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Based on interview and record review the hospital failed to provide a safe and secure environment for four (1, 18, 25, and 24) of 30 patients as evidenced by:

1. Failure to notify one of 30 sampled patients (18) that she will be transferred to a skilled nursing facility. This failure resulted in the violation of the patient's right to be informed of her plan of care. (Refer to A-131)

2. Failure to ensure one of 30 sampled patients (25), a pediatric patient (pediatric patients are at the age of 1 to 13), was cared for in a secure environment. This failure had the potential for the pediatric patient to be harmed. (Refer to A-144)

3. Failure to ensure the electronic protected health information (PHI) for one (24) of 30 sampled patients was kept private and confidential. This had the potential to result in the unauthorized access of PHI. (Refer to A- 147)

4. Failed to include one (1) of 30 sampled patients and their responsible parties, in planning their discharge needs including the Patient's capacity to care for themselves. This resulted in Patient 1 being re-admitted to the hospital three times for symptoms including dehydration, failure to thrive (not eating), urinary tract infections, increased bleeding time and a possible stroke directly related to the lack of assessment of nursing care needs for Patient 1. (Refer to A-130)

The cumulative effects of these systematic problems resulted in violations to patient's health and safety.

Based on interview and record review the hospital failed to include one (1) of 30 sampled patients and their responsible parties, in planning their discharge needs including the patient's capacity to care for themselves. This resulted in Patient 1 being re-admitted to the hospital three times for symptoms including dehydration, failure to thrive (not eating), urinary tract infections, increased bleeding time and a possible stroke directly related to the lack of assessment of nursing care needs for Patient 1. (Refer to A-130)

Findings:

1. During a review of the clinical record for Patient 1 and concurrent interview with the Care Coordination Director, the physician's "Emergency Room Report" dated 1/19/16, indicated "The patient is an 80 year old male brought in by board and care for neck pain and increased weakness. I was not able to get the full story from him. He was not able to tell me how long it has been. He does have a history of dementia (a decline in mental function). When I asked what medical problems he has he was unable to tell me. I will admit the patient for a possible CVA (stroke) and patient also has a supratherapeutic (high) INR (bleeding time increased by a blood thinning medication). Disposition: Admit to hospital."

The physician's "Discharge Summary" dated 1/21/16 indicated, "Diagnosis upon Discharge: Altered mental status due to advanced Alzheimer disease and delirium (confusion). Discharged back to the home and boarding.

The Discharge Plan dated 1/20/16, signed by the Care Coordinator (CC) 2, indicated "Spoke with ORB (owner of room and board) at her facility and willing to take patient back when discharge. Patient lives with staff. Name of caregiver: staff. Alert with periods of confusion. Prior level of function: assisted, patient's plan for discharge: back to Room and Board."

The physician "Discharge Summary" dated 2/3/16 indicated "The patient was recently discharged from the hospital after altered mental status (confused) and received treatment for a urinary tract infection. It is not obvious if the patient stayed compliant with the medication. The medication was given to the patient at the board and care. The patient still has a urinary tract infection and is very dehydrated. The patient was discussed with the case manager that he needs more than bed and board and may need to go to a skilled nursing facility. CC 2 discussed this with the facility and they claim they are providing the full care at the skilled nursing facility for the patient. So, they are not having a problem for taking care of the patient."

The Discharge Plan dated 2/3/16, signed by CC 2 indicated "Patient will be discharged back to Assisted Living Facility."

The Discharge Plan dated 1/20/16, signed by the CC 2, indicated "Spoke with ORB (owner of room and board) at her facility and willing to take patient back when discharged. Patient lives with staff. Name of caregiver: staff. Alert with periods of confusion. Prior level of function: assisted, patient's plan for discharge: back to Room and Board."

