HospitalInspections.org

Based on findings from document reviews and interviews, the hospital's policy regarding the Important Message from Medicare (IM) did not specifically address the Detailed Notice of Discharge which is to be given to medicare patients and/or their representative who have appealed their discharge. Further, in 1 medical record (MR) reviewed there is no evidence the hospital mailed a copy of the first IM to the patient's (Patient A's) representative or provided the second IM (that is required to be given within a specified timeframe prior to the patient's discharge).

Findings include:

-- The hospital's policy and procedure (P&P) entitled "Hand Off Communication 1," dated 11/25/2010, indicated the IM may be delivered via telephone but the notice must be mailed or faxed that same day. Also, although this P&P addressed the IM, it lacked information about the Detailed Notice of Discharge (which must be given when a patient or their representative appeals the pending discharge).

-- Review of Patient A's MR reveals:

** The patient was admitted to the acute care inpatient unit 11/18/11 and discharged to a Swing Bed on 11/25/11. He was deemed not competent to make decisions and had a Health Care Proxy (HCP) as documented by the admitting physician.

** The Care Planner Registered Nurse (CPRN), CPRN #1, stated in a 11/20/11 note "IM delivered to patient's daughter ... via telephone....Advised daughter of right to appeal d/c (discharge), instructions and toll free contact number. IM form left at patient's bedside."

** A copy of the above IM which states "Reviewed via telephone with daughter..." was signed by CPRN #1 in the signature line for the Patient or Representative. It is dated and timed 11/20/11 at 0950.

Patient A's MR lacks a copy of the second IM required to be given within 24 to 48 hours (no less than 4 hours) prior to discharge.

Additionally, the MR lacks evidence that a copy of the first IM discussed with the patient's HCP was mailed to the HCP, as required by hospital policy and CMS (the Centers for Medicare and Medicaid Services) guidelines.

--During interview with the Director, Clinical Resource Management on 4/24/12 at 10:00 am, he/she acknowledged the hospital's policy was not consistent with CMS requirements.

Based on findings from document review and interview, skin care being provided to Swing Bed (SB) patients was not guided by hospital policies that were consistent with generally accepted standards of nursing practice.

Findings include:

-- Per review of the hospital policies entitled "Four Eyed Skin Assessment 1," and "Skin Care Ver 2," each last revised 7/27/11, they lacked:

* definition of a pressure ulcer, as well as description of a valid and reliable risk assessment tool for staff use;

* discussion or description of the required frequency for assessing a patient's risk for pressure ulcer development after the admission assessment;

* identification of and guidance in use of preventative measures (e.g., types of support surfaces, pressure reduction devices) for pressure ulcer development based on risk assessment scores;

* medical record (MR) documentation requirements about the staging and sizing of pressure ulcers;

* accurate guidance and directions for treatment of pressure ulcers; and

* specific criteria for notification of physician, skin care nurse/team and/or ancillary support services (such as dietitians and physical therapists).

Additionally, the hospital policy "Skin Care Ver 2" contains an incomplete chart describing 12 types of dressings (under the section entitled "Skin Care - Wound Stages and Appropriate Dressings"). This chart lacks directions about the circumstances under which the dressings would be used, how often they should be changed, etc. Further, it suggests use of 7 of these dressings for stage 2, 3 and/or 4 wounds without requiring a physician's order or guidance from the certified wound care nurse.

-- Per interview of the hospital Risk Manager on 4/23/12 at 10:35 am, he/she acknowledged the findings above.

Further, based on findings from document review and interviews, in 2 of 3 MRs reviewed (for Patients A and B) the nursing care provided, as documented, did not meet generally accepted standards of care. Specifically, despite the patients' high and moderate risk for developing pressure ulcers (respectively), identified upon admission, nursing staff did not implement all appropriate preventive interventions warranted. Additionally, the nursing documentation in the MRs of Patients A and B was incomplete and did not describe the characteristics of the patients' pressure ulcers and skin tear, respectively.

