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Based on record review (RR) and interview, the facility failed to meet the acceptable standard of practice for medication administration. Specifically, a Registered Nurse (RN) documented in progress notes a verbal order for oxygen for one patient (P)2, which was not documented in the Electronic Medical Record (EMR) as a verbal order, and was not authenticated by the ordering Provider. As a result of this deficiency, there was a risk of administration error which may result in a negative outcome. In addition, there were errors in one patient's (P1) assessment for eligibility for level of care services. As a result of this deficiency, P1 did not qualify for long term care services.

Findings include:

1) P1 is a 65 year old male admitted to the Critical Access Hospital for complex wound care (right lower extremity/RLE) and short term rehabilitation for physical deconditioning. Prior to hospitalization, P1 lived in his car on his property and the only source of water was the hose. P1's emergency contact (Family Member (FM)) did not live on the property and the house was not livable at the time of admission.. FM said they were working on a room with plumbing and electricity for P1 when discharged. FM was not P1's care giver (CG), and said she was unable to change the daily dressings to P1's complex wound post discharge. P1 also expressed fear several times of going home with noone to care for him. The facility was unable to arrange skilled nursing, it expected P1 and/or FM do the daily dressing changes.

On 03/07/2023. the facility completed an 1147 assessment to determine level of care eligibility. Based on the assessment, P1 had 13/15 points (15 required for eligibility) and did not meet criteria. Review of the 1147 and P1's medical record revealed the following:
- Section XXII Social Situation was not completely filled out. The question "If person has a home; caregiving support system is willing to provide/continue care?" was not completed. Other areas not completed included: Assistance required by caregiver, and caregivers name and contact information.
- P1's "Mobility/Ambulation" assessment was documented as: b. Ambulated with/without device/stand-by assist/unsteady/risk for falls and c. Able to walk/be mobile with minimal assist ." This area should have been marked a. and d. Able to walk/be mobile with one-person hands-on moderated assist according to PT notes.
- The interdisciplinary team meeting (IDT) dated 03/07 included 1. Physical Therapy (PT) note: 03/08/23 "... Currently he is still not able to consistently amb (ambulate) household distance. PT suggests that the patient would benefit from extended rehab either through ext (extension) in this program or with a SNF (skilled nursing facility). At discharge, 04/08/2023, P1 was still CGA (contact guard assistance/maintains contact).
- The facility documented P1's bladder function/continence was "c. Incontinent (at least once daily/requires help with bladder care on a regular basis." RR revealed during the assessment period, P1 was documented to be incontinent more than once and dependent all bladder care.

2) RR of P2's nursing progress notes revealed the following entry by RN3 dated 03/23/2023 at 00:55 AM: "Patient alert and oriented x2; patient with expiratory wheeze with O2 (oxygen) 85% (oxygen saturation) room air, resp (respirations) 13. MD (provider) notified and o2 2L (liters) ordered, history of copd (chronic obstructive pulmonary disease) will monitor to titrate o2 [sic] no more than 94%."

Further review of the medication administration records and physician orders revealed RN3 did not enter the verbal order in the EMR and the Provider did not sign or authenticate an order for the oxygen.

Reviewed the facility policy titled Verbal, Text , and Telephone order last reviewed 09/23/22. The policy included: "All verbal or telephone orders shall be signed by the issuing Physician (Provider), or designee within 24 hours," and "The R.N. receiving the order, enters in into EMR."

On 07/26/2023, the Director of Nursing reported after review of P2's records, she confirmed the oxygen order was not documented correctly and the Provider did not authenticate it.

Based on interviews, and record review (RR), the facility's discharge evaluation identified one patient (P)1 of a sample of four, discharge needs were not met. P1's discharge evaluation included, but not limited to daily dressing changes for a complex wound. The facility did not have a reasonable discharge plan in place for the dressing changes. They were not able to obtain Home Health Agency (HHA) skilled nursing, there was no caregiver that agreed to do the daily dressings, and there was no documentation P1 was able to independently complete the task. As a result of this deficiency, there was increased risk for infection, and readmission to a hospital.