During an interview with the ORB on 3/10/16 at 3 PM, she stated "We are only food and bed. I provide sheets, no pillow and a towel. There is one bathroom for three guests. A man, an agent called me and said, I have a man for you, he needs a place to live. He knows we don't take people that need care. I didn't know he needed help. My housekeeper came to clean and she said, he can't change his diaper, he won't eat. I said, oh my God, what are we going to do? My housekeeper said call 911. The ORB stated she has no other staff other than a housekeeper who comes in once a week. Then a few days later, the hospital called and said, does he stay there? and I said, yes. Then he was brought back. I told them I was a food and bed only. Then after a few days my son said, Mom, he will die here like this, so again we called 911."

During an interview with Patient 1's family member (FM 1) on 3/10/16 at 8:30 AM, he stated "I live in town, when he went to the hospital, the doctor stated he had a serious urinary tract infection, his blood was like water, he was medicated wrong. He said he's demented and that it was advancing fast. He cannot feed himself, unable to bathe himself and he is incontinent, he needs his diaper changed frequently. At the long term care facility where he was at before they changed his diaper all day long. I saw him at the hospital he had a high temperature he was real weak and shaky, he didn't talk, he needs care. The hospital didn't tell me where they sent him."

During an interview with the CC 2 on 3/1/16 at 2:30 PM, CC 2 stated, "He's forgetful but alert enough to know his name. He needs minimal assist, he can do things, a little bit. He can feed himself. He has no family, the brother-in-law is from out of town. I don't know about wounds, no one told me about them. I don't know about room and boards."

The Discharge Plan dated 1/20/16, signed by CC 2, indicated "Spoke with ORB (owner of room and board) at her facility and willing to take patient back when discharge. Patient lives with staff. Name of caregiver: staff. Alert with periods of confusion. Prior level of function: assisted, patient's plan for discharge: back to Room and Board."

The hospital policy and procedure titled "Care Coordination Discharge Planning" dated 12/15/14 indicated "The goal of the discharge plan is to improve or maintain the patient's health status. To enable the patient to return to an appropriate level of care." 1. SCREENING: The Registered Nurse Care Coordinator screens all inpatients to determine which ones are at risk of adverse health consequences post discharge...

Based on interview and record review, the hospital failed to notify one of 30 sampled patients (18) that she will be transferred to a skilled nursing facility. This failure resulted in the violation of the patient's right to be informed of her plan of care.

Findings:

During a review of the clinical record for Patient 18, the "Care Notes", dated 3/4/16, at 4:31 PM, indicated the patient's discharge to a rehabilitation facility was held due to generalized weakness, tremors, and a worsening condition of one lung. On 3/8/16, at 2:27 PM, the notes indicated the patient was not accepted to transfer to the rehabilitation facility due to a "low function level", and at 2:48 PM, the patient was referred to local skilled nursing facilities. A review of the "Care Notes", dated 3/10/16, at 10:36 AM, indicated Patient 18 was "Very upset" and "Nobody discussed with her" about the discharge to a skilled nursing facility which was set at 1 PM.

During an interview with the Director for Case Management, on 4/20/16, at 2:12 PM, she reviewed Patient 18's "Care Notes", and was unable to find documentation that Patient 18 was made aware of the transfer to the skilled nursing facility.

Based on observation, interview, and record review, the hospital failed to ensure one of 30 sampled patients (25), who was a pediatric patient (pediatric patients are at the age of 1 to 13), was cared for in a secure environment. This failure had the potential for the pediatric patient to be harmed.

Findings:

During a concurrent observation and interview with the Regulatory Compliance Coordinator (RCC), on 4/19/16, at 9:18 AM, in the Medical-Surgical Unit, Patient 25 was in lying in bed visible from the hallway and not directly visible from the nurses' station. The RCC reviewed Patient 25's clinical record and stated the patient had been admitted to the hospital the previous day, on 4/18/16, at 7:05 PM.

