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Based on review of medical staff Bylaws, Rules and Regulations, clinical record reviews and staff interview, it was determined that the facility failed to ensure that all patient care was provided under the direction of a physician member of the medical staff or was responsible for the quality of care provided. This practice may result in re hospitalization, increased length of stay, and adverse outcomes.

Findings include:

1. Based on medical record reviews and staff interview, it was determined that the facility failed to ensure that the medical staff was accountable for the quality of medical care provided that result in a patient being re admitted to the Intensive Care Unit in another facility approximately nine hours after discharge.

1. Patient #1 was admitted to the facility on 6/5/10 following a motor vehicle accident. The history and physical performed by the attending physician on 6/6/10 documented right rib fractures, compression fracture of the L5 vertebra and pelvic fractures. Physician order written by the Advanced Registered Nurse Practitioner (ARNP) dated 6/12/10 at 10:11 a.m. instructed to discharge the patient to a rehabilitation facility.

Social Worker documentation dated 6/12/10 at 11:45 a.m. revealed the patient was discharged to a Skilled Nursing Facility in another county. The patient was discharge to the Skilled Nursing Facility, located approximately 2-21/2 hours away. Review of the case management notes dated 6/12/10 revealed that the patient was discharge from the hospital to be transported via private car. Physical therapy notes dated 6/12/10 noted with moderate assisted for ten minutes.

Review of patient #1's History and Physical from the other acute care facility in another county revealed that the patient presented to the facility from a skilled nursing facility on 6/12/10 with chief complaint of fever. The patient presented to the hospital approximately 9 hours after leaving the facility. The History and Physical revealed the right thigh had a blackish discoloration with foul smelling drainage and was tender to touch/ The documentation noted the patient was admitted with a Potassium of 2.8 (3.5-5.5) and a sodium of 127 (135-145). The admitting diagnosis included cellulitis of the right thigh, low potassium, low sodium, and a urinary tract infection. The patient was admitted to the Intensive Care Unit and placed on intravenous antibiotic therapy. Review of Infectious Disease consult dated 6/131/0 indicated the patient was seen and an impression of abscess of the right thigh and flank and cellulites of the right thigh, right flank, and left thigh. Review of the operative report dated 6/15/10 revealed 4500 milliliters of brown colored fluid was removed from the thigh. The post operative diagnosis was right thigh and right gluteal necrotizing fasciitis.

There was no evidence of a physician evaluation of the patient from 6/7/10 to the day of discharge on 6/12/10 or the physician ensuring a safe discharge.

2. The facility failed to ensure that the medical staff bylaws, rules and regulations regarding medical staff oversight of patient care for assessing patients and ordering directed physician care were enforced for 4 (#1,#2,#3,#4) of 4 sampled patients. See examples in A0353)

Based on medical record reviews and staff interview, it was determined that the facility failed to ensure that the medical staff was accountable for the quality of medical care provided for 4 (#1,#2,#3,#4) of 4 sampled patients. This practice may have caused an unnecessary re hospitalization and increased length of stay. .

Finding include:

1. Patient #1 was admitted to the facility on 6/5/10 following a motor vehicle accident. The history and physical performed by the attending physician on 6/6/10 documented right rib fractures, compression fracture of the L5 vertebra and pelvic fractures. Physician order written by the Advanced Registered Nurse Practitioner (ARNP) and not signed by the physician dated 6/12/10 at 10:11 a.m. instructed to discharge the patient to a rehabilitation facility.

Physical Therapy documentation dated 6/11/10 indicated the patient complained of numbness and swelling of the right leg, was dizzy upon sitting and was using the back brace. Physical therapy notes dated 6/12/10 noted with moderate assisted for ten minutes.

Social Worker documentation dated 6/12/10 at 11:45 a.m. revealed the patient was discharged to a Skilled Nursing Facility in another county. The social worker met with the patient, and the patient stated s/he would call a family member to transport. The patient was discharge to the Skilled Nursing Facility, located approximately 2-21/2 hours away. Review of the case management notes dated 6/12/10 revealed that the patient was discharge from the hospital to be transported via private car. The patient was later that day sent to the Emergency Room of another acute care hospital.

