HospitalInspections.org

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Based on record review and interviews the facility failed to ensure care was provided in a safe manner in conjunction with nursing practice standards according to the Condition of Participation: CFR 482.23 Nursing Services. Findings:

The facility failed to:

ensure patients were monitored during blood transfusions for 5 patients (#s 3, 12, 16, 17, and 18), out of 5 sampled patients who received blood transfusions. Specifically, nurses failed to 1) document vital signs (VS) within the set time frames according to standards of practice and procedures and/or failed to document a complete set of VS within these time frames to include blood pressure (BP), heart rate (Pulse: P), respirations (R), and temperature (T) and 2) ensure deviations in VS during blood transfusions were reported to the physician or supervisor, documented accurately within nurse's notes, and/or followed appropriate protocol for incident reporting. This failed practice constituted an immediate jeopardy to patient health and safety.

This situation was brought to the attention of the facility's administration on August 30, 2018 at 5:00 pm, at which time the facility was notified of the deficient practice and the high risk to patients. The immediacy was removed by the facility by August 30, 2018 at 9:30 pm.

The facility was out of compliance with the Condition during the investigation. Findings:

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Based on record review, interview, and facility policy review the facility failed to ensure patients were monitored during blood transfusions in 5 patients (#s 3, 12, 16, 17, and 18), out of 5 sampled patients who received blood transfusions. Specifically, nurses failed to 1) document vital signs (VS) within the set time frames according to standards of practice and procedures and/or failed to document a complete set of VS within these time frames to include blood pressure (BP), heart rate (Pulse: P), respirations (R), and temperature (T) and 2) ensure deviations in VS and/or symptoms, during blood transfusions, were reported to the physician or supervisor, documented accurately within nurse's notes, and appropriate protocol for reporting was followed. This failed practice constituted an immediate jeopardy to patient health and safety. Findings:

This situation was brought to the attention of the facility's administration on August 30, 2018 at 5:00 pm, at which time the facility was notified of the deficient practice and the high risk to patients. The immediacy was removed by the facility by August 30, 2018 at 9:30 pm.

Patient #3

Record review from 8/29-30/18 revealed Patient #3 was admitted with diagnoses that included acute respiratory failure with hypoxia (blood supply is shunted away from inside the lung resulting in airspace filling with fluid or airway collapse) and anemia (a condition in which the blood doesn't have enough healthy red blood cells). Additional review revealed Patient #3 was on mechanical ventilation.

Transfusion #1

Record review revealed a transfusion of red blood cells was ordered on 6/11/18 due to Patient #3 having abnormal lab values of hemoglobin (protein component of red blood cells) and hematocrit (packed cell volume: the volume percentage of red blood cells in the whole blood).

Review of Patient #3's VS documentation, dated 6/11/18, revealed BP, P and R were not documented during the transfusion at standard intervals. Additionally, the transfusion rate was increased 30 minutes after the transfusion started without documentation of Patient #3's tolerance to the transfusion. The first set of VS after the transfusion ended revealed an increase in all VS to include P 122, R 48, ronchi breath sounds (a continuous low pitched rattling that indicates obstruction or secretions in larger airways) in both lungs, and T 100.2 F.

VS and transfusion were documented as follows:
12:42 pm - VS documented prior to transfusion BP 128/60, P 102, R 30, T 99.8 F
1:02 pm - Transfusion started 50 milliliters and hour (mL/hr)
1:05 pm - Only T documented 98.8 F
1:15 pm - Only T documented 98.7 F
1:30 pm - Only T documented 98.9 F
1:32 pm - Transfusion rate increased to 250 mL/hr
1:45 pm - Only T documented 98.9 F
2:15 pm - Only T documented 98.9 F
2:45 pm - Only T documented 98.9 F - transfusion stopped
3:14 pm - 1st set of VS documented after transfusion BP 134/62, P 122, R 48, T 100.2 F, SpO2 94% (O2 concentration 40%) documented large amounts of secretions; yellow, pale in color; thick, thin consistency; and ronchi breath sounds on left and right. Documented aeration increased (increase in the amount of oxygen-rich air taken into and expelled from the lungs) for posttreatment of breath sounds. Documented no suspected reaction.

Review of Patient #3's nurse's note, dated 6/11/18 at 6:38 pm, written by LN #1, revealed "[Patient] given blood today. Temp of 100.2 F resolved after Tylenol given. Fentanyl given after observing pulse 130+ which helped lower pulse." Further review VS documentation revealed no documentation of an elevated P of 130, nor a P that exceeded 130. There was no documentation that the provider was notified of the increase in T and P.