During an interview with the unit's Nurse Manager (NM) 1, on 4/20/16, at 1:32 PM, she stated the unit admitted adult patients, pediatric patients, and prisoners. She stated the unit charge nurses coordinated the bed placements for patients who needed to be admitted.

During a concurrent observation and interview with Registered Nurse (RN) 5 and the RCC, on 4/20/16, at 1:38 PM, in the Medical-Surgical unit, she stated she was the charge nurse. RN 5 stated there were two private rooms in the unit designated for prisoners. Patient 25's room was located next to the double doors which led outside to a hallway leading to the exit. Care Coordinator (CC) 1 stated the double doors open by pushing a square plate located on the wall. There were no audible alarms when the doors opened. Next to the double doors was a room currently under renovation with workers walking in and out of the double doors carrying equipment. Next to the room undergoing renovation were two private rooms where the prisoners would be placed.

During an interview with RN 6, on 4/19/16, at 10:08 AM, she stated they referred to a binder, called "Pediatric Binder", which contained information on how to take care of the pediatric patients. RN 6 reviewed the contents of the binder and was unable to find information under the tab called "Pediatric Security." She stated there was "Nothing" in the "Pediatric Security" section. She stated she was not sure as to what information it was supposed to contain and she needed to ask.

During a review of the class materials dated 2014, which was used to educate the unit nurses contained a section called "Pediatric Patient Safety", indicated there was a policy (Policy A) in observing the safety of the pediatric patients. During an interview with the RCC, on 4/19/16, at 10:40 AM, she reviewed the hospital's computer system and was unable to find the policy.

During an interview with the Quality Director (QD), on 4/20/16, at 4:30 PM, she stated Policy A, revised on 3/2009, was already replaced by another policy (Policy B), revised on 7/2014. The QD stated she had to "dig" the records to find out what happened to Policy A which was not earlier found by the unit staff. The QD had no explanation as to why the policy was not made available to the unit staff.

The hospital policy and procedure titled "Pediatric Security", dated 7/2014, indicated "All attempts will be made to place all pediatric patients in one area of the nursing unit with visibility from the nursing station."

The hospital policy and procedure titled "Plan for Provision of Patient Care", dated 06/2012, under the section "Scope of Service and Hours of Operation" for the Medical-Surgical unit where Patient 25 was admitted, indicated the unit cared for adolescents (ages 14 to 17), adult and geriatric (elderly) patients.

Based on observation, interview, and record review the hospital failed to ensure the electronic protected health information (PHI) record for one (10) of 30 sampled patients was kept private and confidential. This had the potential to result in the unauthorized access of the PHI record.

Findings:

During an observation on 4/18/16, at 1:45 PM, in the Acute Medical Surgical Unit central station, the computer facing the hallway was left unattended with Patient 10's information in view from the hallway. There was no privacy screen on the computer. NM 3 confirmed the finding and stated, "... I was using the computer..."

The hospital policy and procedure titled "Safeguarding PHI and Sensitive Information" dated 1/12/15, indicated read in part "V. PROCEDURES FOR ALL FACILITIES: B.1. Keep information that is electronically displayed from view of unauthorized individuals. For example, this may require the use of privacy screens, physical re-orientation of the monitor, password protected screen savers or other appropriate methods."

Based on observation, interview, and record review, the hospital failed to have an effective Quality Assessment and Performance Improvement (QAPI, pro-active and continuous process with the intent to assure care reaches an acceptable level) program when it failed to capture and recognize:

1. Failure to discharge one of 30 patients (1) to the appropriate level of care twice, causing patient to be hospitalized with multiple diagnosis directly related to a lack of nursing care three times. (Refer to A-806)

2. Failure to discharge one of 30 patients (28) to an appropriate facility causing the facility to return Patient 28 to the Hospital Emergency Department. (refer to A-806)

3. Failure to implement hospital Care Coordination Discharge Planning for four of 30 sampled patients (2, 4, 13, and 24). (refer to A-283)

4. Failure to ensure one of 30 sampled patients (25), a pediatric patient (pediatric patients are at the age of 1 to 13), was cared for in a secure environment. This failure had the potential for the pediatric patient to be harmed. (Refer to A-144)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe and secure environment.