Review of patient #1's History and Physical from the other acute care facility in another county, located approximately 2 to 21/2 hours away, revealed that the patient presented to the facility from a skilled nursing facility on 6/12/10 with chief complaint of fever. The patient presented to the hospital approximately 9 hours after leaving the facility. The patient was diagnosed with cellulitis of the right flank and posterior thigh and had a fever on 102. The History and Physical revealed the right thigh had a blackish discoloration with foul smelling drainage and was tender to touch/ The documentation noted the patient was admitted with a Potassium of 2.8 (3.5-5.5) and a sodium of 127 (135-145). The admitting diagnosis included cellulitis of the right thigh, low potassium, low sodium, and a urinary tract infection. The patient was admitted to the Intensive Care Unit and placed on intravenous antibiotic therapy. Review of Infectious Disease consult dated 6/131/0 indicated the patient was seen and an impression of abscess of the right thigh and flank and cellulites of the right thigh, right flank, and left thigh. Review of the operative report dated 6/15/10 revealed 4500 milliliters of brown colored fluid was removed from the thigh. The post operative diagnosis was right thigh and right gluteal necrotizing fasciitis.

.There was no evidence in the medical record that the physician had evaluated the patient prior to discharge or had determined that private car was an appropriate mode of transportation. There was no evidence that the ARNP had evaluated the wounds, sodium and potassium that had a history of being low, or urine culture that had been ordered prior to discharge to ensure the patient was stable and would not need to be re admitted within approximately nine hours to an Intensive Care Unit.

Two of the facility's Director of Nursing and the Performance Improvement Coordinator for the Trauma Service were interviewed on 6/22/10 at approximately 12:30 p.m. They confirmed that there was no evidence of the physician ' s involvement in the plan of care for discharge or follow up to the plan of care.

The Medical Director for the Trauma Service was interviewed on 6/22/10 at approximately 1:30 p.m. He confirmed that the lack of documentation by the attending physician was a weakness of the service. He also confirmed that the physician should have been involved in the decision of appropriate mode of transportation and found no evidence in the medical record that had occurred.

2. Patient #1 was admitted to the facility on 6/5/10 following a motor vehicle accident. The history and physical performed by the attending physician on 6/6/10 documented right rib fractures, compression fracture of the L5 vertebra and pelvic fractures. Review of the progress notes for the patient revealed there was no note written by the attending physician after 6/6/10. The last note written by any physician was written on 6/7/10 by the consulting orthopedic surgeon who signed off the case. The patient was discharged on 6/12/10.

In addition, all orders after 6/6/10 were written either by an Advanced Registered Nurse Practitioner (ARNP) or Physician Assistant (PA) none of the orders were authenticated by the attending physician or any other supervising physician.

Two of the facility's Director of Nursing (DON) and the Performance Improvement Coordinator for the Trauma Service were interviewed on 6/22/10 at approximately 12:30 p.m. They confirmed that there was no evidence of physician evaluation of the patient after 6/7/10 and no authentication of ARNP and PA orders after 6/6/10. They further confirmed that was inappropriate.

3. Patient #1 had an order for a urine culture written by an ARNP on 6/8/10. Review of laboratory results revealed the culture had never been performed. The same ARNP documented the patient's temperature was elevated on 6/9/10. There was no mention of the results of the urine culture on any note from 6/9/10 to discharge on 6/12/10. There is no evidence that the ARNP followed up regarding the urine culture order at any time. or consulted with a physician.

4. Patient #1's ARNP progress note dated 6/10/10 and 6/11/10 showed the patient complained of right lateral thigh numbness. The progress note dated 6/10/10 planned for a MRI for the numbness. ARNP orders, not signed by the physician, dated 6/10/10 instructed for a one time oral dose of potassium, obtain laboratory studies in the morning, and an MRI. ARNP progress notes dated 6/11/10 did not mention the MRI or potassium level. There was no evidence of the right thigh numbness or low potassium being discussed with a physician.

5. Patient # 2 was admitted on 6/5/10 following a motor vehicle accident with a right rib fracture. Review of the progress notes revealed no evidence of attending evaluation on 6/7/10, 6/8/10 or 6/9/10. The patient was discharge on 6/9/10. The discharge order was written by the ARNP with no authentication by the attending physician. The DON confirmed the above findings during interview on 6/22/10 at approximately 2:30 p.m.

6. A clinical record review of patient #3 revealed the patient was admitted on 6/12/10 for a Gun Shot Wound. A review of the physician progress notes revealed a daily progress note written by the ARNP from 6/14/10 to 6/21/10. There was no evidence of the physician reviewing and co-signing the progress notes.
7. A clinical record review of patient #4 revealed the patient was admitted on 6/12/10 following a Motor Vehicle Collision. The Trauma Resuscitation Note revealed a sternum fracture and hematoma. A review of the physicians progress notes revealed the progress note dated 6/18/10 was written by the ARNP but there is no evidence the physician reviewed or co-signed the progress note.
A review of the physician orders for 6/17/10 and 6/18/10 revealed the ARNP wrote the transfer and discharge orders. There was no evidence of a physician reviewing or co-signing the orders. The patient was discharged to a Skilled Nursing Facility.

