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Based on record review and interview, the hospital failed to have an established process for ensuring that 5 (patient (P) 2, P3, P4, P5, P10) out of 5 patients reviewed for discharge planning were given information on their discharge plan. This deficient practice can likely result in patients not being able to make informed decisions about the care they receive and be involved in planning for their discharge.

The findings are:

A. Record review of the hospital policy titled "Patient Care - Discharge Instructions" effective 3/25/2021 on page 1 under "Procedure" bullet #3:
"3) Discharge instructions may include as appropriate: g) Medical equipment and supplies".
The policy further states on page 2,
"5) The AVS [After Visit Summary] should be printed and reviewed with the patient or caregiver prior to discharge.
b) Signature of the patient or surrogate indicating the AVS was reviewed and the patient understands the instructions given by the caregivers should be obtained.
c) The nurse should verify the patient has received a physical copy of discharge prescriptions or that the prescriber has e-Prescribed.
d) The original signed copy of the AVS should be placed in the patient's medical record. The patient will receive a copy.
e) The AVS is transmitted to the patient portal at discharge for patient communication."

B. Record review of the Electronic Medical Record (EMR) for P2 under the supervision of staff (S) 5 (Administrative Director) showed that there is no documentation in chart that the patient or representative received discharge teaching or instructions at the time of discharge.

C. Record review of the EMR for P3 under the supervision of S5 (Administrative Director) showed that there is no documentation in chart that the patient or representative received discharge teaching or instructions at the time of discharge.

D. On the record review of the "Discharge Summary" for P3 dated 10/24/2022 2:01 PM it is documented that "Patient clinically stale, continue with diuretic, oxygen support and anticoagulation." Under "Physical Exam at Discharge" the patient's vital signs are documented showing his oxygen saturation at 93% on 3L (liters) of supplemental oxygen. This indicates that patient was requiring oxygen at the time of discharge. Disposition noted in discharge summary is "Memory care unit, with home health services." Record review revealed no evidence of a referral for home oxygen found during chart review for this discharge. No documentation was found that patient or their designated representative received discharge teaching on 10/24/2022.

E. Record review of a "ED [Emergency Department] Provider Note" for P3 dated 10/25/2022 4:15 AM indicates that patient returned to hospital with oxygen saturation at 77% and the patient was found to be confused. Note states "Patient had home health set up however does not appear that patient had home oxygen."

F. Record review of a "Case Management Note" for P3 dated 10/25/2022 11:29 AM states "Case manager spoke with son (Patient's Son Name) regarding patient discharge yesterday, October 24, 2022. Patient was not discharged with oxygen or home healthcare services."

G. Record review of the EMR for P4 showed that there is no documentation in chart that the patient or representative received discharge teaching or instructions at the time of discharge.

H. Record review of the EMR for P5 showed that there is no documentation in chart that the patient or representative received discharge teaching or instructions at the time of discharge.

I. Record review of the EMR for P10 showed that there is no documentation in chart that the patient or representative received discharge teaching or instructions at the time of discharge.

J. During an interview with S5 (Administrative Director) on 11/01/2022 at 2:00 PM the discharge process was discussed; it was stated that the AVS is printed and given to the patient. It was asked if the AVS is signed and scanned into the chart. S5 stated "No". The only way to track if a patient received discharge instructions is by running a report on who printed the AVS. Did confirm that EMR system does print a signature sheet with the AVS to be signed by patient as receipt of discharge instructions.

K. During an interview with S5 (Administrative Director) and S11 (Director of Regulatory and Compliance Officer) on 11/03/22 at 12:26 PM regarding discharge process. S5 (Administrative Director) verified again that Nurses do not have patients sign the signature page that prints with the discharge instructions. Referenced policy, as noted above, S5 (Administrative Director) stated "That was a process change and the policy did not get changed."

Based on interview and record review, the Hospital failed to follow standards of practice according to The National Quality Forum and failed to provide care in a safe setting by not adhering to policies and procedures by failing to notify physician of falls, inconsistent charting, and not turning patients every 2 hours 1 (patient (P)1) out of 10 patients reviewed. This deficient practice could likely result in patients being at risk for infection and injury.