Based on interview and record review, the hospital failed to document evidence of actions or interventions implemented to address the care coordination discharge planning evidenced by:

1. Hospital failed to implement Care Coordination Discharge planning policy and procedure for four of 30 sampled patients.

This failure resulted/had the potential to result in the hospital's inability to ensure the provision of quality health care in a safe environment.

Findings:

During an interview with Registered Nurse (RN) 1, on 4/18/16, at 10:30 AM, she reviewed the clinical record for Patient 13 and was unable to find discharge planning notes. She stated, "...admitted on April 16 with discharge order today...I don't see any discharge planning notes..."

During an interview with the unit Nurse Manager (NM) 1, on 4/18/16, at 10:55 AM, she reviewed the clinical record for Patient 13 and was unable to find discharge planning notes. She stated "...I don't see any Case Manager Discharge Planner notes documented in the computer..."

During an interview with RN 2, on 4/18/16, at 11:35 AM, she reviewed the clinical record for Patient 24 and was unable to find discharge planning notes. She stated, "...Patient was admitted on 4/17/16 with the diagnosis of A-fib with RVR (irregular heart beat). There's no discharge planning notes." Finding confirmed by NM 2.

During an interview with Care Coordinator (CC), 1 on 4/18/16, at 11:40 AM, she stated, "...We only have 12 hours coverage in Emergency Room. The plan is to have night coverage. When we are busy, we triage our patients. Our load is 15-16 patients per Care Coordinator per day."

During and interview with the Regulatory Compliance Manager, on 3/18/16, at 2 PM, she reviewed the clinical record for Patient 2 and was unable to find discharge planning notes.

During an interview with the Regulatory Compliance Manager, on 3/19/16, at 1:35 PM, she reviewed the clinical record for Patient 4 and was unable to find discharge planning notes before 3/21/16. Patient 4 was admitted on 3/18/16 and re-admitted on 3/29/16. She stated, "...There's no discharge planning notes before the 21st. There was no discharge planning notes for the 3/29/16 admission. I know it should have been within 24 hours of admission..."

The hospital policy and procedure titled "Care Coordination Discharge Planning" dated 3/15/16, indicated read in part "Policy: The discharge planning process addresses transitions between levels of care with and emphasis on continuity of care and assures that a safe and appropriate discharge plan is in place. V. Guidelines: 1. Screening a. Within 24 hours of admission. The admitting RN will screen all inpatients..."

Based on interview and record review the hospital:

1. Failed to provide documented evidence that nurses caring for pediatric patients were provided necessary age specific pediatric education and that they completed pediatric competencies.

2. Failed to provide documented evidence that two Registered Nurses (RN 3 and RN 4) completed required Chemotherapy Skills Competencies prior to administering chemotherapy.

These failures had the potential for nurses to be unprepared to administer chemotherapeutic therapy effectively and for nurses caring for pediatric patients to safely meet the specific care needs of children.

Findings:

1. During a review of the personnel files and concurrent interview with the Education Registered Nurse (ERN) regarding the nurses caring for pediatric patients she stated: "I am aware we have pediatric patients on the medical surgical floors occasionally. We have no competencies for the nurses taking care of pediatric patients. We do give nursing staff an eight hour class annually. I teach the class, no I am not a pediatric nurse, I do hospital wide education."

The hospital policy and procedure titled "Competency Assessment Program" dated 8/2013 indicated B. Identification of high risk competencies will be based on (a) high risk/ low volume problem prone patients and procedures."



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2. During an interview with Nurse Manager 1, on 3/20/16, at 2:30 PM, she reviewed Patient 13's medication administration record and identified the names of the RNs (RN 3) signed and administered chemotherapeutic drugs (drugs to treat cancer). RN 3 administered azathioprine (Imuran-anti cancer drug) 50 milligrams (mg.) by mouth on 4/16/16 at 10 AM.

