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Tag No.: A0154
Based on record review, interview, and policy review, the facility failed to ensure restraints were used appropriately. This affected two (Patients #1 and #5) of two patients reviewed for restraints. The census was 189.
Findings include:
1. Review of Patient #1's record revealed an admission date of 08/19/22. The patient complained of possible allergic reaction to insulin, shortness of breath, swelling, scratching of the throat and a new rash. Review of the Ear, Nose and Throat (ENT) physician note, dated 9/07/22, revealed the patient was emergently intubated after being started on heparin (anticoagulant) and having "copious bloody emesis and hemoptysis." Patient #1 was taken to the operating room and the sphenopalatine artery was cauterized and packed with nasal packing. The patient was then transferred to the intensive care unit where he was sedated, intubated, and mechanically ventilated. While ventilated there was an order placed on 09/07/22 at 5:37 AM and daily through 09/12/22 at 5:12 AM for bilateral soft wrist restraints related to the patient attempting to disrupt therapy interventions.
Review of the restraint flow sheet documented on 09/08/22 at 12:28 AM, 09/09/22 at 6:22 PM and 09/10/22 at 3:57 AM through 09/10/22 at 6:00 AM, the patient was sedated and sleep.
2. Review Patient #5's medical record revealed the patient was admitted on 08/14/22 for increased blood gases, acute kidney injury, diabetes, cirrhosis, heart failure, sepsis, history of falls and elevated troponin.
On 08/18/22 at 4:46 PM an order was placed for bilateral soft wrist restraints to prevent disruption of treatment.
Review of the restraint flow sheet documented on 08/19/22 at 5:56 AM and 08/18/22 at 9:00 PM through 08/19/22 at 7:00 AM, the patient was sedated and sleep or asleep and calm.
During interviews on 10/12/22 and 10/13/22 these findings were verified with Staff A, Staff B and Staff C.
During interview on 10/12/22 at 2:45 PM, Staff D revealed staff should document behaviors on the flow sheet. Staff D verified that a patient who is sedated, calm and/or sleep is not pulling at tubing and/or intravenous therapy lines and would not require restraints.
Review of the policy titled "Restraints", approved September 2021, revealed patients restrained to avoid interruptions in treatment or disruptions of life saving measures/devices must be assessed every two hours by the registered nurse (RN). The registered nurse will assess the patient every two hours to determine if restraints may be discontinued. Restraints will be discontinued when the patient meets the behavior criteria for their discontinuation.
Tag No.: A0799
Based on record review, interview and policy review, the facility failed to ensure proper foot care instructions were provided prior to discharging a patient with foot wounds; failed to ensure proper assistive devices and durable medical equipment would be available upon discharge; failed to ensure proper outpatient wound care was timely set up; failed and failed to ensure therapy provided assessments when consulted prior to discharge.
See A803 and A805.
Tag No.: A0803
Based on record review, interview and policy review, the facility failed to ensure proper wound care instructions were provided to a patient prior to discharge and failed to ensure proper assistive devices and other durable medical equipment (DME) was properly and/or timely coordinated to be available to the patient after discharge. This affected one (Patient #1) of ten medical records reviewed for safe discharge. The census was 189.
Findings include:
Review of Patient #1's medical records since June 2022 revealed the patient was admitted to the hospital on 06/21/22, 07/26/22 and again on 08/20/22.
Review of SP #1's first admission revealed the patient arrived at the hospital emergency room on 06/20/22 complaining of atrial flutter, shortness of breath and bilateral lower extremity edema. The patient had bilateral wounds on the medial plantar aspect of both feet which the patient stated had started as callouses. A podiatry consult was placed and the podiatrist noted both wounds would need debridement due to hyperkeratosis.
On 06/22/22 the left foot wound was debrided. The podiatrist noted that the right foot wound was too hard to cut with the blade and would need to be moistened overnight. On 06/23/22 the right foot wound was debrided. The podiatrist ordered wound care of betadine, adaptic, ABD pad and kerlix. There was no frequency documented for the dressing change.