The findings are:

Failure to Notify Physician:

A. Record review of Facility Policy titled "Patient Care - Fall Risk Identification, Prevention, Reporting and Monitoring" effective 10/13/2020 on page 1, paragraph 1 it states "Purpose: . . . 6) To direct all disciplines in the management of any patient that has fallen". The policy further states on page 8, bullet point "b) Notify and Communicate the fall.
i) Notify the physician
ii) Notify the family member(s) or guardian".
It also states "Documentation
i) Enter in the patient's medical record . . .
ii) Event reporting system"

B. Record review of "Provider Notification" in "Flowsheets" for P1 showed provider was notified of patient fall on the night of 06/07/2022 at 1908 (7:08 PM). When asked to see incident reports for P1, a corresponding incident report was found for fall on 06/07/2022. Another incident report was identified for a fall on 06/09/2022 at 3:00 PM, it states, "While attending to a new pt [patient], case management came to the room and stated pt [P1] was on the floor."

C. Record review of Nursing notes and flowsheets for 06/09/2022 revealed no evidence of documentation or provider notification of a fall.

D. Interview with S5 (Administrative Director) and S11 (Director of Regulatory and Compliance Officer) on 11/03/2022 at 12:26 PM regarding expectations when a patient falls while admitted. S5 (Administrative Director) states it is expected that providers are always notified any time there is a fall. S11 (Director of Regulatory and Compliance Officer) brought up that the trideo (incident report) shows that provider was notified. Confirmed with S11 (Director of Regulatory and Compliance Officer) that this report is not part of patient's medical record. Asked S5 (Administrative Director) if there is any reason that a provider would not be notified, response was "No".
Every 2 hours turns and inconsistent charting:

E. Record review of a National Quality Forum article titled "National Voluntary Consensus Standards for Developing a Framework for Measuring Quality for Prevention and Management of Pressure Ulcers" dated 04/30/2022 by (Author Name) states "Proper repositioning is essential in maintaining skin integrity and is needed in patients who are unable to do this for themselves. Pressure, friction, and shear forces should be avoided during positioning. The most effective way of repositioning is to move the patient every 2 hours so that the ischemic (meaning lack of blood supply) areas can recover."

E. Record review of facility protocol titled "Medical-Surgical Nursing Guidelines of Care" dated September 2022 on page 3 under "Activities of Daily Living" it states "Position-must roll the patient every 2 hours as part of pressure injury reduction program if patient is immobile".

F. Record review of "Flowsheets" for P1 under the category "Mobility" under "Activity" from the dates 06/07/2022-06/20/2022 indicated that patient was "OOB [out of bed] to bathroom" on 06/07/2022 at 1710 (5:10 PM). The only other patient activity noted in "Activity" from dates 06/07/2022-06/20/2022 is either "Patient in Bed" or "Bedrest".

G. Record review of "Flowsheets" for P1 under the category "Mobility" under "Repositioned" from the dates 06/07/2022-06/20/2022 showed lapses of greater than 2 hours between patient repositioning. There was no charting on patient position for the following time frames:
1. 06/07/2022 0800 (8:00 AM) - 06/07/2022 1700 (5:00 PM),
2. 06/07/2022 2044 (8:44 PM) - 06/08/2022 0800 (8:00 AM),
3. 06/08/2022 1024 (10:24 AM) - 06/08/2022 1408 (2:08 PM),
4. 06/08/2022 1901 (7:01 PM) - 06/09/2022 0705 (7:05 AM),
5. 06/09/2022 2000 (8:00 PM) - 06/10/2022 0747 (7:47 AM),
6. 06/10/2022 2000 (8:00 PM) - 06/11/2022 0900 (9:00 AM),
7. 06/11/2022 0900 (9:00 AM) - 06/12/2022 1901 (7:01 PM),
8. 06/13/2022 1226 (12:26 PM) - 06/13/2022 1618 (4:18 PM),
9. 06/13/2022 1901 (7:01 PM) - 06/14/2022 0701 (7:01 AM),
10. 06/14/2022 0826 (8:26 AM) - 06/14/2022 1210 (12:10 PM),
11. 06/14/2022 1901 (7:01 PM) - 06/15/2022 0701 (7:01 AM),
12. 06/16/2022 0648 (6:48 AM) - 06/16/2022 1950 (7:50 PM),
13. 06/16/2022 1950 (7:50 PM) - 06/18/2022 0921 (9:21 AM),
14. 06/18/2022 0921 (9:21 AM) - 06/18/2022 1311 (1:11 PM),
15. 06/18/2022 1509 (3:09 PM) - 06/18/2022 2000 (8:00 PM),
16. 06/18/2022 2000 (8:00 PM) - 06/19/2022 0700 (7:00 AM),
17. 06/19/2022 1700 (5:01 PM) - 06/20/2022 2107 (9:07 PM).

