7/10/14 at 10:00 a.m., Patient #4 was observed in the recliner in the family room next to the nursing station. Her hair remained uncombed. She had one sock on her right foot. There was no sock on her left foot. She again was in a hospital gown.
2. During an interview on 7/9/14 at 11:26 a.m., Staff A said the patient acuity was very high and there were not enough staff to provide activities of daily living (ADL's) care for the patients. She stated, "There was not enough staff last night. We can get by today, but the patients deserve more than that." She said she had reported this to her supervisor and the DON (Director of Nursing) and the Facility Director were aware of the lack of staff.

During an interview on 7/9/14 at 11:50 p.m., Staff B verified there was not enough staff to provide ADL care for the patients in the geriatric unit. He said the urine odor on the unit is sometimes "toxic." He said they are often short of staff. He said today he found Patient #5 at 7:30 a.m. soaked with urine. He said there was only one mental health tech working last night. "That's why he was soaked this morning." He said housekeeping is hardly seen in the building after 3 p.m. or on the weekends.

In an interview on 7/9/14 at 1:00 p.m., the DON said the smell on the unit was caused by staff throwing dirty diapers in the trash cans and not removing them from the unit. She stated incontinent patients are checked every two hours for incontinence. She confirmed that one mental health tech had been sent with a patient to the main campus on 7/8/14, and there had been no replacement for the staff member.

In an interview on 7/10/14 at 3:00 p.m., the DON confirmed she was short of staff. She stated at this time she had openings for 5 mental health techs and 2 as needed registered nurses. She stated she had open positions since January of 2014.

In an interview on 7/10/14 at 4:40 p.m., Staff E, a mental health tech on the 7 p.m. to 7 a.m. shift, confirmed there had only been one mental health tech on the PM shift on 7/8/14. She stated, "There never was enough staff." She confirmed there were times when patients are left longer than 2 hours without being checked for incontinence.

In an interview on 7/9/14 at 12:20 p.m., Patient #8 said a few weeks ago he was sitting in the family room and one of the other patients had urinated on the floor. He went to get up and slipped in urine and injured his hip. He stated, "I was sent to the emergency room."

In an interview on 7/10/14 at 4:45 p.m., mental health Tech Staff F, confirmed staffing on the geriatric units is always short. She confirmed patients often go longer than they should with having incontinence care due to staff being insufficient.
3. A complaint filed by Patient #3's spouse reads, "Husband smells and never washed and wife was told by staff that they have to pick their battles." Review of the investigation done by the facility showed Patient #3 had received 3 showers between admission on 4/2/14 and discharge on 4/18/14 (16 days).

4. Review of Patient #1's nursing note dated 3/17/14, documented wound care nurse from the main campus found the patient in the family room with a large bowel movement. She had been consulted due to Patient #1 developing Stage-2 decubitus ulcers.

Review of the care plan for Patient #1 shows he had a breakdown in skin integrity due to a "lack of movement" and "2 days of diarrhea stools."

5. Patient #1 was admitted to the facility on 2/21/14. He had a history cerebral palsy, high blood pressure, diabetes, and end-stage liver disease. The skin assessment on 3/15/14 for Patient #1 documented an open area on his right buttocks 1.7 cm by 1 cm. The skin assessment on 3/16/14 documented, "Decubitus to coccyx and small blister on left buttocks " and " 2.5 X 2.5 cm discolored open area over left greater trochanter." It is referred to as the size of a dime.
Review of Patient #1's nursing note dated 3/17/14, and timed at 11:00 a.m. reads, "Patient has a large open area to coccyx."
Review of Patient #1's nursing note dated 3/17/14, and timed at 2:30 p.m. was found illegible. The wound care nurse who wrote the note was out on medical leave during the survey.
In an interview on 7/8/14 at 2:00 p.m., Staff H, a wound care nurse, said she had spoken to the nurse who wrote the note and was able to read what was written on the note. She stated the note indicated "She did not find a decubitus." In reviewing the note, Staff H said the wound care nurse found Patient #1 in the dayroom on the geriatric unit. He was found incontinent with a large stool. He was bathed at that time and the nurse found a denuded area on his right buttocks. She also noted two striated areas to his posterior upper thigh. Staff H described these wounds as scratches.
Review of a nursing note dated 3/18/14, and timed at 3:50 a.m. reads, "He has a dime sized open area to his left trochanter. There are a few small open areas on his scrotum."

