HospitalInspections.org

A. Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure two of two patients (1 and 2) received wound assessments to prevent and treat skin injuries. Findings include:

1. Review of patient 2's medical record revealed:
*He had been admitted to the facility for inpatient rehabilitation on 12/9/21.
*His diagnoses included:
-Left-sided ischemic stroke with right-sided weakness.
-Diabetes, type II.
-A complicated history of cerebrovascular accident (CVA) and left sided weakness.
*A skin breakdown on his left hand and a reddened bottom.
*There was no other documentation to support other areas of skin breakdown upon admission.

Review of patient 2's physician progress notes revealed:
*The following inconsistencies in documentation regarding skin or wound injuries.
-12/10/21, he was noted to have "no lesions or rashes."
-12/11/21, he had "sacral ulcer-wound consulting."
-12/12/21, "Sacral ulcer-wound consulting. skin lesion to scalp-granulated. Skin lesion to left wrist with small amount of serosanguineous drainage-dressing changes daily..."
-12/13/21, "No lesions or rashes."
--These inconsistent entries continued throughout the duration of his inpatient rehabilitation (from 12/9/21 through 2/18/22) stay.
-1/29/22, his Foley catheter could have been trialed out if his sacral wound was doing well enough.
-2/2/22, the Foley was supposed to be discontinued and he should have received straight catheterization every eight hours. This was due to failing the voiding trial two times.
*On 2/2/22, there was also a note that stated, "wound care nurse aware of his penis."

Review of patient 2's wound care notes revealed:
*He had three notes completed by the registered nurse/wound care consultant (RN) W.
*Those three notes stated:
-On 12/13/21, "WOC [wound care] RN consulted regarding skin assessment to be completed. This was done by bedside nursing on admission. Patient has breakdown on left hand. Continue to use foam for protective covering. In addition he has a reddened bottom. Will continue to use barrier cream as patient is incontinent. No orders written. Provider updated. Consult complete."
-On 2/3/22, "WOC RN was asked to see by family regarding patients left big toe and medial ankle area. Left big toe has crusted areas noted on the side. Cleansed this with NS [normal saline] and was able to remove the crusted areas easily. Will continue to keep this clean and covered with a either a band-aid or bordered gauze. Left medial ankle area has an abrasion noted that is superficial. Will keep this covered with foam dressing. Discussed the findings with POA [power of attorney's name] over telephone. Will continue to see weekly and as needed."
-On 2/8/22, "WOC RN assessed left medial ankle and left big toe. Left big toe cleansed with NS and applied a new bordered dressing. Minimal drainage noted. Left medial ankle increased in slough. Will add Medihoney for autolytic debridement. Change this 2x a week. Surrounding periwound is slightly reddened. Will continue to monitor. Heel left boots applied as patient heels are very slow to blanch at this time."
*There had been no mention of the wound on his penis.

Review of patient 2's wound documentation pictures from 12/9/21 through 2/18/22 revealed:
*On 2/2/22, he had a picture taken of the wound on his penis.
*That picture showed an approximate 4 centimeter (cm) slit on the underside of the urethra opening, below the catheter.
-There had not been any other follow-up pictures of his penial wound from 2/2/22 through discharge on 2/18/22.

Review of patient 2's wound care flow sheets from 12/9/21 through 2/18/22 revealed:
*He had never had any treatments or documentation initiated for the wound on his penis.
*He had other skin variances listed as:
-"Coccyx erythema [rash]."
-"Scrotum erythema."
-Left hand.
-Left medial ankle.
-The assessments for the above items had many incomplete assessments.
*The left medial ankle had 4 out of 131 opportunities.
*The left hand had 2 out of 131 opportunities.
*There had been 44 missing Braden assessments from 12/9/21 through 2/18/22.
-Braden skin assessments were to be completed every day.
-His Braden scores ranged from 13 to 16, meaning he was at risk for skin breakdown.

2. Interview on 4/4/22 at 2:10 p.m. with patient 1 regarding skin injuries revealed:
*She had areas on her lower legs that were really bothering her.
*She stated:
-There were blisters on her lower legs.
-She believed these were caused from the socks they had her wearing.

Review of patient 1's medical record revealed she:
*Had been admitted for inpatient rehab on 3/27/22.
*Had diagnoses of:
-Stage IV chronic kidney disease.
-Anemia.
-Chronic congestive heart failure.
-Generalize weakness and deconditioning.
-Diabetes.

Review of patient 1's wound care from 3/25/22 through 4/5/22 revealed:
*She had one wound note dated 3/28/22, which stated:
-"WOC RN consulted regarding skin assessment to be completed. This was done by bedside nursing on admission. Patient does have stage I pressure ulcer coccyx POA [present on admission]. Will continue to offload, reposition for treatment. If patient is incontinent, use barrier cream for protection. Patient arrived with bilateral compression wraps. Removed these and no wounds noted on the legs. Applied lotion to the legs and used ACE wrap figure 8 for slight compression. Will take these off at night while patient is laying in bed and reapply in the morning..."
*There had been no other wound care notes regarding the development of the lower leg blisters or worsening of the lower legs.

Review of patient 1's wound care flow sheets from 3/25/22 through 4/5/22 revealed:
*A blister had been noted on 3/30/22.
-That had been the first entry on the patient's lower legs.
*Out of 19 entries, she had been missing 14 skin assessments.
*She had 7 Braden skin assessments missing.
-Her Braden score had ranged from 18 to 16, which meant she was at mild risk for skin breakdown.
*Her coccyx wound had 2 out of 14 assessments completed.

3. Interview on 4/7/22 at 8:10 a.m. with chief nursing officer (CNO) B and wound care RN W revealed:
*Wound care RN W documented her notes from of the bedside nurse's assessment.
*RN W would make a wound note on every patient admitted to the facility.
*RN W had not been made aware of patient 2's penis wound.
-A wound variance should have been initiated so staff could document their assessments once per day.
-She agreed a wound variance had not been completed.
*RN W had been educating new nurses regarding wounds including documentation of the wounds.
*RN W agreed wound flow sheets should have been filled out each day.
*The Braden's were updated every day, the Braden assessments were what she followed each morning.