Based on review of Medical Staff Bylaws, Rules and Regulations, medical record review and staff interview, it was determined that the facility failed to ensure that the medical staff provided oversight of patient care and physician orders were signed for 4 (#1,#2,#3,#4) of 4 sampled patients. This practice does not provided quality of care and places patients at risk for adverse outcomes and prolonged hospital stays.

Finding include:

1. Patient #1 was admitted to the facility on 6/5/10 following a motor vehicle accident. The history and physical performed by the attending physician on 6/6/10 documented right rib fractures, compression fracture of the L5 vertebra and pelvic fractures. Review of the progress notes for the patient revealed there was no note written by the attending physician after 6/6/10. The last note written by any physician was written on 6/7/10 by the consulting orthopedic surgeon who signed off the case. The patient was discharged on 6/12/10.

In addition, all orders after 6/6/10 were written either by an ARNP or PA. None of the orders were authenticated by the attending physician or any other supervising physician. The order to discharge the patient to a rehabilitation facility was written by an ARNP on 6/12/10. Again, the order was not authenticated by the attending. Two of the facility's Director of Nurses (DON) and the Performance Improvement Coordinator for the Trauma Service were interviewed on 6/22/10 at approximately 12:30 p.m. They confirmed that there was no evidence of physician evaluation of the patient after 6/7/10 and no authentication of ARNP and PA orders after 6/6/10. They further confirmed that was inappropriate.

2. Patient # 2 was admitted on 6/5/10 following a motor vehicle accident with a right rib fracture. Review of the progress notes revealed no evidence of attending evaluation on 6/7/10, 6/8/10 or 6/9/10. The patient was discharge on 6/9/10. The discharge order was written by the ARNP with no authentication by the attending physician. The DON confirmed the above findings during interview on 6/22/10 at approximately 2:30 p.m.

3. A clinical record review of patient #3 revealed the patient was admitted on 6/12/10 for a Gun Shot Wound. A review of the physician progress notes revealed a daily progress note written by the ARNP from 6/14/10 to 6/21/10. There was no evidence of the physician reviewing and co-signing the progress notes.
4. A clinical record review of patient #4 revealed the patient was admitted on 6/12/10 following a Motor Vehicle Collision. The Trauma Resuscitation Note revealed a sternum fracture and hematoma. A review of the physicians progress notes revealed the progress note dated 6/18/10 was written by the ARNP but there is no evidence the physician reviewed or co-signed the progress note.
A review of the physician orders for 6/17/10 and 6/18/10 revealed the ARNP wrote the transfer and discharge orders. There was no evidence of a physician reviewing or co-signing the orders. The patient was discharged to a Skilled Nursing Facility.
5. The facility's Bylaws, Rules and Regulations document requires that the all patients will be seen by the attending physician or a physician covering for the attending daily until discharge. It allows that Physician Assistants (PA) and Advance Registered Nurse Practitioners (ARNP) to document in the medical record, but requires review and to be cosigned by the supervising physician. Interview with the Director of Nursing (DON) on 6/22/10 at approximately 12:30 p.m. confirmed that facility policy also requires that orders written by the PA and ARNP are to be authenticated by the supervising physician.

Based on record review and staff interview, it was determined that the facility failed to ensure the Registered Nurses supervised and evaluated the nursing care related to activities of daily living, discharge needs, and implementation of physician orders for 1 (#1) of 4 sampled patients. This practice does not ensure patient goals are met and may prolonged hospital stays.

Finding include:

1. Review of physician orders for patient #1 revealed an order for a urine culture on 6/8/10. Review of the laboratory results and nursing documentation revealed that the test had not been performed. The Director of Nurses was interviewed on 6/22/10 at approximately 11:30 a.m. She confirmed that the order had not been implemented.

2. Patient #1's nursing documentation revealed no evidence that the nursing staff addressed the patient's hygiene needs on 6/8/10, 6/9/10, 6/10/10, 6/11/10 and 6/12/10. During interview on 6/22/10 at approximately 12:30 p.m., the DON confirmed the above findings.