Review of the progress note dated 3/18/14, written by the facility's medical doctor caring for Patient #1 reads, "Stage II decubitus ulcer: The patient needs to be repositioned at least every 2 hours. These instructions have been passed on to the nursing facility where he is being transferred to. Aggressive nursing care is critical in healing these wounds." The medical doctor then documents, "This patient is currently stable and medically cleared to transfer to the adult living facility."

Review of the transfer note written by the discharging nurse documents on 3/18/14, "Small open area of breakdown to buttocks." The nurse documents the patient is "dependent" and has "very poor ambulation." The documentation shows the patient was alert and oriented and he was transported to a group home. There were no instructions on the transfer form for wound care. There were no instructions on the form to turn and reposition the patient every two hours or to provide aggressive nursing care for Patient
#1's decubitus as directed by the medical doctor.

During a phone interview on 7/10/14, around 10:30 a.m., Patient #1's caregiver said when he returned from the hospital he was not able to do anything for himself and he had wounds.

In an interview on 7/10/14, at approximately 10:00 a.m., the medical doctor (MD) caring for Patient #1 at the facility said Patient #1 was not able to care for himself due to having cerebral palsy, having atrophy in his extremities, and being wheelchair bound. He verified the patient had more than one wound to his buttocks when he was discharged.

In a telephone interview on 7/14/14, at 9:08 a.m., Patient #1's caregiver said she went to the facility on the afternoon of 3/17/14, and she said an aide notified her that the patient had a decubitus on his backside. She said when she went in to see Patient #1 he was in a recliner in his room. His diaper was soaked and he smelled of bowel movement. She stated when she said something to the aide about his condition he told her, "You wanted to see him. Here he is." She said he was released the next day. She said it took 4 staff members to get Patient #1 into her car because he was unconscious. She said he was supposed to have a wound care consult. When she called the wound care office, they didn't know anything about it. The wound care office contacted the facility. They were told the facility did not know anything about the consultation because Patient #1 was discharged. The caregiver contacted Patient #1's primary physician and he ordered home health. She said when Patient #1 was discharged from the facility he had decubitus to both sides of his buttocks, on his left hip, and on both of his heels. She said the only instructions given to her were written on the nursing discharge instructions. Review of these instructions showed no wound care or repositioning orders. She said Patient #1 was admitted to the hospital on 4/7/14 ,with infected Stage 4 decubitus.

Patient #1's care plan for "Altered Skin Integrity" was initiated on 3/14/14. There was no documentation of what type of breakdown the patient was having. A wound consult was part of this care plan. The patient did not have a wound consult until 4/17/14. There are no orders for wound care on this care plan. On 3/18/14 at 3:50 a.m., in the morning another care plan is imitated. The nurse documents the patient has developed altered skin integrity secondary to decreased mobility and having 2 days of diarrhea stools. There is no documentation of the wounds being cared for on the care plan.

6. Patient #3 was admitted on 4/2/14, for involuntary examination (under the Baker Act) after having outbursts with the hospice nurses caring for him. Diagnoses included end-stage liver disease. On 4/3/14, the patient had a critical laboratory finding with an ammonia level of 264 (normal 15 - 45 micrograms per deciliter, depending on the lab). Ammonia is a toxic waste product eliminated by the liver. An extremely high ammonia level can result in a patient becoming unconscious, unresponsive, and possibly enter a coma. Lactulose (reduces ammonia in the blood) was ordered three times daily. Patient
#3 remained on the behavioral unit having critical level of ammonia until 4/18/14.

On 4/3/14 at 4:00 p.m., the nurse's note documents, "Patient is lethargic and oriented to self only. Patient very confused, patient unable to walk on his own. Patient refusing Lactulose. Patient incontinent of urine and stool. Patient has been repeatedly assaultive... Patient refusing to eat or drink. Patient found on floor. Patient stated he fell. MD notified. No apparent injuries noted."
Review of the nurse's note shows no documentation on 4/6/14 at 2:00 p.m., why Patient #3 refused Lactulose.
On 4/9/14, a physician's order reads, "Ammonia level in the AM - expected critical do not call."
On 4/11/14 at 1420 (2:20 p.m.), the nurse's note documents, "He went to bed and has been sleeping. Lactulose delayed." There is no further documentation as to why Patient #3 refused Lactulose at 2:00 p.m. or at 10:00 p.m.
Review of the nurse's notes shows no documentation on 4/12/14, as to why Patient #3 refused Lactulose at 6:00 a.m.

The nurse's note dated 4/18/14 at 12:25 p.m. reads, "Lethargic, unable to swallow medicine including Lactulose. Evaluated by Dr. (Medical Dr.), order to send to ER received. 911 called ..." There is no documentation from the nurse regarding the patient's vital signs, oxygen saturation, or color. There is no nursing assessment documenting this patient's change in condition.