Findings include:

1) P1 is a 65 year old male, with medical history that included but not limited to diabetes, anemia, depression and chronic kidney disease. He had been hospitalized in an acute care facility for generalized weakness, lower extremely cellulitis, wounds and sepsis. On 01/29/2023, P1 was transferred and admitted to the Critical Access Hospital for complex wound care (right lower extremity/RLE) and short term rehabilitation for physical deconditioning. Prior to hospitalization, P1 lived in his car on his property and the only source of water was the hose. P1's emergency contact was a FM. FM reported P1 was the only one on the property and the house was not currently livable. FM said they were working on a room with plumbing and electricity for P1 when discharged.

FM expressed said she was not P1's care giver (CG), and expressed concerns throughout P1's hospitalization regarding discharge back to the property. She wanted to seek alternatives including long term care. P1 went through several appeals for discharge and the last was declined. On 04/08/2023 he was discharged back to the previous location with confirmed Home Health Agency services of Physical Therapy (PT)/Occupational Therapy (OT) and Home Health Aide. The facility was unable to arrange skilled nursing for any dressing changes, and it was the expectation that P1 and/or FM do the required daily dressing changes.

2) Reviewed P1's Notices of Medicare Non Coverage (NOMNC), which included two that were not provided giving two days notice as required by regulation, and two that were rescinded after notifying the Quality Improvement Organization (QIO). Summary of the NOMNC's included the following:

02/23/2023 NOMNC: End of service 02/27/23. Additional information: "P1 did not sign and wanted to do an appeal. Pt reported he is not ready to d/c (discharge) because he is not able to walk on his own and care for himself daily. ..."

03/07/2023 NOMNC: End of service 03/09/2023. Additional information: "P1 did not sign the NOMNC and wants to do an appeal. Pt feels he is not ready to discharge home due to not being able to perform ADLs (activities of daily living) independently. Pt. also not safe to discharge home alone because home is not livable condition." 03/08/2023 Case HI-128963, QIO determination letter included: " ...The reviewer found that you no longer meet the Medicare coverage requirements for skilled swing bed services." The reviewer comments included, "Continued skilled services and or nursing care may be helpful to consider but no longer seems to be required on a daily basis." 03/08/2023 Social Worker (SW)1 letter to QIO included: "I am writing this rescind letter regarding a recently opened case, HI-128963. P1's appeal was filed prematurely. Our physician believes patients require continued PT/OT services to improve level of functioning for a safe discharge. His SNF (skilled nursing facility) stay has been extended, therefore no appeal is needed. ..."

03/14/2023 NOMNC: End of service 03/16/2023. Additional information documented by SW2: "The patient is choosing to appeal as his wound still bleeds when he puts pressure on it, especially when walking. ..." 03/14/2023 Case HI-1274684, Letter to QIO from SW1: "P1's appeal was filed prematurely. Our physician believes patient requires continued PT/OT services to improve ... no appeal is needed. 3/17/2023 QIO determination: "PR Disagrees with termination of Hospital services. ..."

03/22/2023 NOMNC: End of service 03/23/2023. Patient was not provided two days' notice of discharge as required. Additional information by SS included: "Pt. stated that he is not ready to go home because his wound on his leg has opened up and is bleeding. Pt stated that he wants to stay and heal so that his wound doesn't get infected. ..." 03/23/23 NOMNC: End of service 03/25/2023. Additional information: "SS met with pt. on 3/23 @ 8:50 AM to file a new appeal. Pt. wants to extend his time here so that his wound can heal. Pt. stated that he was put on a wound vac yesterday. He wants to heal further so that his wound won't get infected. He wants to be able to walk at the level he was before ..." 3/24/2023 Case HI-1282423, Letter to QIO from SW1 "...P2's appeal was filed prematurely. Our physician believes patients require continued PT/OT services to improve level of functioning for a safe discharge. His SNF stay has been extended; therefore, no appeal is needed. ..."

03/28/2023 NOMNC: End of service date 03/28/23, which did not provide the two day notice prior to discharge. Additional information included: "P1 does not agree with NOMNC and wants to appeal. Pt states he is still not able to ambulate long distance due to his wounds on right lower leg. Pt. also not able to care for his wounds + no help at home. Pt also has wound vac & may not have electric to plug in wound vac. ..." 3/30/2023 case HI-1287105, QIO final determination: " ...The physician reviewed disagrees with the termination of services." Determination letter included peer reviewer comments that included: " ...Per social work notes on 03/28/2023, the hospital can not find a facility to accept that can manage the patients wound vac. Termination of hospital services is NOT appropriate due to this."

