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Based on policy review, medical record review and staff interview, the hospital staff failed to document turning and repositioning of patients per physician's order for 2 of 2 bariatric patient records reviewed (Patient #4 and #12).

Findings Included:

Review of the hospital policy titled "Pressure Injury Prevention" effective December 1985, reviewed January 2021 revealed " ... II. INSTRUCTIONS ...3. ENSURING Skin Integrity Status ...d. Utilize the 'clock' turn schedule posted in each room for frequency or position change. The position turned should be recorded in the patient's medical records. (See Attachment D)." Review of Attachment D revealed a picture of a Turn Clock with notation of every two hour turns. The turn clock revealed 12-back, 2-right, 4-left, 6-back, 8-right and 10-left.

1. Open medical record review on 09/23/2021 for Patient #4 revealed a 28-year-old female admitted on 06/18/2021 at 1619 with a diagnosis of sacral wound. Review of the physician orders dated 06/18/2021 at 1723 revealed an order to turn the patient every two (2) hours. Review of the nursing flow sheets from 06/18/2021 at 1723 through 06/30/2021 at 0954 revealed Patient #4 was repositioned on 06/18/2021 at 1723 and next on 06/19/2021 at 0756 (14 hours and 33 minutes later), on 06/19/2021 at 2305 and next on 06/20/2021 at 0304 (3 hours and 59 minutes later), at 0746 (4 hours and 42 minutes later), at 1140 (3 hours and 54 minutes later), on 06/20/2021 at 2317 and next on 06/21/2021 at 0306 (3 hours and 49 minutes later), on 06/21/2021 at 0750 and next at 1154 (4 hours and 4 minutes later), on 06/21/2021 at 1540 and next at 1930 (3 hours and 50 minutes later), on 06/21/2021 at 2128 and next on 06/22/2021 at 0125 (3 hours and 57 minutes later), on 06/22/2021 at 0931 and next at 1501 (5 hours and 30 minutes later) and next on 06/23/2021 at 0115 (10 hours and 14 minutes later), on 06/23/2021 at 0332 and next at 0700 (3 hours and 28 minutes later), on 06/23/2021 at 1700 and next on 06/24/2021 at 1123 (18 hours and 23 minutes later), on 06/25/2021 at 0316 and next at 0722 (4 hours and 6 minutes later), at 1120 (3 hours and 58 minutes later), at 1540 (4 hours and 20 minutes later) and at 1947 (4 hours and 7 minutes later), on 06/25/2021 at 2335 and next on 06/26/2021 at 0413 (4 hours and 38 minutes later), on 06/26/2021 at 0800 and next at 1556 (7 hours and 56 minutes later), on 06/26/2021 at 2327 and next on 06/27/2021 at 0327 (4 hours later), on 06/27/2021 at 2345 and next on 06/28/2021 at 0345 (4 hours later), on 06/28/2021 at 0923 and next at 1318 (3 hours and 55 minutes later), on 06/28/2021 at 2312 and next on 06/29/2021 at 0312 (4 hours later), on 06/29/2021 at 0323 and next at 0723 (4 hours later), on 06/29/2021 at 2323 and next on 06/30/2021 at 0323 (4 hours later). Review of the medical record revealed the hospital staff failed to turn and reposition a patient every 2 hours as ordered by the physician.

Interview on 09/23/2021 at 1222 with RN #1 (Registered Nurse) revealed the staff were expected to turn patients every two (2) hours. Interview revealed the bariatric bed rotated every two (2) hours, however staff assistance was needed to reposition and place wedges between the patient and the bedrails. Interview revealed the staff failed to document repositioning and turning every two (2) hours as ordered by the physician.