Review of the discharge instructions provided to Patient #1 on 07/14/22 revealed the patient was educated on diabetic foot care but there were no instructions documented or noted on specific wound care of the bilateral foot wounds.
Review of the medical record revealed the patient was readmitted on 07/26/22 for sepsis secondary to bilateral diabetic foot ulcers and poorly controlled diabetes. The admitting physician noted the patient had moderately sized ulcers on the balls of both feet below the great toe. The physician documented [the wounds] "appear as they both go deep to the bone and have purulent discharge." There was also a blood blister to the right medial foot near the ulcer. Previous hospital visit wound cultures were used initially and indicated the wounds were sensitive to the antibiotic, vancomycin which was started intravenously until the patient developed a severe allergy on 08/03/22 and the vancomycin was changed to daptomycin. A chest x-ray on 07/26/22 revealed pulmonary congestion without pneumonia. On 07/29/22 an order was placed for continuous Bi-Pap due to hypercapnia and mild hypoxia.
Podiatry was consulted and review of a podiatry note dated 07/26/22 revealed the patient was unable to "keep up" with wound care upon discharge and that he was unable to make the original wound care appointment and was not able to get in for over a month after that. The podiatrist informed the patient that debridement of the wounds and wound cultures would be obtained, and the patient and his wife agreed to the plan. The podiatrist noted the patient had absent sensation to touch to the bilateral lower extremities. The podiatrist also noted the wounds were staged as Wagner stage II ulcerations, indicating deep ulcers extending to the ligament, tendon, joint capsule, bone or deep fascia without abscess or osteomyelitis. A slight odor and slough was noted to the wound beds. The podiatrist noted a blood-filled bulla to the left dorsal metatarsophalangeal (mtp).
The podiatrist took Patient #1 to the operating room and completed an incision and drainage with debridement of multiple planes of the right and left foot and applied PuraPly antimicrobial wound grafts on 07/28/22 and again on 08/03/22. A wound vacuum (vac) was placed on 07/28/22 (Thursday) with orders to be changed Monday, Wednesday and Friday and the patient was noted to be weight bearing on right foot only and with assistance.
On 07/30/22, physical therapy (PT) assessed the patient and determined the patient should ambulate with the assistance of nursing staff and should be sent home with a wide base rolling walker. The wound vac was replaced on the left foot after the debridement on 08/03/22. Again, PT and occupational therapy (OT) were consulted on 08/03/22. Therapy did not assess the patient again after the initial assessment nor after being consulted by the podiatrist on 08/03/22 or prior to discharge.
On 08/05/22 the podiatrist ordered the wound vac to be not applied related to maceration and stated the patient would be heel weight bearing to bilateral lower extremities. Again, the podiatrist ordered PT/OT to evaluate and treat. Podiatry cleared the patient for discharge on 08/05/22 and noted a wound vac would be placed on the wounds the following week on 08/10/22 at the wound clinic due to maceration. The podiatrist ordered limited ambulation using the ortho wedge shoe to the left foot and postoperative shoe to the right foot. The patient was to keep the bilateral foot dressings clean, dry and in place until the outpatient wound clinic visit on 08/10/22.
On 08/05/22 at 3:23 PM a six minute walk test was completed to assess Patient #1's oxygenation. During the walk, the patient's oxygen saturation dropped to 87 percent on room air, indicating the need for home oxygen. Bipap was also required and ordered. Case management reached out to a medical supply company who stated they could provide the oxygen upon discharge on 08/05/22. Staff noted that the Bipap machine was on back order and could not be delivered until 08/19/22, 14 days post discharge. There was no note stating the physician was notified of this delay. The patient was discharged without a Bipap machine.