4. Review of the provider's August 2021 Wound Assessment and Documentation policy revealed:
*The three general categories of wounds mentioned in the policy were:
-Pressure injuries/ulcers.
-Procedure-related wounds.
-Other alterations in skin integrity.
*"All patients admitted to the hospital would be screened within 8 hours for risk of skin breakdown and for alteration in skin integrity by a registered nurse. For a Braden score of 18 or less, the Pressure Injury Prevention Protocol will be initiated and incorporated into the plan of care. Each patient's wound care will be under the direction of a physician."
*"An RN will inspect each patient's integument [skin] daily and as often as indicated."
*"The Braden Scale is used to assess all patients for risk of skin breakdown. Findings are recorded upon admission and weekly at a minimum."
*"Pressure injuries/ulcers are noted in the record upon discovery (either upon admission or throughout stay)."
*"A full skin assessment is completed within 8 hours of admission (or discovery of a new wound) to include descriptions, measurements, and physician notification (as applicable). Additionally, second assessment by a licensed professional qualified to assess wounds will be completed within the same 8 hour period."
*"Photographs, if required may be taken at the time of admission but not later than 24 hours from admission. This will aid in communication with the treatment team prior to staging determination."
*"Wounds will be staged by designated clinicians within 2 days after discovery. For example, a wound discovered on Monday must be staged by the end of the day on Wednesday. The hospital will designate wound staging staff in sufficient numbers to meet patient care needs..."
*"Pressure injuries/ulcers will be staged, measured, and photographed in accordance with the wound treatment plan but no less than weekly."
*"Skin tears, procedure-related wounds, traumatic wounds, or lower extremity ulcers are not staged. These types of alterations in skin integrity should be described, measured, and photographed as addressed further in this policy."
*"Daily documentation of skin and wound inspection completed by an RN will include the following, if present:"
-"skin condition."
-"dressing integrity."
-"description of wound drainage, odor, pain, signs of inflammation or infection, if present."
*"The physician assumes leadership over clinical interventions and wound care treatment. This may involve the use of protocols previously established by the hospital's medical staff, which may be initiated by the WCC [wound care coordinator]..."
*"The Wound Care Coordinator (WCC) has responsibility for oversight of the wound program, This includes review and recommend wound prevention techniques and wound care protocols, training of designated wound stagers, assessment and care of complicated wounds, record reviews for accuracy of documentation, and education of staff in all topics related to wound prevention and care."

5. Review of the Wound Care Coordinator's job description revealed:
*"The Wound Care Coordinator directs, organizes, and develops all wound care services in accordance with applicable federal, state, regulatory, and company standards to ensure the delivery of quality patient care is rendered at all times, and that the plan of care and physician orders are followed with regard to wound care treatments. This position functions independently, demonstrates above-average communication skills and personal integrity, and works effectively with patients, family members, physicians, staff, and outside agencies as required. The Wound Care Coordinator leads hospital wound education efforts, as well as educated patients and family members on wounds and wound care topics. While this position does not specifically supervise clinical staff, as the leader of the wound care program in the hospital, this person does direct clinical teams on wound care treatment. This position required continuous updating of education and treatment techniques in the delivery of wound care."
*The wound care nurse would:
-Complete wound assessments.
-Identify, stage, and record wounds as required.

B. Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure:
*One of five sampled patients (1) received insulin as prescribed by the physician.
*One of five sampled patients (3) received mildly thickened liquids per the physician's diet order.
*One of five sampled patients (4) was administered warfarin (a blood-thinning medication) as prescribed by the physician.
Findings include:

1. Review of patient 1's medical record revealed:
*She had received insulin every night at bedtime and another form of insulin three times per day depending upon glucose levels.
*Patient 1 had not received her bedtime insulin dose on 3/29/22.
*A nurse's note which stated:
-"Not Given: no needles available."
*The next day on 3/30/22 she had elevated blood glucose readings of:
-Morning glucose before breakfast was 297.
-Lunch glucose was 327.
-Dinner glucose before meal was 416.
-Glucose was rechecked at 8:57 p.m. and her blood glucose reading was 423.
--The RN on duty called the on-call doctor to report her blood glucose reading of 423.
*There had been no notes in patient 1's medical record to indicate:
-The physician had been notified when her blood glucose reading was 416 at 4:37 p.m.
-The physician, pharmacist, or POA [power of attorney] had been notified when her insulin was not given due to "no needles available."

On 4/6/22 a telephone interview was attempted with licensed practical nurse (LPN) K regarding the insulin that had not been administered to patient 1. Surveyors were unable to reach her by telephone.

2. An interview on 4/6/22 at 3:23 p.m. with CNO B and pharmacy director I regarding patient 1's insulin revealed:
*They had not realized the situation with patient 1's insulin had occurred.
*They agreed insulin pens come with needles.
*The needles had been available.
*The expectation was:
-LPN should have called the pharmacist on call.
-There were needles in the PYXIS [automated medication dispensing system] that LPN K would have been able to use.
-The physician also should have been made aware.
*Pharmacy director I and CNO B confirmed no one had been contacted regarding this situation.

3. Review of patient 3's medical record revealed:
*An admission date of 3/31/22.
*Swallow status on admission was "modified food consistency/supervision."
*The registered dietitian's nutrition assessment indicated:
-He had a history of tube feeding at home.
-Nutritional risk factors of difficulty swallowing.
-Diet orders: Liquid consistency of level 2 - mildly thick.
*A 4/3/22 at 5:52 a.m. nursing progress note:
-"Writer noted OJ at [the] bedside that was not correct thickness. OJ discarded and appropriately thickened liquids were given for the rest of the shift."

Review of patient 3's Interdisciplinary plan of care (IPOC) updated on 4/1/22 had not included any swallowing or diet interventions.