Specifically, nursing staff did not consistently document the following information:

1) the positions Patient A was placed in when turned and repositioned every 2 hours due to identified high risk for developing a pressure ulcer,

2) repositioning of Patient B every 2 hours as warranted by the patient's risk factors for developing a pressure ulcer,

3) timely use of pressure ulcer preventative measures for Patients A and B as soon as each was identified as being at risk for pressure ulcer development,

4) descriptions & assessments of wound characteristics (size, drainage, status, etc.) and staging of Patient A's pressure ulcer wounds and Patient B's skin tear, and

5) treatment of Patient A's pressure ulcers that was in accordance with the wound care nurse's recommendation.

Findings pertaining to (1) above include:

-- Review of Patient A's MR reveals a physician's order for activity as tolerated. Regardless, Patient A was maintained on bedrest throughout his hospitalization.

Although Patient A was identified as being high risk for skin breakdown during his hospital and swing bed program (SBP) admission assessments, nursing staff did not document the position changes Patient A was placed in when turned and repositioned every 2 hours.

Findings pertaining to (2) above include:

-- Review of Patient B's MR indicates he was identified as a moderate risk for skin breakdown; the nursing care plan identified skin integrity as a concern and listed the intervention of turning every 2 hours.

However, nursing did not document repositioning of the patient during the hospitalization..

Findings pertaining to (3) above include

-- Review of Patient A's MR indicates he was identified as a high risk for skin breakdown on admission to the SBP; he had diabetes mellitus and a prior history of surgical repair for foot ulcers. His nursing assessments identified limited movement in all extremities with hands and legs severely contracted.

Despite these known risk factors, nursing documentation only described intermittent use of spanko boots and indicates an air mattress was not applied to the patient's bed until day 37 of his admission to the hospital. Additionally, there is no documentation of use of padding or other protection for skin pressure points on the patient's severely contracted extremities.

-- Review of Patient B's MR indicates he was identified upon admission to the SBP as a moderate risk for skin breakdown and was incontinent of bowel and bladder. However, nursing staff did not document the use of preventive skin measures related to incontinence (e.g., use of barrier cream) until day 15 of his admission to the swing bed program.

Findings pertaining to (4) above include:

-- Review of Patient A's MR reveals his wounds on admission were described as "buttock red with small open patches on buttock." Throughout the patient's hospitalization and at discharge, this same description continued. Additionally, the nursing documentation indicates that the patient developed:

- a blister on his right 5th toe on 12/7/11,

- an open area as a result of the blister breaking on 12/8/11,

- a blister on the outside of his left great toe on 12/9/11,

- blisters on his right knee and right inner arm on 12/11/11, and

- a blister on his right 4th toe on 12/12/11.

However, the nursing documentation lacked specific description of the wounds, e.g., classification/staging, size in centimeters, presence of tunneling or undermining, peri wound characteristics, quantity and odor of exudates.

-- Review of Patient B's MR reveals that on 3/28/12 nursing documented a skin tear to right foot under the great toe.

However, the nursing documentation lacked specific description of the skin tear (e.g., size, appearance) or interventions for the rest of the hospitalization.

Findings pertaining to (5) above include:

Review of Patient A's MR reveals that on 12/13/11 at 1650 a wound care consult was done due to multiple blisters on his feet. He/She recommended treatment with Aloe Vesta Ointment and keeping the blisters covered with 2 x 2 gauze for protection.

However, at 2230 a nursing note indicates the blistered area had a moderate amount of blood,and that it was cleaned, with Telfa applied, and covered with 4 x 4 gauze. There is no documentation of treatment with Aloe Vesta Ointment.

On 12/16/11, nursing documentation indicates the patient's blister on his right little toe had opened and that "(the) area is covered with Telfa and gauze." There is no documentation of treatment with Aloe Vesta Ointment.

On 12/19/11, nursing documentation indicates the right foot 5th toe blister dressing was changed with triple antibiotic cream. There is no documentation of treatment with Aloe Vesta Ointment or about the type of dressing coverage.