Review of the Facility's Policy of Scope of Assessment/Reassessment shows reassessments should be done "Every twelve hours and sooner as clinically indicated."

Review of the discharge summary from the hospital shows the patient was discharged to his home on 4/20/14. The note reads, "The patient was admitted and it was noted that his ammonia level was 240. He was also anemic. The family wished for him to be a full code and hesitant about placing him back on Hospice. The patient was unable to swallow on admission (to the emergency room), so he was given Lactulose enemas. He was sent to the floor and got a couple of Lactulose enemas. The patient's ammonia level came down to 80, began eating and feeling much better...."

7. On entering the facility on 7/9/14 at 9:30 a.m., a request was made to the director to provide a list of all patients in the behavior unit being treated for a wound. At 11:00 a.m. the director of quality education stated there were currently no patients in the behavior unit being treated for wounds.

On 7/9/14 at 9:40 a.m., Patient #4 was observed to be lying in a recliner in a hospital gown. Her hair was uncombed and she was generally unkempt.

Review of Patient #4's medical record, showed she was admitted to the facility on 6/28/14. The record noted she had a decubitus ulcer to her right heel.
A skin assessment flow sheet showed no documentation from staff as to the measurement of the wound from the time she was admitted on 6/29/14.

In an interview on 7/9/14 at 12:40 p.m., regarding the lack of documentation of wound measurement the DON stated, "They should have documented on the form."
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Based on interview and record review, the facility failed to provide nursing care plans for medical conditions for 7 (Patients #1, #3, #4, #5, #6, and #7) of 8 patients' records reviewed on the behavioral unit. The lack of care planning contributed to Patient #1 and #4 not receiving appropriate wound care and Patient #3 not receiving adequate nursing care for end-stage liver disease. The lack of care planning puts patients at risk for inadequate nursing care.
"Based on the assessment and diagnosis, the nurse sets measurable and achievable short- and long-range goals for this patient ... Assessment data, diagnosis, and goals are written in the patient's care plan so that nurses as well as other health professionals caring for the patient have access to it. Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Care is documented in the patient's record." (source: American Nurses Association website)

Findings include:

1. Patient #1 was admitted to the facility on 2/21/14. He was being medically treated for Stage 2 decubitus ulcers, seizure disorder, high blood pressure and diabetes.
A care plan for "Altered Skin Integrity" was initiated on 3/14/14. There was no documentation of what type of breakdown the patient was having. A wound consult was part of this care plan. The patient did not have a wound consult until 4/17/14.
There was no approach for any wound care on this care plan.
On 3/18/14 at 3:50 a.m., (early morning) another care plan was initiated to include an antifungal cream. The nurse documented the patient has developed altered skin integrity secondary to decreased mobility and having 2 days of diarrhea stools. There was still no approach for any wound care on the care plan.

In an interview on 7/10/14 at 2:00 p.m., with the DON, she confirmed there was no care plan for his other medical needs (the seizure disorder, high blood pressure and diabetes).

2. Patient #3 was admitted to the facility with erratic behavior and impulsivity on 4/2/14. Review of the physician's progress note dated 4/3/14, shows Patient #3 had end-stage liver disease, high blood pressure, esophageal varices (enlarged blood vessels in the throat from liver disease), anemia and chronic obstructive pulmonary disease (COPD).
On admission, Patient #3's ammonia (a toxic waste product eliminated by the liver) level was critically high at 264 according to the lab results. Lactulose (reduces ammonia in the blood) was ordered three times daily.
Review of medical record shows no nursing care plan for Patient #3 for the care of end-stage liver disease. The patient refused the Lactulose on multiple occasions. There was no nursing care plan for his high blood pressure, anemia, or COPD.
The nurse's notes show no documentation as to why Patient #3 was refusing the Lactulose. There is no documentation of encouragement from nursing staff to take this medication or instruction to the patient of what can happen if he does not take this medication.

In an interview on 7/10/14 at 2:00 p.m., with the DON, she stated, "I don't have a care plan for end-stage liver disease."

He continued to have critically high ammonia levels throughout his stay until he was transferred to the emergency room on 4/18/14.