During an interview with the Regulatory Compliance Manager, on 4/20/16, at 3:30 PM, she reviewed RN 3's personnel file and was unable to find evidence of ONS (Oncology Nursing Society) Chemotherapy and Biotherapy Provider course (training needed to safely administer anti-cancer drugs) completion card.

The hospital policy and procedure titled "Competency Assessment Program" dated 8/2013 indicated B. Identification of high risk competencies will be based on (a) high risk/ low volume problem prone patients and procedures."

Based on interview and record review, the hospital failed to implement their Verbal, Telephone, and Written Orders policy and procedure when physicians telephone orders were not signed within 48 hours for four of 30 sampled patients (5, 6, 28 and 23). This failure had the potential to affect patients' care in establishing continuity of care, safety, and appropriateness of the patients current medical care.

Findings:

During a review of the clinical record for Patient 6 the "Physicians Orders" dated 4/2/16 indicated "Right hip X-ray 2 view" and "SNF eval" dated 4/5/16 were not signed by the prescribing physician.

During a review of the clinical record for Patient 5 on the "Physician's Orders" indicated "SNF eval" dated 4/8/16 was not signed by the prescribing physician.

During a review of the clinical record for Patient 28 the "Physician's Orders" indicated "Order Clarification Place in Observation-Med/Surg" dated 4/2/16 and "Place pt as Outpatient in Bed" dated 4/5/16 were not signed by the prescribing physician.

During a review of the clinical record for Patient 23 the"Physician's Orders" indicated "Clarification of admit orders: Observation Status" dated 3/24/16, "place outpatient in a bed" dated 3/26/16, and "Please arrange home health for physical therapy, were not signed by the prescribing physician.

During an interview with the Regulatory Compliance Manager on 4/19/16, at 3:30 PM, she stated, "...I know...Our policy states, Physician signature within 24 hours."

The hospital policy and procedure titled "VERBAL, TELEPHONE AND WRITTEN PHYSICIAN ORDERS" dated Reviewed/Revised 2/2014, indicated in part, "PROCEDURE: 4. Telephone Orders: I. The order shall be counter signed by the practitioner within 48 hours to include a signature, date and time."

Based on observation, interview, and document review, the hospital failed to ensure a sanitary environment that reduced the transmission of infections and communicable diseases as evidenced by:

1. Failure to ensure that health care workers and visitors followed isolation guidelines when entering a room designated as a strict isolation room.

2. Failure to ensure health care workers followed hospital isolation guidelines when entering a strict isolation room with a multi patient use blood pressure machine which held 16 disposable single use blood pressure cuffs.

Findings:

During an observation and concurrent interview on 4/20/16 at 9 AM on the medical surgical floor with the Quality Manager (QM) a two patient room with a sign at the entrance indicating "Strict Isolation" (protection from possible infection) was observed. The signage indicated that all persons entering the room were to wear gloves, gowns and wash hands upon exiting and entering the room. The second bed had two visitors sitting next to the bed, one without gloves and wearing an isolation gown, the other visitor had the isolation gown hanging from her shoulders. A nurse entered the room to see the patient in the second bed, she wore an isolation gown hanging off her shoulders and put gloves on that were in a box by the sink. No handwashing with soap or water or alcohol based handwash was observed when the nurse entered or left the room. The first bed had a visitor who was wearing an isolation gown but no gloves. A second nurse entered the room and put on her yellow gown and gloves in the room, not in the doorway. Medical Doctor (MD) 1 entered the room with a yellow gown hanging loosely over the front of his blue hospital scrubs, his shoes were covered with blue paper booties. MD 1 walked to the sink and put on a pair of surgical gloves and proceeded to pull the curtain of bed 1 around her bed. After the interaction with the patient, MD 1 left the room with his isolation gown still on and preceded to look at a computer in the hallway. MD 1 then walked to the nursing station and looked in another computer. MD 1 did not wash his hands upon taking off his gloves when he exited the room or before he returned to the room wearing the same isolation gown. The trash can was overflowing with used isolation gowns.