4. Review of patient 4's 4/4/22 at 1:53 p.m. omitted warfarin dose investigation revealed:
*The event occurred on 4/3/22 at 8:20 p.m.
*The physician was notified on 4/4/22 at 9:57 a.m.
*Therapy brought registered nurse (RN) R a pill that was found in patient 4's wheelchair. The pill was a 2 mg warfarin pill from the previous shift. The pill was not wet and did not appear to be spat out as there was no degradation of the pill. LPN S had signed off that she gave the 2 mg warfarin at 2020 [8:20 p.m.]. RN R notified nurse supervisor RN T and disposed of the pill in the med [medication] room. RN R also notified medical doctor (MD) U right away who requested that RN R notify pharmacist. RN R spoke to pharmacist V in the pharmacy at 1000 [10:00 a.m.]. INR [international normalized ratio] was 2.3 this morning. No new orders at this time.
-warfarin was marked as a high alert medication involved.

Review of patient 4's medical record revealed warfarin 2 mg had been documented as being administered on 4/3/22 at 8:20 p.m.

Interview on 4/5/22 at 10:40 a.m. with pharmacy director I regarding the omitted warfarin revealed:
*She had been made aware of the omitted warfarin dose for patient 4.
*She was involved with medication errors.
*They were reviewed quarterly at the Quality council meeting.

Interview on 4/6/22 at 1:47 p.m. with interim administrator A and Quality/Risk director C regarding follow-up to incident reports revealed whoever was involved in the incident was responsible to fill out the incident report form.

Interview on 4/6/22 at 3:05 p.m. with doctor of osteopathic medicine (DO) G revealed he thought warfarin was a high risk medication.

5. Review of the provider's June 2021 Sentinel Events policy revealed:
*"The hospital recognizes that all unanticipated adverse outcomes require some level of investigation and evaluation. However, the hospital further acknowledges that certain events such as sentinel events, signals the need for prompt in-depth investigations. The purpose of this policy is to establish a process for identifying and reporting sentinel events and distinguishing those sentinel events that are subject to review by the Home Office Quality & Clinical Excellence and Risk Management staff..."
*Patient safety events were defined as:
-"Sentinel Events are one category (or subset) of patient safety events. A patient safety event is an event, incident, or condition that could have resulted or did result in harm to a patient. A patient safety event can be, but is not necessarily, the result of a defective system or process design, a system breakdown, equipment failure, or human error. Patient safety events also include adverse events, no-harm events, near misses or unsafe conditions which are defined for the purposes of this policy as follows..."
-"Delay in care and/or requires additional medical services as a result of staff failing to follow standard procedure."

6. Review of the provider's June 2021 Medication-Event Reporting policy revealed:
*"When a potential or actual medication event occurs, a specific procedure will be followed to ensure the safety of the patient and provide accurate documentation of the occurrence. The procedures for reporting a medication event and the mechanism for multi-disciplinary review to allow appropriate follow-up and implementation of change to prevent future medication events are outlined."
*"A medication event is any event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, or patient. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use."
*The following steps should have been taken when an event had been discovered:
-Notification of supervisor.
-Patient should have been observed for signs of adverse effects.
-Physician would have been notified.
-Patient treatment interventions would have been ordered.
-An event report would be completed and would have been followed up on.

C. Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure three of five patients (1, 2, and 6) had received grooming and bathing to promote well-being and quality of life since admission. Findings include:

1. Review of patient 1's bath records revealed:
*She had received a modified bath on 3/28/22.
-She had received a bath on 4/5/22, the day she was discharged home.

Interview on 4/4/22 at 2:10 p.m. with patient 1 in regards to bathing revealed:
*She stated nursing would come by and tell her they would give her a bath.
-Then therapy would also come by and say they would be giving her a bath.
-She had received one bath from 3/25/22 through 4/4/22 and would really like to receive a bath.

2. Review of patient 2's bath records revealed:
*He had received 22 bed baths during his 71 day stay at the hospital.
-He received 1 shower on the day of discharge.
-He had 4 documented bath refusals.

3. Observation on the following dates at the following times of patient 6 revealed on:
*4/4/22 at 3:15 p.m.:
-He was lying in bed.
-He had a large amount of facial hair.
-Rehab nursing technician (RNT) L came in to assist him and did not offer to shave him or ask if he wanted to be shaved.
*4/5/22 at 8:25 a.m.:
-RNT M had come out of his room.
-He had finished up with breakfast and she had laid him down.
-He had increased facial hair from the 4/4/22 observation.
*4/5/22 at 9:15 a.m.:
-RNT M and N had assisted patient 6 with removing a bed pan.
-He had facial hair.
*4/6/22 at 10:40 a.m.: he was in the therapy room and had not been shaved.

Interview on 4/6/22 at 4:35 p.m. with RNT O regarding patient 6's ability to shave independently revealed they usually shaved him.

Review of patient 6's medical record revealed:
*An admission date of 2/22/22.
*Diagnoses of stroke with right sided weakness.
*He was receiving physical therapy, occupational therapy, and speech therapy.
*There was no documentation if he had been offered to shave or had refused to be shaved.

Interview on 4/4/22 at 3:40 p.m. with interim administrator A and CNO B regarding patient 6 revealed:
*He was dependent with activities of daily living.
*Her expectations were if he wanted to be shaved, he should be.
*He needed to let the staff know if he wanted to be shaved.
*They could not force a patient to be shaved.
*Best practice was to document if he was or was not shaved and why.

On 4/5/22 at 4:10 p.m. a bathing policy had been requested from interim administrator A. Interim administrator A stated they did not have a bathing policy.

Interview on 4/6/22 at 3:30 p.m. with director of therapy operations H regarding patient grooming revealed:
*It would depend on the patient's goals if grooming was part of their therapy program.
*Patient 6 would fluctuate in what he could do with his upper extremities. Some days were good, and some days were bad.

Interview on 4/6/22 at 4:40 p.m. with interim administrator A and CNO B regarding bathing and grooming:
*There was no set standards for bathing. It varied from patient to patient.
*She did not expect her staff to shave the patient. If he wanted to be shaved or asked, they would have shaved him. They did not make him get shaved.