3. Patient #4 was admitted to the facility on 6/28/14. The patient was admitted with a diabetic ulcer to her right foot. Review of the physician's progress notes shows the physician documented on admission: Patient #4 had a 1.5 cm diabetic ulcer to her right foot.
The orders for wound care dated 6/29/14 reads, "Santyl and Bactroban to foot ulcer twice daily with Optifoam (a special absorbent dressing). "Review of the MAR shows on 6/29/14, 7/1/14, 7/2/14 and 7/3/14 at 10:00 p.m., the dressing changes were not done. No reason is given for not doing the dressing change. The nurse's notes show no documentation for wound care for Patient #4 beyond the Medication Administration Record (MAR). The ulcer was never measured by nursing staff until 7/9/14. The wound at that time measured
2.5 x 2.5 x 0.5 cm.

In an interview on 7/9/14 at 12:40 p.m., regarding the lack of documentation of wound measurement the DON stated, "They should have documented on the form."
In an interview on 7/10/14 at 3:35 p.m., Staff D she stated she used Kling Gauze as a dressing for Patient #4. She stated Patient #4 did not have any special dressing ordered for her wound. When questioned further, she was able to produce a box of Optifoam dressings.

There was no nursing care plan for this wound until the surveyor arrived and a wound consult was done on 7/9/14.

4. Patient #5 was admitted to the facility on 5/26/14. Review of a nurse's note dated 6/28/14, shows Patient #5, "was found on the floor in his room and head was bleeding.
B/P (blood pressure) was 214/120, pulse was 80....Transferred to ER (emergency room) ..." The nurse's note dated 7/1/14 ,shows Patient #5 received 5 staples in his scalp as the result of the fall.
A 'Report Tool' dated 7/7/14 shows at 12:00 a.m., Patient #5 had a blood pressure of 185/97. Review of the nurse's note for that date shows no documentation this blood pressure was reported to the physician.
The physician's progress note shows Patient #5's blood pressure on 7/8/14, was recorded as being "slightly low" in the a.m.; the physician does not document that this high blood pressure was reported to him.

There was no nursing care plan for Patient #5's head wound or for his fluctuating blood pressures.

5. Patient #6 was admitted to the facility with Type 2 Diabetes. Physician's progress note documented the patient was a brittle diabetic. Brittle diabetes is an unstable condition that often results in disruption of life and often recurrent and/or prolonged hospitalization (per National Institute of Health). Review of the nurse's notes found nursing staff were monitoring Patient #6's blood sugars.

There was no nursing care plan for diabetes for Patient #6.

6. Patient #7 was admitted to the facility on 3/21/14. Review of the physician's progress note dated 4/7/14, shows Patient #7 was admitted with swelling in his tongue (angioedema) which can block the airway. His other diagnoses included Type 2 Diabetes and hypertension. He was receiving prednisone (a corticosteroid medication) to reduce the swelling. Prednisone has known side effects of raising the blood sugar as well as blood pressure. Nursing was monitoring his blood sugar and blood pressure.

There was no nursing care plan for angioedema, diabetes, or hypertension for Patient #7.

7. Review of Patient #8's medical record shows that he was admitted on 3/26/14. Review of the physician's progress note dated 7/8/14, shows the patient was being treated for diabetes, hypertension, and hepatitis.

There was no nursing care plan for diabetes, hypertension, or hepatitis for Patient #8.
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Based on interview and record review, the facility failed to ensure the discharge planning process applies to all patients on the behavioral unit.

The facility failed to arrange for an adequate discharge plan for 4 (Patient #1, #2, #4, and #8) of 10 patients sampled from the behavioral unit (refer to A-820). As a result of inadequate planning, one patient was sent to a group home without wound care and developed a Stage 4 pressure wound. One patient was sent to an assisted living facility (ALF) without means to provide insulin administration, putting him at risk for elevated blood sugar with related complications. Two patient discharges were not coordinated with the patients and/or their families about their need for a higher level of care at discharge.

The facility failed to appropriately transfer 2 of 10 patients surveyed for discharge on the behavioral unit (refer to A-837). As a result of inappropriate discharge, one patient was transferred to a group home with inadequate wound care and developed a Stage 4 pressure wound. Another patient was transferred to an assisted living facility (ALF) without means to provide insulin administration, putting him at risk for elevated blood sugar with related diabetic complications.

The overall effect of these failures puts inpatients on the behavior unit with medical problems at risk for an unsafe discharge.
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Based on interview and record review, the facility failed to arrange for an adequate discharge plan for 4 (Patient #1, #2, #4, and #8) of 10 patients sampled from the behavioral unit. As a result of inadequate planning, one (Patient #1) was sent to a group home without wound care and developed a Stage 4 pressure wound. One (Patient #2) was sent to an assisted living facility (ALF) without means to provide insulin administration, putting him at risk for elevated blood sugar with related complications. Two (Patients #4 and #8) discharges were not coordinated with the patients and/or their families about their need for a higher level of care of care at discharge.