During an observation and concurrent interview on 4/20/16 at 9:15 AM on the medical surgical floor with the Infection Control Nurse (ICN) she stated, "these patients are required to be in isolation according to their condition and everyone should follow the protocol. Everyone should get their gloves and gowns out of the cupboard by the door. The isolation gowns should cover their backs and be tied around the waist and neck. The doctor should not wear his surgical booties into an isolation room and everyone is expected to perform hand hygiene before and after leaving the room."

During an observation and concurrent interview on 4/20/16 at 9 AM on the pre-operative floor with the Risk Registered Nurse and the ICN, a room with a sign at the entrance that indicated "Strict Contact Isolation" (protection from possible infection) was observed. In the room was a multi patient use blood pressure machine which held 16 disposable single use blood pressure cuffs. The ICN stated "the disposable blood pressure cuffs should not be taken into an isolation room and they all needed to be thrown out. The machine should be cleaned with a germicidal solution if taken into an isolation room."

The hospital policy and procedure titled, "Strict Contact Isolation Precautions" dated 7/2014 indicated "3. practice hand hygiene before donning gloves and gown when entering the patient's isolation room and after removal of gloves and gown just prior to leaving room. 4. Gown and gloves must be worn by all persons upon entry and and removed just prior to leaving the room. 5. dedicate the use of disposable patient care equipment to a single patient."

Based on interview and record review the hospital failed to provide a safe discharge plan for multiple residents as evidenced by:

1. Failure to discharge Patient 1 to the appropriate level of care twice, causing him to be hospitalized with multiple diagnosis directly related to a lack of nursing care three times. (refer to A-806)

2. Failure to implement hospital Care Coordination Discharge Planning for four of 30 sampled patients (2, 4, 13, and 24). (refer to A-800)

The cumulative effects of these systematic problems resulted in discharges to an unsafe environment for multiple patients and for discharge needs to go unmet for multiple patients.

Based on interview and record review, the hospital failed to implement care coordination discharge planning policy and procedure for four (13, 2, 4, and 24) of 30 sampled patients. This failure had the potential to result in unsafe and inappropriate level of care and or re-admission to hospital.

Findings:

During an interview with Registered Nurse (RN) 1, on 4/18/16, at 10:30 AM, she reviewed the clinical record for Patient 13 and was unable to find discharge planning notes. She stated, "...admitted on April 16 with discharge order today...I don't see any discharge planning notes..."

During an interview with the Unit Nurse Manager (NM) 1, on 4/18/16, at 10:55 AM, she reviewed the clinical record for Patient 13 and was unable to find discharge planning notes. She stated "...I don't see any Case Manager Discharge Planner notes documented in ED..."

During an interview with RN 2, on 4/18/16, at 11:35 AM, she reviewed the clinical record for Patient 24 and was unable to find discharge planning notes. She stated, "...Patient was admitted on 4/17/16 with the diagnosis of A-fib with RVR (Irregular heart beat). There's no discharge planning notes." Finding confirmed by NM 2.

During an interview with Care Coordinator (CC) 1, on 4/18/16, at 11:40 AM, she stated, "...We only have 12 hours coverage in Emergency Room. The plan is to have night coverage. When we are busy, we triage our patients. Our load is 15-16 patients per Care Coordinator per day."

During and interview with the Regulatory Compliance Manager (RCC), on 3/18/16, at 2 PM, she reviewed the clinical record for Patient 2 and was unable to find discharge planning notes.