Interview on 4/7/22 at 9:15 a.m. with interim administrator A, CNO B, and quality/risk director C regarding bathing of patients revealed:
*They had felt they were overseeing the bathing process.
*Patients could request a bath at any time.
*They agreed with surveyor patients might not be aware they can request a bath.
*They have no standard for the number of baths a patient should receive.
*They agreed it is a patient's right to receive a bath.

4. Review of the Rehabilitation Technician's job description revealed:
*"The rehabilitation Technician I assists rehabilitation nurses and/or therapists with rehabilitation treatment and patient care according to hospital, state, professional, and federal regulations and guidelines. In addition, the position requires effective communication skills for working with patients, families, and caregivers; requires competency in assisting with delegated rehabilitation treatment and patient care; performs tasks as delegated by and supervised by rehabiliation nurses and/or therapists..."
*They would assist patients with tasks such as:
-Dressing, grooming, bathing, eating, toileting, and mobility.

D. Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure investigations had been thoroughly conducted for incidents involving two of two sampled patients (3 and 4). Findings include:

1. Review of patient 3's 4/2/22 at 6:20 p.m. incorrect diet investigation revealed:
*"Informed during report this morning that patient had received thin liquids on Saturday, April 2. Further informed patient's nurse, [name of licensed practical nurse (LPN) P], had reported to night shift that patient was able to have thin liquids and given to patient. After report, night nurse [name of nurse/Q], double checked orders and noted patient to be on mildly thick liquids. when night nurse walked into patient room, noted 2 glasses of thin liquid orange juice on patient bedside table. These were removed. [Name of nurse/Q], then assessed patient lung sounds and noted to be slightly wet. Continued to monitor patient into Sunday. On Sunday, noted patient lung sounds to have improved."
*The physician was contacted on 4/4/22 at 8:32 a.m.
*There was no documented follow-up investigation.

2. Review of patient 4's 4/4/22 at 1:53 p.m. omitted warfarin dose investigation revealed:
*The event occurred on 4/3/22 at 8:20 p.m.
*There was no documented follow-up investigation.

Interview on 4/6/22 at 3:25 p.m. with CNO B regarding the investigation of the omitted warfarin revealed:
*She had not had time to do any investigation to the omitted warfarin due to surveyors had been in the building.
*She was responsible with conducting the investigations and did not have a designee to assist her.
*She had not talked to the staff member regarding the omitted warfarin.

Interview on 4/7/22 at 10:05 a.m. with interim administrator A, CNO B, and quality/risk director C regarding the above investigations for patients 3 and 4 revealed:
*They had not had time to review any of their incident investigations.
*CNO B had not been able to review the investigations.
-Her expectations with medications were for the staff member to remain with the resident until it had been taken, then sign off as having been given.
*The thorough investigation goal was to have been completed within fifteen days.
*They had a medication event team.

Review of the provider's June 2021 Medication-Event Reporting policy revealed:
*The following steps should have been taken when an event had been discovered:
-Notification of supervisor.
-Patient would have been observed for signs of adverse effects.
-Physician would have been notified.
-Patient treatment interventions would have been ordered.
-An event report would have been completed and would be followed up on.

E. Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure three of three sampled patients (1, 2 and 7) and their representatives had the opportunity to participate planning their care. Findings include:

1. Interview on 4/4/22 at 2:10 p.m. with patient 1 regarding her involvement in her care revealed:
*They do not invite her or her husband to her care conference or plan of care meetings.
*She would like to attend.

Review of patient 1's IPOC revealed:
*The only mention of her skin issues was:
-"At Risk for Skin Breakdown. Last update date 3/27/22."
*There had been no revisions after her blisters developed.
*There had been no mention of her bathing preferences.

2. Review of patient 2's IPOC revealed:
*His patient and caregiver goals had not been updated since the day after his admission on 12/10/21.
*His wounds had not been mentioned on his IPOC.
-The IPOC mentioned he was at risk for skin breakdown.

3. Interview on 4/4/22 at 2:45 p.m. with patient 7 revealed:
*They had care conference, but she had not been involved.
*Someone would let her know what changes were made with her medications and/or therapy.
*She was not to have any weight bearing on her right foot.
*She planned to be discharged home in the next 48 hours.
*She knew she would go home with the wound vac and the peripherally inserted central catheter (PICC) line infusions.

Review of patient 7's medical record revealed:
*An admission date of 3/26/22.
*A discharge date of 4/5/22.
*Diagnoses of type II diabetes mellitus, hypertension, chronic kidney disease stage 3, osteomyelitis,and fifth toe right foot amputation.
*She had a wound vacuum to her right heel.
*She received antibiotics through a PICC line.
*She had been started on vancomycin (an antibiotic) on 4/2/22 due to suspicion of cellulitis.

Review of patient 7's IPOC revealed it had not included interventions or goals for a wound vac or antibiotic treatment.

F. Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure two of two sampled patients (5 and 6) had interdisciplinary plans of care that were centered around the patient's goals and preferences. Findings include:

1. Review of patient 5's medical record revealed:
*Admission date of 3/31/22.
*Diagnoses of COVID myopathy, deconditioning, uremic myopathy, dysphagia, hypoxia, atrial fibrillation, deep vein thrombosis, pulmonary emboli, and respiratory failure.
*He had a feeding tube, a catheter, and used oxygen.
*He was dependent with activities of daily living.

Review of patient 5's IPOC revealed it had not included interventions or goals for a feeding tube, catheter and oxygen.

2. Review of patient 6's medical record revealed:
*An admission date of 2/22/22.
*Diagnoses of stroke with right sided weakness.
*He was receiving physical therapy, occupational therapy, and speech therapy.
*There was no documentation if he had been offered to shave or had refused to be shaved.
*He was dependent on the staff for activities of daily living.

Review of patient 6's IPOC revealed it had not included interventions or goals for shaving.