Findings include:

1. Patient #1 was admitted by his caregiver to the facility on 2/21/14. He had a history cerebral palsy, hypertension and Type 2 Diabetes.
Review of the Skin Assessment for Patient #1 showed on 3/15/14, staff documented an open area on his right buttocks 1.7 cm by 1 cm. On the skin assessment form of 3/16/14, staff documented Patient #1 has: "decubitus (pressure sore) to coccyx and small blister on left buttocks. On the same form there is documentation Patient #1 had a, "2.5 x 2.5 cm discolored open area over left greater trochanter (hip joint)."
Review of a nursing note dated 3/18/14 at 3:50 a.m., reads: " He has a dime sized open area to his left trochanter. There are a few small open areas on his scrotum."
Review of the progress note dated 3/18/14, written by the medical doctor caring for Patient #1 reads: "Stage II Decubitus Ulcer: The patient needs to be repositioned at least every 2 hours. These instructions have been passed on to the nursing facility where he is being transferred to. Aggressive nursing care is critical in healing these wounds. "The medical doctor then documents: "This patient is currently stable and medically cleared to transfer to the adult living facility."
Review of the transfer note written by the discharging nurse documents on 3/18/14, "Small open area of breakdown to buttocks. "The nurse documents the patient is "dependent" and has "very poor ambulation." The documentation showed the patient was alert and oriented. He was transported to a group home. There are no instructions on the form for wound care. There are no instructions on the form to turn and reposition the patient every two hours or to provide aggressive nursing care for Patient #1's decubitus.

During a phone interview on 7/10/14 around 10:30 a.m., the caregiver said Patient #1 went to the behavioral unit on 2/21/14, was because of an incident at the Agency for Persons with Disabilities (APD) group home. She was told to take him to the behavioral health hospital and that Patient #1 should not ever return to her house. She said upon discharge, the patient wanted to go back to her house and the other group home residents agreed it was okay. She said when Patient #1 returned from the hospital he was not able to do anything for himself and he had wounds. The caregiver is not a nurse.
Patient#1 was discharged to the home of a caregiver trained by APD, not a nursing facility. The patient had home health prior to admission. Patient #1's case manager was not notified. No home health care was arranged by the facility.

In an interview on 7/9/14 at 10:00 a.m., therapist Staff G, said he had nothing to do with the medical aspect of patients' care. He said he did not know of any case manager for Patient
#1. He said there was only the caregiver's name listed on the face sheet.

During an interview on 7/9/14 around 10:30 a.m., the Director of Nursing (DON) at the behavioral health unit confirmed there was no coordination of discharge with the home health agency or the patient's case manager. She said the facility was not aware of any home health agency involved in the care of Patient #1. He was sent home to the private home with a caregiver.

In a second interview on 7/10/14 at 9:30 a.m., therapist Staff G stated, "I usually have a sit down with the nursing staff about 2 or 3 days before patients are discharged." He admitted this was not done with Patient #1.

Review of the 'Summary of Discharge/Update of Social Work Information' shows on 3/18/14, therapist Staff G documented: "The patient has been cleared and is stable and ready for discharge per doctor's order." The therapist documents: "The patient will be returning home where he will be cared for by (caregiver) and be transported by this individual this day of his discharge." The therapist checked the resident has "stable housing" and "information and referral to needed community based support..."

In an interview on 7/10/14 at approximately 10:00 a.m., the medical doctor (MD) caring for Patient #1 said the patient was not able to care for himself due to having cerebral palsy, having atrophy in his extremities, and being wheelchair bound. He confirmed the patient had more than one wound to his buttocks when he was discharged. The MD was not aware of the dime size wound documented by nursing staff on 3/17/14. He stated the care he provided was to apply Lantiseptic Balm to the wounds and leave them open and turn and reposition the patient every two hours. He was not aware of the physicians order dated 3/17/14, written by the wound care nurse to apply antifungal cream to the ulcer on buttocks and to hold the Lantiseptic Cream until skin had healed. He confirmed that this order should have been on the discharge orders for the patient's wound care and that it was not. The medical doctor stated, "I don't have anything to do with discharging patients."

In an interview on 7/10/14 at 4:00 p.m., the DON verified the medical doctor was not involved with discharging patients in the behavioral facility. She stated, "The psychiatrist will sometimes come in at 7:00 p.m. at night and discharges patients without ever clearing with the medical doctor that these patients are ready for discharge."