3. Patient #1 History and Physical revealed the patient was admitted to the facility on 6/5/10 with right rib fractures, compression fracture of the L5 vertebra and pelvic fractures.

Physical Therapy documentation dated 6/11/10 indicated the patient complained of numbness and swelling of the right leg, was dizzy upon sitting and was using the back brace. Physical therapy notes dated 6/121/0 noted sitting with moderate assisted for ten minutes was tolerated.

Social Worker documentation dated 6/11/10 indicated the patient was agreeable to transfer to a Skilled Nursing Facility in another county. Social Worker documentation dated 6/12/10 at 111:45 a.m. revealed the patient was discharged and the patient stated s/he would call a family member to transport. The patient was discharged to the Skilled Nursing Facility, located approximately 2-21/2 hours away. The patient was later that day sent to the Emergency Room of another acute care hospital.

Review of the admission History and Physical from the acute care facility in another county, dated 6/12/10 revealed the right thigh had a blackish discoloration with foul smelling drainage and was tender to touch. The admitting diagnosis included cellulitis of the right thigh and a urinary tract infection. The patient was admitted to the Intensive Care Unit and placed on intravenous antibiotic therapy.

There was no evidence in the medical record that the nurse discussed or reassessed the appropriateness of the timing of the discharge and the mode of transportation to ensure the patient's needs and safety were met.

Based on clinical record reviews and staff interview it was determined that the facility failed to reassess the patient's discharge for appropriateness for one (#1) of four records reviewed. This practice may cause an unnecessary re hospitalization.

Findings include:

1. Patient #1 History and Physical revealed the patient was admitted to the facility on 6/5/10 following a motor vehicle accident. The history and physical documented right rib fractures, compression fracture of the L5 vertebra and pelvic fractures.

Review of Advance Registered Nurse Practitioner (ARNP) progress note dated 6/10/10 and 6/11/10 indicated the patient complained of right lateral thigh numbness. The progress noted dated 6/10/10 planned for a MRI for the numbness. The 6/11/10 noted did not mention the MRI. Review of ARNP progress note dated 6/12/10 had no mention of the MRI result to determine if the patient was stable for discharge.

Physical Therapy documentation dated 6/11/10 indicated the patient complained of numbness and swelling of the right leg, was dizzy upon sitting and was using the back brace. Physical therapy notes dated 6/121/0 noted sitting with moderate assisted for ten minutes was tolerated.

Social Worker documentation dated 6/11/10 indicated the patient was agreeable to transfer to a Skilled Nursing Facility in another county. Social Worker documentation dated 6/12/10 at 111:45 a.m. revealed the patient was discharged and the patient stated s/he would call a family member to transport. The patient was discharged to the Skilled Nursing Facility, located approximately 2-21/2 hours away. The patient was later that day sent to the Emergency Room of another acute care hospital.

Review of the admission History and Physical from the acute care facility in another county, dated 6/12/10 revealed the right thigh had a blackish discoloration with foul smelling drainage and was tender to touch. The documentation noted the patient was admitted with a Potassium of 2.8 (3.5-5.5) and a sodium of 127 (135-145). The admitting diagnosis included cellulitis of the right thigh, low potassium, low sodium, and a urinary tract infection. The patient was admitted to the Intensive Care Unit and placed on intravenous antibiotic therapy. Review of Infectious Disease consult dated 6/131/0 indicated the patient was seen and an impression of abscess of the right thigh and flank and cellulites of the right thigh, right flank, and left thigh. Review of the operative report dated 6/15/10 revealed 4500 milliliters of brown colored fluid was removed from the thigh. The post operative diagnosis was right thigh and right gluteal necrotizing fasciitis.

There was no evidence in the medical record that the physician had evaluated the patient prior to discharge or had determined that private car was an appropriate mode of transportation for the patient. Two of the facility's Director of Nurses and the Performance Improvement Coordinator for the Trauma Service were interviewed on 6/22/10 at approximately 12:30 p.m. They confirmed that there was no evidence of a physician ' s evaluation of the patient after 6/7/10. The Medical Director for the Trauma Service was interviewed on 6/22/10 at approximately 1:30 p.m. He confirmed that the lack of documentation by the attending physician. He also confirmed that the physician should have been involved in the decision of appropriate mode of transportation and found no evidence in the medical record that had occurred. In addition, there was no evidence of the nurse and case manager discussing or reassessing the appropriateness of the timing of the discharge and the mode of transportation to ensure the patient's needs and safety were met.