3. Interview on 4/6/22 at 1:03 p.m. with case manager (CM) E and CM director F regarding resident IPOCs revealed:
*Each CM had a patient assigned to them.
*It was the CMs responsibility for the IPOC.
*The physician signed it after he reviewed it.
*The IPOCs were not updated.
*Updates were found in the progress notes.
*"It is an all encompassing care plan."
*They did not do care plans.
*Nursing passes off information in a separate report to the nursing staff.
*They did have team conferences every seven days.
*They document in the case management notes.
*Patients did not attend the care conference.
*IPOC goals were updated in the therapy notes, IPOCs were written upon admit and then not updated.

Interview on 4/6/22 at 3:05 p.m. with DO G revealed he reviewed the IPOCs daily and signed off on them.

Interview on 4/6/22 at 4:00 p.m. with CM director G and interim administrator A regarding IPOCs revealed:
*They did not have traditional care plans.
*There was no nursing care plan.
*Nurses put their information into the IPOC and team conference notes as care provided progresses.
*The IPOC was updated weekly in team conference.

Interview on 4/6/22 at 4:20 p.m. with CNO B and interim administrator A regarding the IPOCs program revealed:
*"All the documents feed into a summary."
*Each nurse tech had an iPad and care tracker they used to care for the patients.

Review of the provider's August 2021 Care Planning policy revealed:
*"Care planning involves planning for patient's needs from the perspective of the patient and caregiver and includes but is not limited to physical needs, cognitive needs, functional needs and the potential limitations from co-morbid [multiple] conditions."
*"The RN will initiate the IPOC within 24 hours of admission of each patient. The evaluating interdisciplinary team (IDT) and rehab physician will complete the IPOC following patient assessment, by day 4."
*"IDT members have the primary responsibility for completion of the IPOC including goal setting as per their discipline and area of expertise."
*"IDT will document the patient/family goals."
*"Each body system or functional area with identified problems will be followed by specific interventions by specific interventions designed to meet the needs of the patient."
*"IDT will initiate all applicable interventions."
*"Long Term Goal (LTG's) are identified by IDT for each problem area and are established with input from the patient/family. Short term Goals (STG's) for each week will also be set."
*"Following completion by the IDT, the rehab physician will review the IPOC, make recommendations as needed, complete, approve the plan, and sign and date the form by day 4."
*"The plan must include anticipated interventions including physical, occupational, speech-language pathology, and prosthetic/orthotic therapies required by the patient during the inpatient rehabilitation stay including..."
*"The case manager (CM) will review the completed IPOC with patient/family. CM will authenticate the IPOC including indicating it was reviewed with the patient and/or care plan."
*"New STG's or adjustments to LTG's are prepared for team conference for the following week, by noon the day prior to team conference. Appropriateness of goals are reviewed at team meeting, new interdisciplinary interventions are discussed and added to the IPOC as indicated by team members."
*"Updates to the IPOC are documented in the plan. Any new problems or interventions are identified and initiated. Any completed or discontinued interventions are documented."

Review of the CEO's job description revealed:
*"The Chief Executive Officer is responsible for all day-to-day operations of the hospital. This position is accountable for planning, organizing, and directive the hospital to ensure quality patient care is provided and the financial integrity of the hospital is maintained. The CEO ensures compliance with all applicable laws, regulations, policies, and procedures set forth by the Governing Board and Medical Staff, as well as Joint Commission standards."
*"The CEO is responsible for creating an environment and culture that enables the hospital to fulfill its mission by meeting or exceeding its goals, conveying the hospital mission to all staff, holding staff accountable for performance, motivating staff to im

Based on interview, record review, review of anonymous complaints received by the South Dakota Department of Health (SD DOH), policy review, and job description review, the provider failed to ensure:
*One of five sampled patients (2):
-Had an effective transition from the hospital to post-discharge care to ensure the patient's goals and the patient's support person/representative's goals had been met.
-Discharge plans were consistent and focused on the patients' goals and treatment preferences.
-Included the patient's support person/representative in discharge planning.
-Re-evaluation of patient 2's condition to identify changes for modification of the discharge planning.
*The discharge planning process was evaluated on a regular basis by reviewing a representative sample of closed records to identify effectiveness if the plan, the provider's responsiveness to patients' post-discharge needs, and modify the discharge process based on identified trends.
*Transportation options had been thoroughly investigated to ensure two of two patients' (1 and 2) discharge plans were patient centered.
Findings include:

1. Review of anonymous complaints received [time withheld due to anonymity] by SD DOH revealed:
*Patients were being discharged to incorrect level of care.
*Patients were being accepted for rehabilitation and charged for transportation home.
*There were issues with care being provided to patients.

Review of patient 2's medical record revealed:
*He had been admitted to the facility for inpatient rehab on 12/9/21.
-He had been admitted from a swing-bed hospital.
*His diagnoses included:
-Left-sided ischemic stroke with right-sided weakness.
-Diabetes, type II.
-Complicated history of cerebrovascular accident (CVA) with left side hemiparesis (weakness).