In a second telephone interview on 7/14/14 at 9:08 a.m., Patient #1's caregiver verified Patient #1 had several decubitus wounds when he was discharged from the facility. She stated, "I was never given any instructions for his care when he was discharged." She said she went to the facility on the afternoon of 3/17/14, and asked where Patient #1 was. A facility aide told her that Patient #1 was still in his bedroom. It was at that time she was notified by the aide the patient had decubitus on his backside. She said he was released the next day. She says it took 4 staff members to get Patient #1 into her car because he was unconscious. She stated he was supposed to have a wound care referral. When she called the wound care office, they didn't know anything about it. The wound care office contacted the facility. The office was told by the facility they did not know anything about the consultation because Patient #1 was discharged. The caregiver contacted Patient #1's primary physician and he ordered home health. She said when Patient #1 was discharged, he had decubitus to both sides of his buttocks, on his left hip, and on both of his heels. She said the only instructions given to her were written on the nursing discharge instructions.
Review of these instructions showed no wound care or repositioning instructions. She said Patient #1 was later admitted to the hospital on 4/7/14, with infected Stage 4 decubitus. He remained in the hospital until 4/18/14, and then went to a nursing home.

The development of a Stage 4 wound on Patient #1 was confirmed by a separate survey of the home health agency.

2. Patient #4 was admitted to the facility on 6/28/14. Review of the physician's progress note showed the patient was being treated for several chronic medical conditions including chronic obstructive pulmonary disease (COPD), a diabetic foot ulcer, high blood pressure, congestive heart failure (CHF) with edema, and cerebral vascular disease.
Review of the 'Active Discharge Plan/Discharge Summary' showed under Housing Concerns/Goals: "Plans to return home."

In interview on 7/10/14 at 4:20 p.m., the director and the DON both agreed the patient would not be able to be sent home or to an ALF at discharge. They both stated Patient #4 would need to be sent to a skilled nursing facility (a nursing home). They were asked to show what steps had been taken to inform the family of the need for the patient to be placed after being in the facility for 12 days.
At 4:25 p.m., the director was on the phone speaking to therapist Staff G, about the need to contact Patient #4's family and inform them that the patient would need to be placed in a nursing home upon discharge.

In an interview on 7/10/14 at 5:00 p.m., therapist Staff G stated, he didn't have anything to do with medical care regarding discharge. He verified at that time that there had been no ongoing discharge plan to discharge Patient #4 to a nursing home.

3. Patient #2 was admitted to the facility on 4/23/14 with psychosis. The medical record shows he was an insulin-dependent diabetic. Review of the 'Active Discharge Plan/Discharge Summary' dated 4/24/14, notes under housing goals and concerns: "Discharge to an ALF."

Review of the discharge summary completed by nursing staff shows, "Potential for unstable blood sugars... Potential for unstable blood pressure..." The nurse documented Patient #2's destination was an ALF. A check with the AHCA Field Office on 7/9/14 at 4:00 p.m. , revealed the ALF where Patient #2 was discharged did not have nursing care available.

Review of the AHCA Form 1823 (ALF admission assessment) signed by the discharging psychiatrist on 5/1/14 shows, "Nursing/treatments/therapy services requirements: Medication Management." Under "Cognitive or Behavioral Status: Severely confused and cogitatively impaired." Under section 1D, "In your professional opinion, can this individual's needs be met in an assisted living facility which is not medical, nursing or psychiatric facility?" with "Yes" marked. On page 4 of the AHCA Form 1823, Patient #2's medications included Novolog Insulin to be administered on a sliding scale according to his blood sugar level twice daily. On the same page, there is a mark indicating the patient needs assistance with self-administration of medications.

In a telephone interview on 7/9/14 at 5:00 p.m., the psychiatrist who signed AHCA Form 1823 verified Patient #2 was not able to self-administer insulin due to his cognitive function. He confirmed Patient #2 would need to have insulin administered to him on a sliding scale. He stated he was aware that many ALF's do not have the capability to administer insulin.

Supervision or assistance with self-administration of medications is a key element of the personal services provided by assisted living facilities (ALFs) ... Unlicensed staff are not allowed to prepare syringes for injection (i.e., insulin) or administer medication by any injectable route. (source: Florida Department of Elder Affairs website)
In an interview on 7/9/14 at 5:10 p.m., the MD caring for Patient #2 while he was in the facility verified Patient #2 was not able to administer insulin to himself. He verified the patient should not have been discharged to the ALF without nursing services.