04/05/2023 NOMNC: End of services 04/07/2023. Additional information documented by SW2 for appeal: "P1 refused to sign because he reports he is not able to walk due to the wound on his RLE. Pt also reports his not able to change his own wounds & lives at home alone. ..."
The appeal was denied and P1 was discharged home on 04/08/2023.

3) Reviewed the Wound Care Specialist (WCS) notes dated 04/03/2023 when she changed P1's dressings and assessed the wounds. At that time a wound vac (vacuum-assisted closure of a wound), was being used on the RLE wound (started on 03/22/2023). RR revealed the following entries:
RLE Posterior (back of leg) wound 26.00 centimeters (cm = .39 inch) x 35.50 x Unknown (L x W x D). "... There were no signs of infection however, and the moderately foul odor present throughout the session."
Right heel 1.7 x 1.10 unknown.

On 07/17/2023 at 12:00 PM, during a telephone interview with WCS, she said P1 had a "Bad bad bad wound." She went on to say the wound was almost all the way around his lower leg, with tendon exposed. WCS recalled P1 had been on a wound vac, but was discontinued because of pain, and could not be managed post discharge. She said there may have been an issue with electricity. The WCS reviewed documentation of her last assessment and dressing change dated 04/03/2023. She debrided the wounds at that time and did the dressing changes. She said she did not teach P1 how to do dressing changes. WCS said she spoke with the FM once, and the FM said she could not do the dressing changes. WCS said the nursing staff tried to get FM to come in for training, but she did not come. WCS said she felt P1 "may be able to physically change his own dressing, but he did not like seeing the wound and did have some depression." WCS said the standard of care to ensure someone is independently able to change a dressing would be to have them demonstrate and document such. She said community resources are very limited for wound care, and sometimes backed up for weeks, so the facility provides supplies and education as much as they possibly can.

4) Review of Physical Therapy (PT) Discharge note dated 04/07/2023 included: "Treatment Plan Recommendations: ... Pt shows poor tolerance to standing 3 x 30's max (maximum tolerance standing with three attempts was 30 seconds). Pt. continues to require SBA (stand by assist/standing next to the client, but no client contact) for transfers (i.e. bed to wheelchair, toilet) and CGA (contact guard assist/maintains contact) with FWW (front wheel walker) for ambulation. PT recommending d/c with full time care HHPT (Home Health Agency PT) and OT (occupational therapy). ..."

On 7/20/2023 at 09:20 AM, during an interview with the Director of Rehabilitation (DOR), reviewed P1's PT Discharge note dated 04/07/2023. DOR said he participated in P1's Interdisciplinary Meetings (IDT), where the team discussed discharge plans. Inquired what his understanding was of resources available to P1 post discharge. He said he thought P1 had a FM, "who was going to be serving as the caregiver to the patient." DOR said he personally did not have any contact with the FM. Inquired his recall of discussions regarding dressing changes and appeals. DOR said SS mentioned a NOMNC at the end of March, and at that time, it was fairly clear P1 needed ongoing assistance. He said P1 was not able to ambulate "household distance," and explained that meant he could not independently ambulate 30-40 feet safely to get around to needed areas of the house (i.e. bathroom, kitchen) for ADL's.

5) RR of Social Services progress notes included the following:
03/30/2023 03:37 PM: "...FM was frustrated due to the NOMNC's and having to appeal several times for the pt. and doesn't understand why pt. can't just use his 100 days here and SS explained to her that it does not work that way ..."

04/04/2023 07:43 AM: "Call from FM to f/u on pt. d/c date and SS informed that we have a TDD (tentative discharge date) of 4/10. FM stated that she just wanted to know so that she didn't have to pay for the portable bathroom ..."