On 12/20/11, nursing documentation indicates that all blisters on the patient's feet were left open to air. Again, there is no documentation of treatment with Aloe Vest Ointment or dressing coverage.

-- During interview of Charge Nurse #1 on 4/23/12 at 12:35 PM, he/she acknowledged the findings above.

Based on findings from document reviews and interview, in 1 out of 1 medical record (MR) reviewed nursing staff did not document anatomical injection sites for administrations of insulin recorded on the Diabetic Record. Additionally, the hospital's policy regarding medications administered intramuscularly or subcutaneously (SQ) did not require documentation of the injection sites used. This lack of documentation can pose a risk of patient harm from nursing staff unknowingly repeatedly using the same injection sites.

Findings include:

-- The hospital policy and procedure (P&P) entitled "Medication Administration Ver 2," last reviewed 10/18/11, states "if injections are given frequently, rotate sites." The policy lacks specific instructions regarding how sites are to be rotated and does not require documentation of each injection site used.

In Patient A's MR the "Diabetic Record" indicates insulin administrations occurred numerous times. The date, time, glucometer results, coverage (in units), route, time and initial of administering person is included on the form. However it does not contain sites of injections. Patient A received insulin SQ 2 to 4 times a day for his entire hospital stay.

-- During interview with Charge Nurse # 1 on 4/23/12 at 12:00 pm, he/she verified that nursing does not document injection sites.

Based on findings from document reviews and interview, in 1 medical record (MR) reviewed, complete documentation of a surgical consultation was not in the MR.

Findings include:

-- Review of Patient A's MR reveals a surgeon performed a consultation evaluation on 12/31/11, and dictated a brief progress note in the MR (indicating a full, consultation note would follow).

-- During interview with the Director of Medical Records on 4/19/12 at 3:30 pm, he/she verified Patient A's MR did not have the full surgical consult note.

Based on findings from document review, interviews and observation, an ongoing activities program was not in place in the hospital's Swing Bed Program (SBP). In 4 of 4 medical records (MRs) reviewed, each lacked documented evidence that an activities assessment was performed, an activities plan of care was developed and/or that the patient participated in planned activities on a periodic/daily basis, as required by both hospital policy and this regulation.

Findings include:

-- Review of the following hospital policies revealed the information noted:

"Swing Bed Admission Process 1," last reviewed 2/1/2011 - it stated "An activity schedule should be posted in patient's room. Consult the activities therapist to review activity assessment ....An activities therapist is available for consultation as needed. Otherwise, each patient will be offered a daily activity of choice and the nurse will chart the patient's choice, the interest level, and the patient's response to the chosen activity on the shift-to-shift assessment.... The Activities Director will complete a patient assessment and give input into the interdisciplinary care plan in respect to diversional and social activity interests."

"Swing Bed Assessment of Patients 1," last reviewed 2/1/2011 - it stated "...an activity plan is developed based on the functional nursing assessment of the patient. Daily, varied activities will be offered to the patient. The chosen activity will be documented on the patient's Swing Bed Flow Sheet....The medical center's activities coordinator will be available for consultation on an as-needed basis as follows: the patient does not demonstrate interest in the activities offered or activity plan of care requires modification for appropriateness as determined by the interdisciplinary team. ....Patient care services will minimally include: assistance and supervision with activities of daily living, daily planned recreational activities..."

Regardless,

-- Per review of Patient A's MR, he was a swing bed patient from 11/25/11 - 1/4/12. There was no evidence that an activities assessment or activities plan of care was completed for Patient A, or that he participated in an activity(ies) during his stay in a swing bed.

-- Per review of Patient B's MR, he was admitted to the swing bed program on 3/21/12. As of the date of this survey, 4/11/12, there was no documentation in the MR regarding an activities plan of care or offer of an activity each day.

-- Per review of Patient C's MR, she was admitted to the swing bed program on 2/3/12. As of the date of this survey, 4/11/12, there was no documentation in the MR regarding an activities plan of care or offer of an activity each day.