4. Patient #8 was admitted to the facility on 3/26/14. Review of Patient #8's 'Active Discharge Plan' dated 3/27/14, shows the patient will need to be placed in a skilled nursing facility (nursing home). There was no documentation the patient or the patient's family was notified of the patient's need to be placed in a nursing home.

During an interview on 7/9/14 at 12:18 p.m., Patient #8 said he plans to go home when he leaves the facility. He said staff had not told him about where he was going when he was discharged.

In an interview on 7/10/14 at 5:00 p.m., the DON and director verified there was no documentation in the record of discussing discharge with Patient #8 or his family.
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Based on interview and record review, the facility failed to appropriately transfer 2 (Patients #1 and #2) of 10 patients surveyed for discharge. As a result of inappropriate discharge, one (Patient #1) was transferred to a group home with inadequate wound care and developed a Stage 4 pressure wound. Another (Patient #2) was transferred to an assisted living facility (ALF) without means to provide insulin administration, putting him at risk for elevated blood sugar with related diabetic complications.

Findings include:

1. Patient #1 was admitted by his caregiver to the facility on 2/21/14. He had a history cerebral palsy, hypertension and Type 2 Diabetes.
Review of the skin assessment for Patient #1 showed on 3/15/14, staff documented an open area on his right buttocks 1.7 cm x 1 cm. On the skin assessment form of 3/16/14, staff documented Patient #1 has: "Decubitus (pressure sore) to coccyx and small blister on left buttocks. On the same form there is documentation, Patient #1 had a, "2.5 x 2.5 cm discolored open area over left greater trochanter (hip joint)."
Review of a nursing note dated 3/18/14 at 3:50 a.m. reads: "He has a dime sized open area to his left trochanter. There are a few small open areas on his scrotum."
Review of the progress note dated 3/18/14, written by the medical doctor caring for Patient #1 reads: "Stage II Decubitus Ulcer: The patient needs to be repositioned at least every 2 hours. These instructions have been passed on to the nursing facility where he is being transferred to. Aggressive nursing care is critical in healing these wounds. "The medical doctor then documents: "This patient is currently stable and medically cleared to transfer to the adult living facility."
Review of the transfer note written by the discharging nurse documents on 3/18/14, "Small open area of breakdown to buttocks." The nurse documents the patient is "dependent" and has "very poor ambulation." The documentation showed the patient was alert and oriented. He was transported to a group home. There are no instructions on the form for wound care. There are no instructions on the form to turn and reposition the patient every 2 hours or to provide aggressive nursing care for Patient #1's decubitus.

During a phone interview on 7/10/14 around 10:30 a.m., the caregiver said Patient #1 went to the behavioral unit on 2/21/14, was because of an incident at the Agency for Persons with Disabilities (APD) group home. She was told to take him to the behavioral health hospital and that Patient #1 should not ever return to her house. She said upon discharge, the patient wanted to go back to her house and the other group home residents agreed it was okay. She said when Patient #1 returned from the hospital he was not able to do anything for himself and he had wounds. The caregiver is not a nurse.
Patient#1 was discharged to the home of a caregiver trained by APD, not a nursing facility. The patient had home health prior to admission. Patient #1's case manager was not notified. No home health care was arranged by the facility.

In an interview on 7/9/14 at 10:00 a.m., therapist Staff G said he said he had nothing to do with the medical aspect of patients' care. He said he did not know of any case manager for Patient #1. He said there was only the caregiver's name listed on the face sheet.

During an interview on 7/9/14 around 10:30 a.m., the Director of Nursing (DON) at the behavioral health unit confirmed there was no coordination of discharge with the home health agency or the patient's case manager. She said the facility was not aware of any home health agency involved in the care of Patient #1. He was sent home to the private home with a caregiver.

In a second interview on 7/10/14 at 9:30 a.m., therapist Staff G stated, "I usually have a sit down with the nursing staff about 2 or 3 days before patients are discharged." He admitted this was not done with Patient #1.

Review of the 'Summary of Discharge/Update of Social Work Information' shows on 3/18/14, therapist Staff G documented: "The patient has been cleared and is stable and ready for discharge per doctor's order." The therapist documents: "The patient will be returning home where he will be cared for by (caregiver) and be transported by this individual this day of his discharge." The therapist checked the resident has "stable housing" and "information and referral to needed community based support..."