Review of patient 2's Case Management (CM) notes revealed:
*On 12/9/21:
-He lived in a multi-level home, with internal and external stairs.
-Barriers to discharge were home environment, medical issues, and many medications.
*On 12/15/21:
-"...current barriers include patient requires substantial assistance for bathing and to propel the wheelchair, partial assistance for upper body dressing, and is dependent for bed mobility, toileting and transfers..."
*On 12/28/21:
-"...Discharge plan is currently LTC [long term care]. Discussed with patient I will start the referral process for LTC. Patient verbalized understanding. Call to [power of attorney's name (POA)]. Same items discussed. [POA's name] is unable to help patient transfer at this time..."
*On 1/3/22:
-CM notes stated they had called four LTC facilities. Three were accepting referrals and a message was left with the fourth facility.
-CM stated they would send referrals the next day (1/4/22).
*On 1/11/22:
-"...Discussed with [POA's name] that patient is still dependent for transfers and most self care tasks. [POA's name] stated at this time she is not able to provide that amount of care to patient. Reassure [POA's name] that we will continue to work to get patient to a nursing home..."
-There had been no specific updates in the note regarding the LTC facilities that had been called or an updated status.
*On 1/14/22:
-They were going to expand referrals to 100 miles around his residence.
-Ten LTC facilities had been listed with their current referral status.
*On 1/25/22:
-"...Current barriers include: dependent for transfers, dependent to max assist for ADL's [activities of daily living], awaiting facility placement.
*On 2/17/22 the appeal was denied.
*On 2/18/22:
-"...Discussed plan for discharge home with home health today. Notified them [transportation company name] will provide transportation today at 1300 [1:00 p.m.]. Requested [POA's name] to call and pay for the transportation, contact information provided. [POA's name] verbalized understanding. Notified them patient prescriptions have been sent to [pharmacy name and location]. Notified them the hoyer [Hoyer] will be delivered from [provider's name]..."
*There ended up being thirteen LTC facilities had been called, those:
-Thirteen had not been updated since 1/25/22.
*There was no further documentation to show attempts were being made daily to find LTC placement or find out updated information.

Review of patient 2's physician discharge progress notes dated 2/18/22 revealed:
*"Patient is evaluated today for rehab services. Patient going home with family today due to insurance. Family or significant other is very worried about caring for him at home. Patient making progress with therapy by ambulating in wheelchair further than he has ever before..."

Interview on 4/6/22 at 8:06 a.m. with interim administrator A, chief nursing officer (CNO) B, and quality/risk director C revealed:
*Typically, two staff used a Hoyer lift to transfer patients but they left it up to the staffs' professional judgement on using one or two staff members.
*CNO B stated best practice would be for staff to use two staff members when completing patient transfers.
*They had done family training for Hoyer lifts.

Interview on 4/6/22 at 1:02 p.m. with CM E and CM director F revealed they can do extended stays if the patient is still making progress.

Interview on 4/6/22 at 1:31 p.m. with CM D and CM director F regarding patient 2 revealed they:
*Had not felt a swing-bed facility would be a good option for him.
*Typically, had not discharged patients to swing-bed facilities.
-A swing-bed facility was a "lateral move" and "why would they send a patient to a place that offers the same services that they do."
*Were forced to send him home since insurance denied continuing therapy.
-He often refused therapy; it would be documented in his therapy notes.
*Were paid as a bundle payment based off of a patient's diagnosis.
*Agreed patient 2's wife was not comfortable providing care for him at home.
*Had not talked to the physician regarding being unable to get him into the nursing home.
*Had not arranged a meeting between the patient, their representative, and the physician.
*CM D confirmed:
-Patient 2's house had no stairs, and the basement was at ground level where he would stay.
*Were unsure if it would be safe for one person to use the Hoyer to move patient 2.
-CM D was unsure if patient 2's house had carpet.
--She acknowledged a Hoyer lift could be difficult to move on carpet.
*They tried to follow-up nursing home referral calls daily and they had documented those calls.
*Surveyor had requested a details regarding days and times that nursing homes were called for patient placement.
-Survey team had received no additional details regarding patient placement by the end of the survey on 4/7/22 at 12:00 p.m.

Interview on 4/6/22 at 3:02 p.m. with doctor of osteopathic medicine (DO) G regarding patient 2 revealed:
*He was not meeting insurance's therapy goals.
-Insurance had stopped paying for his stay.
*They would be able to use a swing-bed facility.

Interview on 4/6/22 at 3:31 p.m. with director of therapy H regarding patient 2 revealed:
*They were getting some rehab return from patient 2 but not what they should have been getting.
*He:
-Required extensive assistance from staff.
-Required a lot of assistance for self-care.
-Had been able to propel himself in his wheelchair.
*She had not recalled if patient 2 refused therapy but if he did it was not very often.

Interview on 4/6/22 at 4:32 p.m. with rehab nursing technician (RNT) O revealed they always used two staff members for a mechanical lift.

Interview on 4/7/22 at 9:15 a.m. with interim administrator A, CNO B, and quality/risk director C revealed:
*Interim administrator A had expected case management to follow-up with nursing homes regarding placement.
-They left it up to case management regarding the frequency.
-They did not have a specific policy related to that.
*Patient 2 was sent home because they were not able to find nursing home placement.
*Her expectation was for staff to find nursing home placement the patient was satisfied with.
*When asked if interim administrator A had ever talked to patient 2 and his wife regarding their concerns, she stated:
-She had stopped by his room on the day of his discharge.
-Patient 2's wife had voiced concerns regarding discharge.
-His wife had questions and concerns regarding; transportation, transferring, medications, etc.
-She felt the patient and his wife needed someone to show compassion and listen.
*They had not initiated a grievance or concern form related to patient 2's wife's concerns.
-She could not recall specifics but had not felt there was anything that needed to be looked into.
*Interim administrator A had felt that sending him home was a safe discharge plan, and everything was appropriate.

Review of the provider's 2/18/22 physician discharge summary for patient 2 revealed:
*He had been admitted to the hospital for intensive inpatient rehabilitation.
*"...The patient participated in rigorous physical, occupational and speech therapies. In addition the patient received a higher rest quality nursing care and oversight by wound care nurse. A hospitalist oversew [oversaw] all chronic and acute medical conditions for the duration of the patient's stay. The patient was seen by rehab physician more than 3 times per week to maximize the benefits of therapy while the patient was at [hospital name]. The patient progressed well and was stable for discharge..."
*The discharge summary made note of the wound on his penis and that wound care nurse was following for that. Refer to A 385, finding 1.
*He had been discharged home with a Hoyer lift.
*Potential complicating risk factors were mentioned as:
-"Comorbid condition uncontrolled (CHF [congestive heart failure], COPD [chronic obstructive pulmonary disease], Asthma, Diabetes, etc.), High Fall risk, Polypharmacy (more than 8 routine medications)."
*Occupational therapy limitations included:
-"Balance deficits, Coordination deficits, Impaired activity tolerance, Decreased knowledge of equipment use, Mobility deficits, Range of motion deficits, Strength deficits."
*In order to toilet his caregiver would need to use the Hoyer lift or place the resident on a bedpan.