Review of the discharge summary dated 08/05/22 revealed the patient was to be discharged home with home health services. Five home health agencies in the area were contacted but home health services were not set up due to them not accepting the patient's insurance. The patient was not to change bilateral foot dressings but keep them clean and dry until the wound clinic appointment on 8/10/22. The patient was educated on signs and symptoms of infection and was informed to call the office with concerns. The patient ambulated in an ortho wedge shoe to the left foot and the postoperative shoe to the right foot. He noted the patient's condition as fair and stated the patient is stable for discharge home with self-care.
During interview on 10/11/22 at 10:30 AM, Case Management leadership staff (Staff G, Staff H and Staff I) revealed if a patient qualifies for home oxygen "we make sure it is in the home on discharge." Case Management leadership also stated if a patient needs home health care services, they try to find someone and they keep looking. If they cannot find someone, they would plan for more frequent wound care. Review of Patient #1's medical record during the interview revealed the initial wound care appointment was on 08/08/22 but was moved to 08/10/22, a later date.
During interview on 10/11/22 at 12:30 PM, Staff G revealed oxygen therapy was set up on 08/05/22 for the patient and at the home upon discharge. He stated the Bi-Pap was not delivered to the patient's home. On 08/19/22, Patient #1 showed up to the critical access hospital, was intubated and was eventually sent to a facility for a higher level of care. Staff G also verified there was no follow up on Patient #1's walker.
During interview on 10/12/22 at 11:00 AM, the Rehab Manager, Staff J, revealed after the initial PT/OT evaluation order is placed, they triage based on need but try to see patients within 48 hours. Staff J stated the use of the Bipap machine would not stop staff from evaluating the patients unless the nurse says so. Staff J stated, "we typically assess for falls and ask about previous falls." Staff J stated if durable medical equipment (DME) is recommended, it is documented, and case management/social worker pulls that information off of the therapy note to ensure follow through. Staff J verified that the therapy assessment dated 07/30/22 stated the patient had no DME at home and the therapist recommended the patient to go home with a wide base rolling walker related to the weight bearing restriction. No arrangements were made to ensure the assistive device was available for the patient.
During interview on 10/12/22 at 11:00 AM, the Respiratory Care Manager, Staff K, revealed when a patient is placed on Bipap, the respiratory therapist is to document initially and every four hours after. Staff K stated a patient should not be sent home without the needed/ordered Bipap machine as carbon dioxide levels would continue to increase.
During interview on 10/12/22 at 2:27 PM, Staff F, Patient #1's RN Case Manager), revealed she could not find a home health care service provider in the area to accept Patient #1's insurance. She stated the physician was notified and the wound clinic appointment would be made sooner. Staff F verified that the patient's wound clinic appointment was not made sooner than the original date of 08/08/22, it was on 08/10/22. Staff F stated as for the order for the mobility walker, she would need a new order on the day of discharge and if there was none, the physician should be consulted to ensure it is not a requirement. Staff F verified there were no notes in the medical record to determine the physician was notified of the therapy orders to obtain a rolling weight bearing walker for the patient on 08/05/22. Staff F was asked what should be done if a patient has an order for a Bipap machine, but the machine cannot be delivered for 14 days. Staff F provided no explanation.
During interview on 10/12/22 at 2:30 PM, the Case Management Manager, Staff G, revealed if a patient is requiring a Bipap machine in the home post discharge and they cannot get one delivered for 14 days, the provider should be notified to see if they are comfortable releasing the patient. Staff G verified there were no notes in the medical record that Staff F or any other staff member informed the physician that the Bipap would not be available for the patient for 14 days.
Review of the hospital policy titled "Rehab Scope of Services", approved January 2020, revealed all patients are assessed according to the time frames delineated in the departmental policy. The assessment data along with the physician referral, patient/family goals/expectations and prior functioning level are utilized to develop an individualized plan of care. Deviations from the physicians referral will be written in the plan of care and requires review and signature from the referring physician.