In an interview on 7/10/14 at approximately 10:00 a.m., the medical doctor (MD) caring for Patient #1 said the patient was not able to care for himself due to having cerebral palsy, having atrophy in his extremities, and being wheelchair bound. He confirmed the patient had more than one wound to his buttocks when he was discharged. The MD was not aware of the dime size wound documented by nursing staff on 3/17/14. He stated the care he provided was to apply Lantiseptic Balm to the wounds and leave them open and turn and reposition the patient every two hours. He was not aware of the physicians order dated 3/17/14, written by the wound care nurse to apply antifungal cream to the ulcer on buttocks and to hold the Lantiseptic Cream until skin had healed. He confirmed that this order should have been on the discharge orders for the patient's wound care and that it was not. The medical doctor stated, "I don't have anything to do with discharging patients."

In an interview on 7/10/14 at 4:00 p.m., the DON verified the medical doctor was not involved with discharging patients in the behavioral facility. She stated, "The psychiatrist will sometimes come in at 7:00 p.m. at night and discharges patients without ever clearing with the medical doctor that these patients are ready for discharge."

In a second telephone interview on 7/14/14 at 9:08 a.m., Patient #1's caregiver verified Patient #1 had several decubitus when he was discharged from the facility. She stated,
"I was never given any instructions for his care when he was discharged." She said she went to the facility on the afternoon of 3/17/14, and asked where Patient #1 was. A facility aide told her that Patient #1 was still in his bedroom. It was at that time she was notified by the aide, the patient had decubitus on his backside. She said he was released the next day. It was at that time she was notified by the aide the patient had decubitus on his backside. She said he was released the next day. She says it took 4 staff members to get Patient #1 into her car because he was unconscious. She stated he was supposed to have a wound care referral. When she called the wound care office, they didn't know anything about it. The wound care office contacted the facility. The office was told by the facility they did not know anything about the consultation because Patient #1 was discharged. The caregiver contacted Patient #1's primary physician and he ordered home health. She said when Patient #1 was discharged, he had decubitus to both sides of his buttocks, on his left hip, and on both of his heels. She said the only instructions given to her were written on the nursing discharge instructions.
Review of these instructions showed no wound care or repositioning instructions. She said Patient #1 was later admitted to the hospital on 4/7/14, with infected Stage 4 decubitus. He remained in the hospital until 4/18/14, and then went to a nursing home.

The development of a Stage 4 wound on Patient #1 was confirmed by a separate survey of the home health agency.

2. Patient #2 was admitted to the facility on 4/23/14, with psychosis. The medical record shows he was an insulin-dependent diabetic. Review of the 'Active Discharge Plan/Discharge Summary' dated 4/24/14, notes under Housing Goals and Concerns: "Discharge to an ALF."

Review of the discharge summary completed by nursing staff shows, "Potential for unstable blood sugars... Potential for unstable blood pressure..." The nurse documented Patient #2's destination was an ALF. A check with the AHCA Field Office on 7/9/14 at
4:00 p.m., revealed the ALF was recently closed due to inadequate care for residents. The ALF where Patient #2 was discharged did not have nursing care available.

Review of the AHCA Form 1823 (ALF admission assessment) signed by the discharging psychiatrist on 5/1/14 shows "Nursing/treatments/therapy services requirements: Medication Management." Under "Cognitive or Behavioral Status: Severely confused and cogitatively impaired." Under section 1D, "In your professional opinion, can this individual's needs be met in an assisted living facility which is not medical, nursing or psychiatric facility?" with "Yes" marked. On page 4 of the AHCA Form 1823, Patient #2's medications included Novolog Insulin to be administered on a sliding scale according to his blood sugar level twice daily. On the same page, there is a mark indicating the patient needs assistance with self-administration of medications.

In a telephone interview on 7/9/14 at 5:00 p.m., the psychiatrist who signed AHCA Form 1823 verified Patient #2 was not able to self-administer insulin due to his cognitive function. He confirmed Patient #2 would need to have insulin administered to him on a sliding scale. He stated he was aware that many ALF's do not have the capability to administer insulin.

Supervision or assistance with self-administration of medications is a key element of the personal services provided by assisted living facilities (ALFs) ... Unlicensed staff are not allowed to prepare syringes for injection (i.e., insulin) or administer medication by any injectable route. (source: Florida Department of Elder Affairs website)

Review of the discharge summary completed by nursing staff shows, "Potential for unstable blood sugars... Potential for unstable blood pressure..." The nurse documented Patient #2's destination was an ALF. A check with the AHCA Field Office on 7/9/14 at
4:00 p.m., revealed the ALF where Patient #2 was discharged did not have nursing care available.

In an interview on 7/9/14 at 5:10 p.m., the MD caring for Patient #2 while in the facility verified that Patient #2 was not able to administer insulin to himself. He verified the patient should not have been discharged to the ALF without nursing services.