-- Per review of Patient D's MR, she was admitted to the swing bed program on 3/8/12. As of the date of this survey, 4/11/12, there was no documentation in the MR regarding an activities plan of care or offer of an activity each day.

-- Per interview on 4/11/12 at 1:15 pm of the staff person identified by the hospital's Assistant Vice President of Patient Services as the Activities Director, he/she stated he/she is not the Activities Director of the Swing Bed Program (SBP) but does assist the SBP when requested. Although he/she does do activity assessments on new admissions to the SBP, there is no follow up with the patients. Additionally, the activities plan for patients on the SBP consists of puzzles & cards for individual use; there are no group activities planned. He/She does not develop an activities calendar.

Also, per interview with Charge Nurse #1 on 4/11/12 at 11:15 a.m., physical and occupational therapies are considered forms of activities; there are no recreational activities offered. The room identified as the Activities Room is not used by patients, and there is no activity schedule to post in patient's rooms. He/she acknowledged there is no formal activities program.

Also, per interview with Patient D, she didn't recall anyone talking with her about activities. She does like to play cards and would enjoy doing so. Further, contrary to hospital policy referenced above, an activities schedule was not posted in the patient's room.

Based on findings from document reviews and interview, in 1 medical record (MR) reviewed facility staff did not provide the assistance requested by a patient (Patient C) in obtaining podiatric and dental services, and did not inform the patient about the hospital's obligation to provide routine dental services to patients in its Swing Bed Program.

Findings include:

-- Per review of Patient C's MR, a note written by the patient's case manager (Care Planner Registered Nurse/ CPRN #2) on 3/22/12 at 1355 indicates he/she spoke with the patient and a friend regarding appointments for podiatry and dentistry. The MR lacks further documentation concerning the appointments.

-- Per interview on 4/23/12 at 2:00 pm with CPRN #2, the patient was informed he/she had to make her own appointments and arrange own transportation for appointments to a dentist or podiatrist, i.e., assistance was not provided. When the hospital's obligation to provide routine dental services was raised during the interview, CPRN #2 did not indicate awareness of the obligation and referred the Department of Health (DOH) interviewer to his/her Director (Director of Clinical Resources).

-- During interview on 4/23/12 at 3:00 pm with the Director of Clinical Resources, he/she was not aware of the hospital's obligation to provide routine dental services until informed by the DOH interviewer.

Based on findings from document reviews and interviews, the facility did not provide the dental services required by this regulation and/or hospital policy to all patients in its Swing Bed Program (SBP). Specifically, in 5 medical records (MRs) reviewed for patients in the SBP (Patients A, B, C, D and E), none contained documentation of an oral assessment within 48 hours of admission, as required by hospital policy. Routine dental services requested by Patient C were not provided. Also, the MR of Patient A, who underwent extractions of numerous teeth during an outpatient procedure at the hospital during his stay in the SBP, lacked a copy of the report of the procedure and lacked the pre- and post-operative instructions/orders in connection with that procedure.

Findings include:

-- The facility's policy and procedure (P&P) entitled "Swing Bed Dental Services 1," last reviewed 2/2011, requires the performance of an oral assessment within 48 hours of admission to the SBP and describes procedures for the provision of emergency and routine dental services to patients in the hospital's SBP.

However,
-- In 5 out of 5 SBP MRs reviewed (for Patients A, B, C, D, and E), all lacked documentation of an initial oral examination following admission to the SBP.

-- Review of Patient C's MR reveals routine dental services requested were not provided to her. See the findings in Tag A1538.

Additionally, during interview of the Assistant Vice President of Patient Services on 4/11/12 at 9:30 am, he/she indicated the facility can make arrangements for patients who request dental services, but the facility does not provide routine dental services to the patients.

-- Review of Patient A's MR reveals he underwent extractions of 28 teeth on 12/28/11 at the hospital's outpatient service. Regardless, the MR did not contain a report of the procedure performed, and lacked documentation of the involved pre- and post-operative instructions/orders for care.