04/05/2023 11:53 AM: "SS called niece to update her on pt. d/c date and that it will be 4/8 and LCD (last covered day) by insurance is 4/7 and that SS will go and see pt. to issue the NOMNC and that pt. can appeal if he wants to. SS informed that pt will not d/c 4/6 to allow 2 days for pt. to do an appeal if he wished to do that. ...SS informed niece that pt. will most likely not go home with wound vac because the out patient wound clinic will not put the wound vac back on the the pt, ...so the wound care specialist will remove the wound vac before pt. goes home. FM reported that the pt. does have electricity and his home is ready for pt. to d/c too. FM asked SS if pt. will have help and SS informed her that pt. will have PT/OT/HHA come in once pt. is d/c from hospital to do their assessment and will continue to work with pt. ..."

04/06/2023 07:27 AM: "SS received a phone call with QIO (Medicare Contracted Quality Improvement Organization) reporting that pt. appeal was declined, and that PR (Physician Review) agrees with termination and liability (patients financial liability) starts on 4/7. ..."

04/07/2023 08:20 AM: "SS received a phone call from FM reporting that the intern informed her that pt. will need daily wound changes and that she can't tolerate changing his wounds. SS explained to FM that the wound vac was removed... SS informed FM that someone will have to change the pt. wound if she can't and if she has anyone else, she can think of that can help ...and FM stated that there was no one. SS informed that pt. OP appt. is on 4/17 and SS can call to see if they have an earlier appt. and call pt. PCP (Primary Care Physican) to see if they have any outreach program for pt. and she can call Home Health Agency (HHA6 to see how soon they can come out for services. SS reminded FM that HHA6 only will assist with PT/OT/HHA because they are not servicing for SN (skilled nursing wound care) due to shortage of staff. ..."

04/08/2023 09:12 AM: "This note was inputted on behalf of SS intern. This note was reviewed by this writer. ...FM asked what pt's d/c plan is and if SS found services to provide pt's wound dressing. SS told FM that all the HHA agencies we contacted have a shortage of SN staff for wound care and the OP (Outpatient) wound care can only do wound dressing changes for up to 2 times a week. SS said that even if pt is confirmed with HHA for SN, it would be max 3 days a week. FM asked who would do the rest of the days if pt needs daily changes. SS informed her that either her (FM), a family member or a CG (caregiver) would do the rest of the day [sic]. FM asked if SS send pts home in similar situations as she is worried about pt being reinfected at his wound. SS informed her that we had many similar situations as we have to follow insurance orders and we tried to appeal and extend multiple times. FM seemed frustrated ..."

6) RR of Nursing Progress notes and documentation included but not limited to:
03/02/2023: "... Pt is to be discharged next week; pt is visibly upset p (after) participating in PT/OT realizing pt has limited help at home and pt requires total care at this time. ...Social services stepped in and working on a care home upon discharge. ..."

03/21/2023: "...Discuss with pt FM on the phone regarding dc planning, per FM she would like to know status of appeals process. Informed her that appeal was denied and pt set for discharge this Friday 3/24. Discussed with social services as well as patients extensive wound still requiring daily dressing changes, per SS pt is not covered for skilled nursing at home due to shortage (of Home Health RN's for wound care). Request to set up time for FM to learn wound care and per SS she has refused to learn wound teaching as she is not comfortable. ..."

03/22/2023: "...Patient stated no one to help with wound care at home. Writer attempted wound care training with patient, but unable to reach RLE to perform dressing change. NP (Nurse Practitioner) and SS notified.

03/27/2023: "Spoke to FM. Pt said she is the only one person who can help him. FM said she might be able to learn how to wound vac (NPWT/negative pressure wound therapy), however she said patient may need to live in a car again, because he doesn't have constant electricity, he might not be able to use wound vac. WCS suggested to change the wound therapy to the previous one ...due to not having electricity and the complexity of the wound care. It took 2 hours to finish his wound care with WCS. this is not possible for non medical person to handle wound vac by herself. ..."

03/28/2023: "...Pt (P1) had NPWT applied to right lower leg. Suction is at low setting ...and is continuous. Patient at this time set to be discharged tomorrow. In the case he is discharged tomorrow wound care instruction must be clarified by wound specialist due to patients destination will be his car which will not facilitate an adequate setting for NPWT to be continued. ..."

03/29/2023: " SS called ....to f/u on the referral and she asked if pt. is independent with his ADL's and SS informed that pt. is incontinent with his bladder and only goes to the bathroom for his bowl's [sic]. ...stated that pt. needs to be independent because they don't have the staff to assist with ADL's.