Transfusion #2

Record review revealed a transfusion of red blood cells was ordered on 6/20/18 due to Patient #3 having abnormal lab values of hemoglobin and hematocrit.

Review of Patient #3's VS documentation, dated 6/20/18, revealed no complete set of VS documented at any time during the transfusion. Additionally, no VS were documented 30 minutes after the transfusion stopped. The first set of VS after the transfusion occurred (1 hour and 8 minutes later) revealed a drop in BP, and increase in R.

VS and transfusion were documented as follows:
1:10 pm - VS documented at time of transfusion BP 117/59, P 115, R 32, T 99.2 F - Transfusion started at 75 mL/hr
1:15 pm - VS documented BP 120/59, no P, R 33, T 99.3 F
1:30 pm - VS documented BP 96/59, no P, no R, T 99.0 F
2:30 pm - VS documented BP 118/65, no P, no R, T 99.0 F
3:12 pm - VS documented no BP, P 110, R 41, no T
3:17 pm - Documented large amounts of secretion; yellow, creamy color; thick consistency; breath sounds course on left, right, upper airway. Aeration increased posttreatment breath sounds
3:26 pm - VS documented BP 124/62, P 109, R 23, T 99.0 F - Transfusion stopped
4:34 pm - 1st set of VS documented 1 hour, 8 minutes after transfusion stopped: BP 107/62, P 108, R 36, T 100.2 F

Additional review of Patient #3's VS documentation revealed the next set of VS documented after 4:34 pm was at 7:22 pm: BP 126/63, P 105, R 39, T 97.7.

Review of Patient #3's nurse's note, dated 6/20/18 at 5:35 pm, written by LN #2 revealed "[Vital signs] were critical at the beginning of shift. [Patient] received 2 liters of [normal saline] and one unit of blood. VS are currently stable." Further review revealed no documentation that the provider was notified of the blood pressure or respiratory changes.


Transfusion #3

Record review revealed a transfusion of red blood cells was ordered on 6/30/18 due to Patient #3 having abnormal lab values of hemoglobin and hematocrit.

Review of Patient #3's VS documentation, dated 6/30/18, revealed fluctuations in blood pressure were documented throughout the transfusion and increased from 104/60 at the start of the transfusion to 140/56 30 minutes after the transfusion ended.

VS and transfusion were documented as follows:
10:20 am - VS documented prior to transfusion started BP 104/60, P 88, R 22, T 97.8 F, SpO2 99%
10:24 am - Transfusion started at 50 mL/hr
10:30 am - VS documented BP 109/66, P 89, R 22, T 97.7 F, SpO2 100%
10:45 am - VS documented BP 109/66, P 87, R 22, T 99.7 F - Transfusion rate increased to 150 mL/hr
10:48 am - VS documented BP 119/70, P 89, R 22, T 99.7 F
11:00 am - VS documented BP 113/66, P 88, no R, T 97.6 F
11:32 am - VS documented BP 103/64, P 84, R 22, T 97.7 F, SpO2 98%
12:00 pm - VS documented BP 109/68, P 82, no R, T 97.6 F, SpO2 99%
12:15 pm - VS documented BP 119/74, P 82, no R, T 97.7 F, SpO2 100%
12:35 pm - VS documented no BP, no P, R 24, T 97.7 F, SpO2 99% -- Transfusion stopped
12:45 pm - VS documented no BP, P 90, R 25, no T, SpO2 96%
1:02 pm - VS documented BP 140/56, P 86, R 25, T 97.7 F, SpO2 96%

Review of Patient #3's nurse's note, dated 6/30/18 at 6:16 pm, written by LN #3 revealed "Infused 1 unit [packed red blood cells] with no adverse reaction."

Patient #12

Record review from 8/29-30/18 revealed Patient #12 was admitted with diagnoses that include diverticulitis of intestine, with perforation and abscess without bleeding (diverticulosis: the formation of numerous tiny pockets, or diverticula, in the lining of the bowel formed by increased pressure on weakened spots in the intestinal wall. Perforation: holes in the intestine. Abscess: a pocket of inflamed tissue filled with pus in the intestine) and anemia (a condition in which the blood doesn't have enough healthy red blood cells).

Further review revealed a transfusion of red blood cells was ordered on 6/28/18 due to Patient #12 having abnormal lab values of hemoglobin and hematocrit.