During an interview with the RCC, on 3/19/16, at 1:35 PM, she reviewed the clinical record for Patient 4 and was unable to find discharge planning notes before 3/21/16. Patient 4 was admitted on 3/18/16 and was re-admitted on 3/29/16. She stated, "...There's no discharge planning notes before the 21st. There was no discharge planning notes for the 3/29/16 admission. I know it should be within 24 hours of admission..."

The hospital policy and procedure titled "Care Coordination Discharge Planning" dated 3/15/16, indicated "Policy: The discharge planning process addresses transitions between levels of care with and emphasis on continuity of care and assures that a safe and appropriate discharge plan is in place. V. Guidelines: 1. Screening a. Within 24 hours of admission. 2. Evaluation: The RN care Coordinator and/or a Social Worker will perform an evaluation of the post-discharge needs of inpatients...2d. Evaluation of need for post hospitalization services..."

Based on interview and record review, the hospital failed to properly evaluate one (1) of 30 sampled patients, for discharge needs including the patient's capacity to care for himself. The hospital failed to provide safe and respectful care when:

1. Patient 1 was transferred to a room and board facility (a home that provides a room with sheets and blankets, meals and a shared bathroom with no care assistance provided) that was unable to care for his nursing needs on two separate occasions. This failure resulted in Patient 1 being re-admitted to the hospital three times for symptoms including dehydration, failure to thrive (not eating), urinary tract infections, increased bleeding time and a possible stroke directly related to the lack of nursing care for Patient 1 at the room and board.

Findings:

1. During a review of the clinical record for Patient 1 and concurrent interview with the Care Coordination Director (CCD), the physician's "Emergency Room Report" dated 1/19/16, indicated: "The patient is an 80 year old male brought in by board and care for neck pain and increased weakness. I was not able to get the full story from him. He was not able to tell me how long it has been. He does have a history of dementia (a decline in mental function). When I asked what medical problems he has he was unable to tell me. I will admit the patient for a possible CVA (stroke) and patient also has a supratherapeutic (high) INR (bleeding time increased by a blood thinning medication). Disposition: Admit to hospital."

The Physician's History and Physical for Patient 1 dated 1/19/16, indicated "the patient per son- in- law is having dementia for a long time he is not really making any sense."

The "Physical Therapy Notes" for Patient 1 dated 1/20/16 at 11 AM indicated, "The physical therapist recommends the following: gait training (learning to walk) bed mobility training (moving in bed). The Physical Therapy Discharge recommendation indicated, "LTC (long term care)."

The "Skin Care Guidelines" for Patient 1 dated 1/20/16 at 11:10 AM and signed by the hospital Registered Nurse Wound Specialists indicated "skin tears to scrotum, penis and groin, moisture related damage, interventions (care that should be given): Triad paste to scrotum, penis and groin four times a day and after incontinence (unable to hold urine).

The "Photographic Wound Documentation" for Patient 1 dated 2/2/16 indicated the patient was admitted with a deep tissue injury (tissue injury below the skin surface with restriction of blood flow causing the tissue to die, due to prolonged pressure to the back and buttocks) to his sacrococcyx area (lower back to buttocks).

The "Physician's Order" for Patient 1 dated 1/21/16 indicated "Discharge to Bed/Boarding today, follow up INR (bleeding time lab test), and start Coumadin (medication to increase bleeding time tonight."

The Physician's "Discharge Summary" for Patient 1 dated 1/21/16 indicated, "Diagnosis upon Discharge: Altered mental status due to advanced Alzheimer disease and delirium (confusion). Discharged back to the home and boarding.

The "Instruction for Home Care" for Patient 1 dated 1/21/16 and signed by a registered nurse indicated "Discharge to a Boarding Care today. Follow up in 3 days for an INR and start Coumadin tonight. The area on the form that indicated "I understand the instructions" indicated "Patient unable to sign."