03/29/2023 07:56 AM: "...SS called QIO to f/u on pt. appeal and stated it was invalid due to lack of two day notice and that the next step is to issue a new NOMNC..."

04/07/2023: "Wound care training provided to Pt. Pt also instructed to video dressing and share with his FM. Consulted with wound care specialist to facilitate home wound care orders [sic]."

04/08/2023 Discharge Check List: "Final Discharge Plan. Pt. (P1) will be d/c home alone with help from his FM. Pt will be d/c with PT/OT/HHA (home heath aide) with ... Pt hospital bed is pending delivery to his house. Pt wound vac was removed on 4/5 due to pt. not able to tolerate the pain and the wound change. Pt was trained on wound change and a video was taken on the pt. phone in case he will need it to help him and his FM when needs to be changed. Pt has a OP (outpatient) wound clinic apt....4/17 at 10:30 AM. SS tried to reschedule for an earlier day but there was no available days... Pt FM was concerned about pt wound care that it has to be changed daily and that she is not able to tolerate changing his wounds. SS reached out to PCP (Primary Care Provider) to see if pt can be seen by by them for wound change and PCP said he will send referral to see pt 1x a week. SS called pt FM 4/6 and LVM (left voice message) informing that pt can also come here to the OP (outpatient) wound care 1x a week if pt is agreeable. ...HHA1 said that pt can be put on their AIM program where an RN can see pt. 1x a month. SS sent referrals to HHA2 and it was declined on 4/5, not accepting pt's insurance. Referral was also sent to HHA3 and HHA4 and declined due to shortage of SN. HHA5 does not have PCP (associated with insurance) and HHA6 does not have SN for wound care. ...SS rounded with RN, and will send pt. home with wound supplies..."

7) On 07/19/2023 at 12:45 PM, conducted a phone interview with the RN2 who discharged P1 and did the dressing change video. She said "his wounds were so severe." She went on to say at discharge, he was able to ambulate with a FWW, but not far. RN2 said she recalled some discussions a FM said she couldn't take him and can't manage the care. She said SS tried to find him a place to go to. RN2 said she thought the FM felt bad, and finally said OK and think there was a room for him. She said P1's wound dressings were modified so they could be handled at home. RN2 said "FM said she would assist, as far as I know. That's why took video on his phone." Inquired if P1 was able to do the dressing change himself, and she said "It would have been difficult for him, especially because it was the back of leg." RN2 said she had the impression FM was going to help."

On 07/19/2023 at 2:30 PM, during an interview with APRN, she said P1 was at the facility for complex wound care. She said when she spoke with the FM initially, she said she was trying to get the home ready, but then heard from colleague the FM could not take care of him. FM came in, saw the wound, and said she could not do the dressing changes. The APRN said P1 appealed his discharge 3 times, and SS tried to find something else, but he wanted to go back. "We all wanted him to stay, he should have qualified for long term care."

8) RR of IDT meeting minutes included, but not limited to the following entries:
Discharge Planner notes:
04/03/2023: "Patient appealed discharge and was approved though 4/01 by QIO. Insurance disagrees with QIO decision, Insurance issued NOMNC with new discharge date of 4/8."

Nursing Notes:
04/03/2023: "...focusing on plan for discharge and education on wound care management.

OT Notes:
03/21/23: "Pt is CGA (contact guard assist) for fx'al (functional?) mobility and fx'al transfers and able to complete LE dress and toileting with min a (assist); however pt does not consistently go to the BR (bathroom) and needs to be changed bed level ..."
03/28/23: "Pt d/c from OT today. Recommend full time caregiver."

PT Notes:
03/08/23: "Patient has been demonstrating good improvement in functional mobility and increasing levels of independence. He has improved to CGA with transfers in and out of bed. Currently he is still not able to consistently amb (ambulate) household distance. He is also still min A (minimal assist) for toilet transfers. PT suggests that the patient would benefit from extended rehab either through ext (extension) in this program or with a SNF. ..."
3/14/2023: "Patient continuous to demo (demonstrate) progress and is now SBA with transfer and CGA with walking. Pt still limited to walking 20 feet at a time sec (secondary) to increased right lower leg pain. Pt will continue to benefit from therapy to target transfer mod I and walking short distance to carryover to home environment safely. TDD (tentative discharge date) 3/23."
03/21/2023: "Patient demo decline in function sec to increased right left lower leg pain. Pt unable to perform STS (sit to stand) and transfer without extended amount of time and has not been walking. Pt also demo self neglect and signs [sic] that will not ask help upon DC stating that this is his last stop and will die upon DC."