H. Record review of "Flowsheets" for P1 under the category "Mobility" under "Repositioned" from the dates 06/07/2022-06/20/2022 revealed the position the patient was in was only charted on 06/09/2022 at 1610 (4:10 PM) as "Lying left side" and on 06/09/2022 1434 (2:34 PM) and 0800 (8:00 AM) as "Lying right side".

I. Record review of "Flowsheets" for P1 under the category "Integumentary" under "Skin Integrity" on 06/18/2022 at 2040 (8:40 PM) it is charted "Redness; Excoriation peri area and coccyx". Meaning the patients skin was showing signs of irritation and/or injury in the groin and tailbone area.

J. Record review of "Flowsheets" for P1 under the category "Integumentary" under "Skin Integrity" on 06/19/2022 at 1030 (10:30 AM) it is charted "Excoriation; Other (Comment) small open area on coccyx". Meaning the patients skin was showing signs of injury in the tailbone area.

K. Record review of "Flowsheets" for P1 under the category "Provider Notification" under "Reason for Communication" on 06/19/2022 at 1402 (2:02 PM) showed provider was notified of open area on coccyx.

L. Record review of "Discharge Summary" for P1 dated 06/20/2022 at 1:47 PM "Physical Exam" states "Skin: Warm and dry, no rash visualized."

M. Interview with S5 (Administrative Director) on 11/02/2022 at 1:30 PM regarding expectations of staff when a patient has decreased mobility and needs assistance turning. S5 (Administrative Director) stated that patients are expected to be turned every 2 hours with assistance from staff. S5 (Administrative Director) was asked if the lack of turning as seen in P1's chart could have contributed to the development of a pressure injury and it was stated that "Yes, extended periods of no turns are going to contribute to pressure injuries."

Based on record review, interview, and observation the facility failed to ensure daily patient nourishment refrigerator temperature log was completed causing a break in safety practices of food handling. This failed practice can lead to bacterial or viral food borne infection of all patients in the Emergency Department.

The findings are:

A. Record review of facility policy titled "IC - Temperatures: Refrigerator/Freezer, Medication, Patient Nourishment, Laboratory Specimens" dated 04/17/2016 shows, "2. Procedure: 2.4 Units should use refrigerator/freezer log to document temperatures for each refrigerator and/or freezer located on the unit."

B. Record review of Patient Nourishment Refrigerator Temperature Log, Instructions: 2. Record temperature by placing an "X" in the appropriate temperature box. 4. Ensure items are labeled and dated.

C. Observation on 11/02/22 at 10 am, missing Patient Nourishment Refrigerator Temperature Log for Unit ER-A Pod-(Facility Name) for November 2022.

D. Record review of Patient Nourishment Refrigerator Temperature Log for Unit ER-A Pod-(Facility Name) for October 2022 shows: 28 of 31 days are missing staff initials showing temperature and contents were checked, 20 of 31 days missing temperature checks, 20 of 31 days food items were not checked for labels and dates.

E. Record review of Patient Nourishment Refrigerator Temperature Log for Unit ER-A Pod-(Facility Name) , September 2022 shows: 24 of 30 days are missing staff initials showing temperature and contents were checked, 19 of 30 days missing fever checks, 19 of 30 days food items were not checked for labels and dates.

F. Interview with Staff (S) 11, Director of Regulatory/Compliance Officer, on 11/02/22 at 11:00 am, when asked if the Dietary fridge log is supposed to be marked off every day, S11 answered, "Yes, looks like they have missed 18 checks and there is no sheet for November."

G. Interview with S20, Dietary Director on 11/03/22 at 10:30 am, when asked "Who is responsible for checking the fridges?" S20 answered, "My team is, the dietary department, for all patient units and the ER." When asked, "How often are they checked", S20 answered, "Daily". When asked if there was a system in place to make sure checks were done daily, S20 answered, "They are supposed to bring me the reports at the end of the month." When asked if something was missed, or not done would it be noticed before the end of the month, S20 answered, "I can't go behind them every day and check the refrigerator, there's a lot in the building." Director was showed log for October and asked what happened on days that were empty, S20 answered, "We have just been having some staffing issues to be perfectly honest. I have noticed they have been falling below and am working on a system to get them automated rather than manual."