The "Discharge Plan" for Patient 1 dated 1/20/16, signed by the Care Coordinator (CC) 2, indicated "Spoke with ORB (owner of room and board) at her facility and willing to take patient back when discharged. Patient lives with staff. Name of caregiver: staff. Alert with periods of confusion. Prior level of function: assisted, patient's plan for discharge: back to Room and Board."

The "Physician's Emergency Room Report" for Patient 1 dated 2/1/16 (second hospital visit) indicated "Clearly this patient is having issues taking care of himself. He is not completely oriented, maybe a little out of it due to this urinary tract infection. Patient is currently staying in a board and care Facility where he just cannot take care of himself. The patient is to be admitted and placed in a facility after that."

The "Physician Progress Note" for Patient 1 dated 2/1/16, indicated "Significant Alzheimer disease. The patient looks very dehydrated possibly due to poor oral intake..."

The "Physician Discharge Summary" for Patient 1 dated 2/3/16 indicates "The patient was recently discharged from the hospital after altered mental status (confused) and received treatment for a urinary tract infection. It is not obvious if the patient stayed compliant with the medication. The medication was given to the patient at the board and care. The patient still has a urinary tract infection and is very dehydrated. The patient was discussed with the case manager that he needs more than bed and board and may need to go to a skilled nursing facility. CC 2 discussed this with the facility and they claim they are providing the full care at the skilled nursing facility for the patient. So, they are not having a problem for taking care of the patient."

The "Discharge Plan" for Patient 1 dated 2/3/16, signed by CC 2 indicated "Patient will be discharged back to Assisted Living Facility."

During an interview with the ORB on 3/10/16 at 3 PM, she stated "We are only food and bed. I provide sheets, no pillow and a towel. There is one bathroom for three guests. A man, an agent called me and said, I have a man for you, he needs a place to live. He knows we don't take people that need care. I didn't know he needed help. My housekeeper came to clean and she said, he can't change his diaper, he won't eat. I said, oh my God, what are we going to do? My housekeeper said call 911. The ORB stated she has no other staff other than a housekeeper who comes in once a week. Then a few days later, the hospital called and said, does he stay there? and I said, yes. Then he was brought back. I told them I was a food and bed only. Then after a few days my son said, Mom, he will die here like this, so again we called 911."

During an interview with Patient 1's family member (FM 1) on 3/10/16 at 8:30 AM, he stated "I live in town, when he went to the hospital, the doctor stated he had a serious urinary tract infection, his blood was like water, he was medicated wrong. He said he's demented and that it was advancing fast. He cannot feed himself, unable to bathe himself and he is incontinent, he needs his diaper changed frequently. At the long term care facility where he was at before they changed his diaper all day long. I saw him at the hospital he had a high temperature he was real weak and shaky, he didn't talk, he needs care. The hospital didn't tell me where they sent him."

During an interview with CC 2 on 3/1/16 at 2:30 PM, CC 2 stated, "Patient 1 was an observation patient both visits, but he had a room on the floor. He's forgetful but alert enough to know his name. He needs minimal assist, he can do things, a little bit. He can feed himself. He has no family, the brother-in-law is from out of town. I don't know about wounds, no one told me about them. I don't know about room and boards." During a review of the clinical record for Patient 1 and concurrent interview with the Care Coordination Director on 3/1/16 at 2:30 PM, she reviewed the clinical record and was unable to find documentation of an assessment of needs and risks for Patient 1 throughout his hospital stay.

The "Physician's History and Physical" for Patient 1 from Hospital 2 (third hospital admission), dated 2/17/16, indicated "admit,weakness, has not been eating and worsening mental status." Patient 1 was discharged to a Skilled Nursing Facility on 3/3/16.

The hospital policy and procedure titled "Care Coordination Discharge Planning" for Patient 1 dated 12/15/14 indicated "The goal of the discharge plan is to improve or maintain the patient's health status. To enable the patient to return to an appropriate level of care." 1. SCREENING: The Registered Nurse Care Coordinator screens all inpatients to determine which ones are at risk of adverse health consequences post discharge...