SS notes:
03/22/23: "...Pt will be discharging home alone. Pt's family did say that his home will be ready for him upon d/c and will confirm. However, pt's FM is also requesting that he get transferred to another skilled nursing facility so that he can stay longer. SS will educate FM on the matter."
3/28/23: Pt appealed his NOMNC and was approved due to lack of allowing pt. 2 days notice and new notice will be given for pt. ...D/C with limited access to electricity and water.

There is very limited information reflected in the IDT minutes about the discharge plans for the daily dressing changes. It was known that the FM said she could not do the wound care and the plan would not provide the identified needs. In addition, there was limited information regarding the appeals.


9) RR of Physician Discharge Summary dated 04/08/2023, included the following:
"...Patient wound care did include a wound vac during stay in hospital, how ever this was not tolerated due to the pain, it was noted that it was not healing as anticipated and so a complex wound dressing was then applied with some healing, however the bone and tendons still are seen. Patient had appealed his discharge numerous times and was successful, however the last appeal did not sway in his favor. Patient is homeless and will ambulate with a wheel chair, wound care was simplified for the days that he would care for his wounds, able to film the process with his phone. Patient has some support, however this is limited and will need to perform wound care on his own. Patient to follow up with his PCP ...wound care clinic (4/17/2023)."

Included in the physician discharge summary was a section titled "After-Hospital Care Plan Social Services," which included the wound care instructions: "Right lower extremity-Cleanse with Dakin's strength daily, apply 1/4 Dakins wet to dry gauze to wound and cover with ABD pads Daily." List of supplies provided at time of discharge included Dakin's 1/4 strength (will send home one bottle)."

RR of Order sheet signed by Registered Nurse (RN)1 included:
04/08/23 09:00 AM, Dressing Change: "Right medial (inside) heel: Cleanse with vashe (wound cleanser), apply nickle thick Santyl (ointment that removes dead tissue), Hydrafera blue (provides wound protection), cover with gentle bordered foam."
04/08/2023 09:00 AM, Dressing Change: "RLE: cleanse/soak with vashe, apply santyl to slough/necrotic (dead) tissue. Apply promogran (maintains moist environment) over viable wound tissue ensuring no overlap with santyl. Cover with abdominal pads and kerlix. Change daily and prn.
These orders did not match the orders documented in the Physician's discharge summary.

10) On 07/20/2023, contacted P1's FM for a phone interview. Inquired what her understanding what was for P1's dressing changes when he was discharged. FM said they did a video on his phone how to change the dressing. She said the last time she spoke with someone at the facility she told them she could not do the daily dressing changes. FM went on to say she was told it was OK, and that "You can change it every two days, three at the most." FM said P1 was not able to change the dressing himself.

11) A review of the facility policy titled "Discharge Planning" last review date 08/15/2023 was completed. The policy included the following statements:
"... Medical Center has an effective discharge planning process that: a. Addresses patients goals, needs and treatment preferences. ...d. Promotes a safe and effective discharge and transition. e. Reduces factors that lead to preventable readmissions."
"Discharge planning will include "involvement of the Interdisciplinary Team (IDT) in the ongoing process of developing the discharge plan, including review of the plan weekly and revision as needed..."
"V. Weekly interdisciplinary team meeting for the review of patient's care, and the ongoing process of discharge planning. a. Discharge plans are reviewed and revised by the interdisciplinary team after each assessment. "
"V11. If patient expresses interest in returning to the community: ...c. discharge to community is determined unsafe or unfeasible, per attending MD and interdisciplinary team, documentation must be inputted into the patient's EMR."

12) Cross Reference F1049 Nursing Services
The facility completed an 1147 assessment form on 03/07/2023 to determine if P1 was eligible for ongoing services at the ICF (intermediate care facility) level. Based on the completion of the form, it was determined he did not meet criteria. Review of medical records and the 1147, revealed there were inaccuracies documented of P1's condition.