Review of Patient #12's VS documentation, dated 6/28/18, revealed no VS were documented 30 minutes after the transfusion stopped. The first set of vital signs after the transfusion occurred (56 minutes later) revealed an increase in all VS which included BP 163/82, P 83, R 20, and T 100.2 F.

VS and transfusion were documented as follows:
4:17 pm - VS documented prior to transfusion BP 148/82, P 68, R 19, T 97.7 F
4:44 pm - Transfusion started 50 mL/hr
4:49 pm - VS documented BP 149/79, P 70, R 20, T 98.9 F - Transfusion rate increased to 75 mL/hr
4:59 pm - VS documented BP 145/66, P, 70, R 16, T 99.2 F
5:07 pm - Only T documented 98.8 F - Transfusion rate increased to 150 mL/hr
5:15 pm - VS documented BP 152/87, P 80, R 16, T 99.1 F
5:30 pm - No VS documented -- Transfusion rate increased to 200 mL/hr
5:45 pm - VS documented BP 159/80, P 82, R 16, T 99.5 F
6:15 pm - VS documented BP 155/76, P 69, R 18, T 99.2 F
6:45 pm - VS documented BP 140/71, P 77, R 16, T 98.8 F
7:00 pm - VS documented BP 158/89, P 69, R 18, T 99.7 F
7:05 pm - Transfusion stopped, documents no suspected reaction
8:01 pm - VS documented after transfusion (56 minutes later) BP 163/82, P 83, R 20, T 100.2 F

Review of Patient #12's nurse's note, dated 6/28/18 at 2:57 pm, written by LN #4 revealed "Patient had one unit of blood infused today. Patient monitored closely. No transfusion reactions noted." This note was written 1 hour and 47 minutes before the transfusion started.

Patient #16

Record review from 8/29-30/18 revealed Patient #16 was admitted with a diagnoses that included bullous pemphigoid (a rare skin condition causing large, fluid-filled blisters) and acute post hemorrhagic anemia (a condition in which a person quickly loses a large volume of circulating blood).

Further review revealed a transfusion of 2 units of red blood cells was ordered on 6/2/18 due to Patient #16 having abnormal lab value of hemoglobin.

Transfusion # 1 (2 units)
First Unit

Review of Patient #16's VS documentation of the first transfusion, dated 6/2/18, revealed no VS were documented 5 minutes after the transfusion started.

VS and transfusion were documented as follows:
1:26 pm - VS documented at start of transfusion BP 114/49, P 65, R 16, T 97.9 F
1:26 pm - Transfusion started at 100 mL/hr
1:39 pm - VS documented BP 111/45, P 65, R 14, T 97.8 F
1:44 pm - VS documented BP 112/50, P 65, R 14, T 98.9 F
1:54 pm - VS documented BP 111/49, P 65, R 16, T 98.4 F - Transfusion rate increased to 400 mL/hr
2:25 pm - VS documented BP 122/57, P 60, no R, T 99.1 F
2:30 pm - Transfusion stopped

Second Unit

Review of Patient #16's VS documentation of the second transfusion, dated 6/2/18, revealed no VS were documented 5 minutes after the transfusion started. Additionally, VS were not documented 30 minutes after the transfusion stopped. Only the BP and P were documented 1 hour and 48 minutes later.

VS and transfusion were documented as follows:
2:25 pm - VS documented prior to start of transfusion BP 122/57, P 60, no R, T 99.1 F
2:35 pm - R 16 - Transfusion started at 100 mL/hr
2:45 pm - VS documented BP 133/57, P 68, R 18, T 99.2 F - Documented no suspected reaction
2:54 pm - VS documented BP 140/58, P 67, R 18, T 99.0 F
3:08 pm - VS documented BP 138/64, P 66, R 18, T 99.4 F
3:21 pm - VS documented BP 133/57, P 67, R 18, T 98.8 F
3:48 pm - VS documented BP 129/58, P 68, R 16, T 98.9 F - Transfusion rate increased to 400 mL/hr
4:23 pm - Transfusion stopped, documented no suspected reaction
6:11 pm - 1st set of VS documented after transfusion occurred (1 hour, 48 minutes later) BP 125/81, P 71, no R, no T

Review of Patient #16's nurse's note, dated 6/2/18 at 7:59 pm, written by LN #5 revealed "Two units of PRBCs given as ordered for [hemoglobin] of 6.8. [Patient] stable by end of shift, no reaction noted."