2. Interview on 4/4/22 at 2:10 p.m. with patient 1 revealed she:
*Had been transferred from a hospital in Rapid City, SD.
-She had concerns regarding transportation since her spouse was in a wheelchair.
-She was informed transportation would be arranged to get her to Sioux Falls and back to Rapid City.
*Was now being informed in order to get back to Rapid City she would have to pay $900 for a ride home.
-The money would have to be paid up front.

Interview on 4/6/22 at 1:02 p.m. with case manager (CM) E and CM director F regarding transportation for patient 2 revealed:
*The patient was responsible for the ride home if they had private insurance.
*The hospital in Rapid City provided the ride here and they would not cover the ride home.
*They called their contact person at a local transportation company and he usually provided the rides.
-They had not called other transportation companies to find out additional quotes for the ride back to Rapid City.
*The facility had a transportation van but due to staffing they did not use it very often.
-Their van was usually used to transport patients around town.

Interview on 4/6/22 at 1:31 p.m. with CM D and CM director F revealed:
*He was unable to be transported in his family representative's car due to being a Hoyer lift.
*They called their contact person at a local transportation company and would have to pay $600 for transportation home.

Interview on 4/7/22 at 9:15 a.m. with interim administrator A, CNO B, and quality/risk director C revealed:
*Interim administrator A had no expectations regarding calling transportation companies.
-Her only expectation was patient's having a safe transport.

Further interview on 4/7/22 at 10:35 a.m. with interim administrator A, CNO B, quality/risk director C, and CM director F revealed:
*CM director F stated:
-It was not a requirement for them to review or check with different transportation companies regarding finding the most cost-effective transportation method.
*They acknowledged why it may bother patients.
*When asked by surveyors if they had initiated a grievance or concern related to these issues they stated they had not but they could.

On 4/6/22 at 12:30 p.m. surveyors had requested the provider's transportation policy from interim administrator A. She confirmed they did not have a policy related to transportation.

3. Review of the provider's November 2021 Patient Rights and Responsibilities policy revealed:
*"To communicate and inform patients of their rights as a patient during their stay at the hospital, and to provide an organization-wide statement regarding the patient's rights, responsibilities, and their proper implementation."
*"Administrative Leaders and Medical Staff shall be responsible for assuring that "Patients' Rights and Responsibilities are observed and practiced throughout the hospital."
*"It is the policy of the hospital to at all times, and in accordance with applicable state and federal laws and regulations, observed and respect a patient's rights and responsibilities without regard to age, race, color, gender, national origin, religion, culture, physical or mental disability, personal values or belief systems:

Review of the provider's undated Wellness Information and Tools for Health (WITH) book provided to patients upon admission revealed:
*Their mission was:
-"...to take exceptional care of people by providing world-class rehabilitation services delivering care in a compassionate, respectful and responsible way and helping our patients live their lives to the fullest extent of their disabilities."
*Transportation statement:
-"If, during your hospital stay, you have an outside appointment that is required by your [provider's name] physician, we will arrange transportation services. Your family members will be told of the appointments so they can come with you if they wish. Family members are not usually asked to provide transportation to medically necessary appointments outside appointments without approval from your physician and therapists. Your therapists would need to decide if you and your family can safely transfer in and out of the car. For outside appointments, such as dental visits, hair appointments, or social visits that are not medically necessary; we ask that they be rescheduled for after you are discharged from the hospital to prevent any possible delays in your care or insurance issues. Your case manager can provide additional information regarding this policy."
*The day of discharge:
-Team members would make sure the patient was ready for discharge.
*Patient rights included:
-Communication, which included a prompt resolution of patient grievances.
-Informed decisions, including being involved in all aspects of their patient care.

Review of the provider's February 2022 Discharge Planning policy revealed:
*"Discharge planning is a patient-centered, interdisciplinary process that involves the patient, caregiver(s), support person(s), authorized representative(s), physicians, hospital clinical staff, and case managers. The discharge planning process beings during the preadmission screening and continues throughout the inpatient rehabilitation stay. It is re-evaluated and adjusted as the patient's condition, functional status and clinical care needs change throughout the stay. The discharge plan is individualized and supports patient independence and self-management. The goal of the discharge planning process is to ensure an effective transition of care and reduce factors leading to preventable acute inpatient hospital readmissions."
*The discharge planning evaluation and considerations included:
-"All patients admitted to the inpatient rehabilitation hospital receive discharge planning evaluations and discharge planning services provided by a case manager."
-"The case manager reviews the anticipated discharge plan in the pre-admission screen."
-"The case manager begins the discharge planning evaluation process in a timely manner after admission and encourages the patient/patient representative to be actively involved in the discharge planning process."
-"Throughout the patient's stay, the case manager works with the patient/patient representative to develop a discharge plan based on the patient's clinical care requirements, goals of care and treatment preferences, and available support network."
-"The multidisciplinary team assesses progress toward rehab goals, potential barriers, and risk of acute inpatient hospital readmission as part of their interdisciplinary assessments."
-"Weekly Team Conferences are a critical component of the discharge planning process. The physician, case manager, nurse and therapists from each discipline with current knowledge of the patient meet and assess the appropriateness of the discharge plan based on the patient's condition, functional status and clinical care needs and adjust the plan as needed."
-"The discharge planning process includes case management evaluation of the availability of appropriate post-discharge care and services and the patient's access to those services."
-"The case manager discusses the discharge plan with the patient/patient representative at multiple points during the stay and documents the discussions in the medical record."
*Considerations in the discharge planning process:
-"Inpatient Rehabilitation Discharge."
-"Patient relayed goals of care."
-"Patient relayed treatment preferences."
-"Need for clinical care and chronic condition management after discharge."
-"Patient's insurance benefits/coverage."
-"Patient's support network."
-"Economic status- Patient/patient representative's daily ability to cover potential out-of-pocket expenses."
-"Availability of local/resources in the patient's community."
*"The hospital assesses the effectiveness of the discharge planning process on a regular basis. The assessment process includes a review of a representative sample of discharge plans in closed medical records to determine whether the discharge plan was effective and responsive to the patient's post-discharge needs. Based on the findings and identified trends, the discharge planning process may be modified."