Transfusion #2

Further review revealed a Physician's note, dated 6/12/18 at 5:00 pm, which documented, "In light of significant bone marrow depression from the rituximab (a medication used to treat certain autoimmune diseases and types of cancer), multiple oozing skin lesions in spite of platelet transfusion, and general debilitated state I elect to give 1 unit of packed red blood cells ..."

Further review revealed a transfusion of red blood cells was ordered on 6/12/18 due to Patient #16 having abnormal lab values of hematocrit.

Review of Patient #16's VS documentation, dated 6/12/18, revealed no documentation as to when the blood transfusion stopped. No VS after 30 minutes of blood transfusion could be ascertained.

VS and transfusion were documented as follows:
5:29 pm - VS documented prior to transfusion BP 162/74, P 72, R 20, T 97.7 F
5:37 pm - Transfusion started 50 mL/hr
5:42 pm - VS documented BP 154/58, P 75, R 18, T 99.7 F
5:52 pm - VS documented BP 162/63, P 75, R 18, T 98.2 F
5:56 pm - Transfusion rate increased to 150 mL/hr
6:02 pm - VS documented BP 142/74, P 77, R 18, T 99.7 F
6:11 pm - VS documented BP 155/67, P 74, R 22, T 99.0 F
6:46 pm - VS documented BP 156/63, P 76, R 19, T 98.8 F
8:02 pm - VS documented BP 157/75, P 71, R 19, T 99.5 F

Review of Patient #16's nurse's note, dated 6/12/18 at 7:48 pm, written by LN #5 revealed, "[Patient] received 1 unit of platelets at end of shift. Infusion of 1 unit of [packed red blood cells] started during shift, still running at shift change. No transfusion reaction observed."

Patient #17

Record review from 8/29-30/18 revealed Patient #17 was admitted with a diagnoses that included mitral valve replacement with deconditioning and remaining chest tubes (heart valve from the left atrium to the left ventricle replaced. Chest tubes: a flexible plastic tube inserted through the chest wall into the chest cavity outside of the lung) and acute post hemorrhagic anemia (a condition in which a person quickly loses a large volume of circulating blood).

Further review revealed a transfusion of red blood cells was ordered on 3/2/18 due to Patient #17 having abnormal lab values of hemoglobin and hematocrit.

Review of Patient #17's VS documentation, dated 3/2/18, revealed no VS were documented 5 minutes after the transfusion started. Further review revealed Patient #17 had a drop in blood pressure after the first 9 minutes of the transfusion from 118/48 to 103/50. Additionally, no VS were documented 30 minutes after the transfusion stopped. The first set of VS documented after the transfusion stopped occurred 42 minutes later.

VS and transfusion were documented as follows:
10:06 pm - VS documented at time of transfusion BP 118/48, P 90, R 20, T 98.2 F
10:06 pm - Transfusion started 50 mL/hr
10:15 pm - VS documented BP 103/50, P 109, R 18, T 98.0 F - documented no suspected reaction
10:32pm - VS documented BP 117/62, P 88, R 16, T 98.0 F - documented no suspected reaction
10:32 pm - Transfusion rate increased to 150 mL/hr
11:00 pm - VS documented BP 112/53, P 119, R 16 T 98.2 F
11:15 pm - VS documented BP 110/54, P 86, R 18, T 98.0 F
12:00 am - VS documented BP 114/54, P 105, R 18, T 98.1 F - Transfusion stopped - documented no suspected reaction
12:42 am - First set of VS documented after transfusion BP 118/60, P 115, R 18, T 98.1 F (42 minutes later)

Review of Patient #17's medical record revealed a nurses note, dated 3/3/18 at 3:51 am, written by LN #6 that documented "[Patient] tolerated well no signs or symptoms of transfusion reaction."

Patient #18

Record review from 8/29-30/18 revealed Patient #18 was admitted to facility after a surgical operation for coronary artery bypass graft (a procedure to restore normal blood flow to an obstructed coronary artery of the heart). He/she also has a diagnosis of iron deficiency anemia (too few healthy red blood cells due to too little iron in the body).

Further review revealed a transfusion of red blood cells was ordered on 1/2/18 due to Patient #18 having abnormal lab values of hemoglobin and hematocrit.

Review of Patient #18's VS documentation, dated 1/2/18, revealed no VS were documented 5 minutes, nor 15 minutes after the transfusion started. Further review revealed documentation of a low oxygen level in the blood (SpO2), 86%, and Patient #18 required oxygen to correct this. Diminished breath sounds were also documented in both lungs. Additionally, no VS were documented 30 minutes after the transfusion ended.

VS and transfusion were documented as follows:
2:14 pm - VS documented prior to transfusion BP 99/69, P 61, R 16, T 98.0 F, SpO2 96%
2:30 pm - Transfusion started 50 mL/hr
2:55 pm - VS documented BP 115/65, P 69, R 16, T 97.6 F
3:10 pm - VS documented BP 116/57, P 66, R 16, T 98.5 F - Transfusion rate increased to 100 mL/hr
3:11 pm - Documented "Found on room air, [again] SpO2 was 86, placed on 2 [liters per minute]", SpO2 94% after O2
3:12 pm - Diminished breath sounds documented on left and right side
3:41 pm - VS documented BP 130/71, P 59, R 14, T 97.9 F, SpO2 99%
4:18 pm - VS documented BP 132/64, P 57, R 20, T 97.9 F, SpO2 98%
4:55 pm - VS documented BP 133/68, P 57, R 14, T 98.0 F, SpO2 99% -- Transfusion rate increased to 130 mL/hr
5:15 pm - Transfusion rate increased to 200 mL/hr - No VS documented
5:33 pm - VS documented 136/70, P 64, R 14, T 98.1 F, SpO2 99%
5:52 pm - Transfusion stopped, documented no suspected reaction
6:31 pm - 1st set of VS documented after transfusion (38 minutes later) BP 122/71, P 67, R 14, T 98.1 F, SpO2 97%
7:58 pm - SpO2 97%, lowered O2 to 1 liter per minute
7:59 pm - Breath sounds diminished on left side, crackles on left upper lung

Review of Patient #18's nurse's note, dated 1/2/18 at 7:19 pm, written by LN #7, revealed no documentation of need for oxygen, low SpO2 rate, or diminished breath sounds during blood transfusion.

During an interview on 8/30/18 at 2:46 pm, a Quality Staff #1 stated blood transfusions and the corresponding documentation are monitored monthly during Quality Assurance and Performance Improvement (QAPI) meetings. He/she stated a lack of VS monitoring and documentation had been identified as deficient in accuracy throughout the 2018 year, 89% accurate as of the second quarter of 2018. He/she further stated that no plan of correction has been implemented to correct this deficiency.

During an interview on 8/30/18 at 3:10 pm, LN #3 stated the standard interval of taking VS during a blood transfusion were: 30 minutes before blood administration, 5 minutes after blood infusion had begun, then at 15 minutes post initial transfusion, every 30 minutes during blood transfusion, and within 30 minutes after transfusion had completed. He/she further stated if VS are not done or missed, the patient's health could be at risk.

LN #3 stated transfusion reaction signs and symptoms are: tachycardia (increased heart rate), feel flushed, fever, BP spike or change from norm, tachypnea (breathing that is abnormally rapid and shallow). He/she further stated the LN is to report to the supervisor or charge nurse and the physician if a reaction occurs.

During an interview on 8/30/18 at 3:25 pm, LN #2 stated he/she does consider blood transfusions a high risk intervention. He/she stated VS should be obtained 10 to 15 minutes prior to blood being given and 15 minutes after blood starts. He/she further stated VS should be taken every 15 minutes for the first hour of the blood transfusion, then every 30 minutes. In addition, LN # 2 stated a set of VS should be obtained once transfusions stops. He/she stated if VS are missed, the patient could receive an injury from the transfusion.

LN # 2 stated transfusion reaction signs and symptoms are: BP will decreased dramatically, shortness of breath, tachypnea, and increased pulse. If these are observed, LN # 2 stated the transfusion should stop and be reported to the house supervisor, pharmacy, and blood bank. An incident report would then be completed. He/she reiterated that abnormal VS are reportable to the supervisor.

During an interview on 8/30/18 at 3:45 pm, the Medical Director stated blood transfusions are high risk interventions to the patients. He further stated that following protocol of taking VS is important because nurses could miss a severe reaction and result in harm for the patient. He stated that doctors should be called if there is a change in VS during a transfusion. He further stated that policies are in place to assure continuity of care for all patients.

During an interview on 8/30/18 at 4:28 pm, the Risk Manager stated there have been no blood transfusion reactions reported by nurses this year. He further stated there have been no investigations in regards to blood transfusions this year.

Review of the facility policy "Transfusion of Blood and Blood Components," last reviewed January 2018, revealed the following:
- G. Pre-Administration: "Take patient's vital signs within 30 minutes before initiating the transfusion and document in the [medical record software] ...Include Temperature, Heart rate, Blood Pressure, and Respiration."