4. Review of the CEO's job description revealed:
*"The Chief Executive Officer is responsible for all day-to-day operations of the hospital. This position is accountable for planning, organizing, and directive the hospital to ensure quality patient care is provided and the financial integrity of the hospital is maintained. The CEO ensures compliance with all applicable laws, regulations, policies, and procedures set forth by the Governing Board and Medical Staff, as well as Joint Commission standards."
*"The CEO is responsible for creating an environment and culture that enables the hospital to fulfill its mission by meeting or exceeding its goals, conveying the hospital mission to all staff, holding staff accountable for performance, motivating staff to improve performance, recognize and reward performance, and being responsible for the operations behind measurement, assessment, and improvement of hospital performance."

Review of the Certified Case Management Director's job description revealed:
*"As a member of Senior Leadership, the Certified Director of Case Management (CDCM) is responsible for the day to day operations and human resource management of the department of Case Management. With a central focus on census management, patient care outcomes, and key care indicators, the CDCM oversees the interdisciplinary plan of care and the discharge planning process to ensure the effectiveness and appropriateness of services. The CDCM is a patient and family advocate to ensure that services are delivered to meet the needs of the patients and their families, and that the utilization of resources is appropriate."

Review of the Chief Nursing Officer's job description revealed:
*"The Chief Nursing Officer (CNO) is responsible for the development and implementation of the plans for providing nursing care, treatment, and services, including determination of the types and numbers of nursing personnel necessary to provide nursing care and the development of a patient focused, team oriented culture, working in conjunction with all other medical, clinical and therapeutic disciplines to ensure optimal service and superior outcomes. The CNO holds full responsibility for the quality of nursing care provided and represents nursing on the Governing Body and other hospital committees. This position creates an environment and culture that enables the hospital to fulfill its mission by providing patient safety and patient-centered treatment."

Review of the provider's August 2021 Patient and Customer Complaint or Grievance policy revealed:
*"Effective resolution of complaints is a key factor in achieving patient satisfaction. Complaints are an important part of the hospital's continous performance improment process and should receive respectful, prompt and efficient attention. Each employee is empowered to resolve issues and complaints within his/her authority or professional expertise. The hospital provides education and training to employees to facilitate their confidence in handling patient complaints through new employee orientation and the 'Heart of the Patient Experience' service satisfaction training. The hospital must inform the patient and/or the patient's representative of the internal complaint process, including whom to contact to file a formal complaint (grievance)..."
*"Prompt and effective resolution is the goal for resolving patient complaints, regardless of whether it is a minor complaint or a serious grievance."
*"The hospital must maintain a system for tracking all complaints and grievances using the Patient/Family concern form. Seperate logs will contain complaints and grievances."
*"Complaints meeting any of the following requirements were to be considered a grievance and required a written response:
-Complaint regarding patient's care or with an allegation of abuse, neglect, patient harm, or failure of the hospital to comply with one or more CoPs [conditions of participation], or other CMS [Centers for Medicare and Medicaid services]."

Based on record review, interview, policy review, and Centers for Medicare and Medicaid (CMS) Service guidance review, the provider failed to ensure:
*A contingency plan was implemented for staff who were not fully vaccinated for COVID-19.
*Weekly testing for exempted staff who had not completed their primary vaccination series.
*Staff who had not completed their primary vaccination series had worn the appropriate personal protective equipment (PPE) (NIOSH-approved N95 or equivalent or higher-level respirator for source control).
Findings include:

1. Interview on 4/7/22 at 9:15 a.m. with interim administrator A and chief nursing officer (CNO) B regarding staff COVID-19 vaccinations revealed:
*They received Medicare and Medicaid reimbursement for their patients.
*They had followed the CMS memo regarding COVID-19 staff vaccinations.
*They had available staff vaccine records and exemptions including the contracted staff.
-All contracted staff were vaccinated.
*All new staff were educated on vaccinations and given resources on where they could obtain the COVID-19 vaccine.
*They had to be vaccinated or had to have an exemption on file before they could start work at the facility.
*They did not test patients or staff unless they were symptomatic.
-An evaluation would be completed first then followed by a COVID-19 test if necessary.
*They did screen everyone who came into the building.
*The patients were screened through assessment and vital signs every day.
*There were a total of 109 staff.
-Of those 109 staff:
--19 staff had religious exemptions.
--There were no staff medical exemptions.
*They had a process for tracking and securely documenting the COVID-19 vaccination status of their employees.
*They had not implemented the staff with exemptions to get tested weekly and/or wear an approved N95 or equivalent or higher-level respirator.
*Exempted staff not vaccinated were not tested for COVID-19 unless they had become symptomatic.
*Staff wore surgical masks at all times.
-An N95 mask was worn when caring for COVID-19 positive patients.
*They were aware of the CMS Memo for staff vaccinations.
*There were no current patients with COVID-19.

Review of the provider's 2/24/22 CMS Vaccine Mandate policy and procedure revealed:
*"3. The hospital has a process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID."
*"19. There are a variety of actions the hospital may implement to potentially reduce the risk of COVID-19 transmission including, but not limited to:
-Requiring staff who have not completed their primary vaccination series to use a NIOSH- approved N95 or equivalent or higher-level respirator for source control, regardless of whether they are providing direct care to or otherwise interacting with patients."
*There was indication exempted staff would receive weekly testing.

Review of CMS Quality Safety and Oversite (QSO)-22-09-ALL memorandum dated 1/14/22 and Hospital Attachment QSO-22-11-ALL revealed:
*"The guidance in this memorandum specifically applies to the following states: ...South Dakota..."
*The provider was not in compliance with the Federal vaccine mandate for staff vaccination.