- J. During Administration: "4. Begin transfusion slowly for first 15 minutes. [Registered Nurse] or Provider remains with the patient during this time. 5. Monitor patient status for signs or symptoms which may indicate a transfusion reaction (Breathing effort/quality ...significant change from baseline vitals), retake vital signs 5 minutes and 15 minutes after initiation of transfusion and every 30 minutes during transfusion and document in the medical record. 6. All vital signs, interventions, notifications, etc. Related to the administration of the blood/component are to be documented in the [medical record software] ...signs of volume overload may include the following new symptoms and would require Provider notification: Shortness of breath ... [high blood pressure ... [high heart rate]."

- K. No Transfusion Reaction: "2. Vital signs will continue to be taken every 30 minutes during transfusion. Vital signs will be obtained 30 minutes after the transfusion has completed."

- L Transfusion Reaction - Apparent/Potential: "1. Symptoms of a transfusion reaction may include the following: chills, fever, rash, itching, dyspnea, hypotension ... 2. Stop transfusion immediately if significant change in patient condition or vital signs is noted ... 4. Notify Provider [immediately] of symptoms of transfusion reaction, vitals, and discontinuance of blood/component."

- M Post Administration: "3. If no concern regarding transfusion reaction, take vital signs within 30 minutes after transfusion is complete and do a brief exam including breath sounds (which could indicate fluid overload) ...5. If not stable via exam or vital signs, notify Provider STAT and implement orders - assume patient is having a transfusion reaction and follow policy above related to Transfusion Reaction ...10. An Incident Report is required if: There is an apparent or suspected transfusion reaction ..."

Additional facility policy review revealed a quick reference guides Licensed Nurse's (LN's) use during their shift entitled, "Transfusion of Blood and Components Update: Changes to Blood Administration within [medical record software]," no date, which reads: "Vital Signs - All vital signs must be documented as follows.
- Up to 30 minutes pre-transfusion
- 5 minutes post start of transfusion
- 15 minutes post start of transfusion
- 30 minutes post start of transfusion
- Every 30 minutes thereafter during transfusion
- 30 minutes after end of transfusion

Review of the CDC protocol, "National Healthcare Safety Network Biovigilance Component Hemovigilance Module Surveillance Protocol," dated April 2018, revealed the following complications can occur with blood transfusions:

Hypotension Transfusion Reaction: occurs during or within 1 hour after cessation of transfusion. Drop in systolic BP of greater than or equal to 30 mmHg and systolic BP less than or equal to 80 mmHg.

Febrile Non-Hemolytic Transfusion Reaction (FNHTR): occurs during or within 4 hours of cessation of transfusion AND EITHER fever (greater than or equal to 100.4F) and a change of at least 1.8 F from pre-transfusion value.

Shock: A drop in blood pressure accompanied by a drop in cardiac output including rapid heart rate (increase to 100 beats per minute or more) and rapid breathing.

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Based on record review and interview, the facility failed to demonstrate a mechanism for ongoing reassessment of its discharge planning process to identify preventable re-admissions. This failed practice had the potential to reduce the quality of communication and dialogue about discharge planning which could lead to negative outcomes for patients. Findings:

Record review on 8/30-31/18 of the facility's Quality Assurance/Performance Improvement (QAPI) plan lacked data and/or information about discharge process review for quality purposes.

During an interview on 8/31/18 at 1:20 pm, the facility Risk Manager stated the facility did not perform assessments of readmissions to evaluate whether readmissions were due to discharge planning process failure.

During an interview on 8/31/18 at 1:30 pm, Registered Nurse Case Manager #1 stated the facility made follow up phone calls to discharged patients but there was no formal process for evaluation of effectiveness of the discharge plan process.

During an interview on 8/31/18 at 1:40 pm Medical Records Manager revealed that there was no data tracking or trending on readmissions.

During an interview on 8/31/18 at 2:00 pm, Quality Assurance member #1 (QA1) stated that readmission rates were not tracked. The QAPI further stated QAPI team does not review readmission issues to determine if re-admissions are preventable. When asked where the information could be found, the QA1 stated Medical Executive Committee may discuss readmission data.

During an interview on 8/31/18 at 3:50 pm, the Medical Director (MD) stated the Medical Executive committee talked about discharges to acute facilities and percentage of discharge locations. The MD further stated readmission rates were kept by the MRM.

A review of Medical Executive Committee notes from July 2017 through April 2018, revealed no discussion of readmissions or discharge plan issues that may have prevented readmission.
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