2. Open medical record review on 09/23/2021 for Patient #12 revealed a 67-year-old female admitted on 02/06/2021 at 2206 with a diagnosis of generalized weakness, diarrhea, nausea and vomiting. Review of the physician orders dated 06/04/2021 revealed an order to turn the patient every two (2) hours. Review of the nursing flow sheets from 09/14/2021 at 1536 through 09/18/2021 at 2324 revealed Patient #12 was repositioned on 09/14/2021 at 1536 and next on 09/15/2021 at 0940 (18 hours and 4 minutes later), at 1335 (3 hours and 55 minutes later), on 09/15/2021 at 1735 and next at 2117 (3 hours and 42 minutes later), on 09/16/2021 at 0514 and next at 0935 (4 hours and 21 minutes later), on 09/16/2021 a 1739 and next on 09/17/2021 at 0600 (12 hours and 21 minutes later), on 09/17/2021 at 1735 and next on 09/18/2021 at 0126 (7 hours and 51 minutes later), and at 2124 (19 hours and 58 minutes later). Review of the nursing flow sheets from 07/02/2021 through 07/04/2021 revealed Patient #12 was repositioned on 07/02/2021 at 1345 and next on 07/03/2021 at 0930 (19 hours and 45 minutes later), at 1330 (4 hours later), on 07/03/2021 at 1700 and next on 0/04/2021 at 0738 (14 hours and 38 minutes later). Review of the medical record revealed the hospital staff failed to turn and reposition a patient every 2 hours as ordered by the physician.

Interview on 09/23/2021 at 1222 with RN #1 (Registered Nurse) revealed the staff were expected to turn patients every two (2) hours. Interview revealed the bariatric bed rotated every two (2) hours, however staff assistance was needed to reposition and place wedges between the patient and the bedrails. Interview revealed the staff failed to document repositioning and turning every two (2) hours as ordered by the physician.

Based on policy review, medical record review and staff interviews, the hospital staff failed to coordinate home health services per physician orders for 1 of 6 patients discharged home (Patient #3).

The findings include:

Review on 09/23/2021 of the hospital policy titled, "Procedure Discharge Planning" with an effective date of 03/2018 revealed, "... The discharge planning shall be completed on a timely basis so that appropriate arrangements are made before discharge, and unnecessary delays in discharge are avoided ..."

Review on 09/21/2021 of the closed medical record for Patient #3 revealed a 55-year-old female admitted to the hospital on 05/11/2021 at 1139 with a diagnosis of "cardiac arrest with ROSC (return of spontaneous circulation). Review of the second History and Physical note dated 07/24/2021 at 1935, after patient transferred out of the intensive care unit (ICU) revealed Patient #3 had a past medical history of polysubstance abuse, bipolar disorder, and "previous heart attack". Review revealed on 05/14/2021 (while a patient in the ICU) a "Code Blue (hospital emergency code used to describe a medical emergency)" was called for Patient #3 "found unresponsive". Review revealed "ROSC was achieved." Review revealed "Assessment/Plan: 1. Hypoxic/ischemic (lack of oxygen to the tissues/decrease blood flow to the tissues/organs)brain injury s/p (status post) Cardiac Arrest: continue rehab until accepted to a SNF for rehab ..." Review of the Progress note dated 07/21/2021 at 1724 revealed "OT (occupational therapy) Received On: 07/21/2021 ... Plan: Treatment Interventions: ADL (activities of daily living) retraining; Functional transfer training; UE (upper extremity) strengthening/ROM (range of motion); Endurance training; Patient/family training; Neuromuscular reeducation; Progress: Slow progress, cognitive deficits; OT Frequency: 3-5 x (times)/wk (week); OT Duration: For 3 weeks ... Recommendation: OT Recommendation: Long-term skilled OT." Review of the Progress note dated 07/29/2021 at 1902 revealed "Plan: Progress: Discontinue OT; Recommendation: Defer at this time; No Skilled OT." Review of the Progress note dated 08/10/2021 at 1733 revealed "PT (physical therapy) Received On: 08/10/2021 Subjective: Observed pt this am walking w/ (with) nursing ... Additional Pertinent History: Pt (patient) agitated this am; Talked w/ nursing; observed pt amb'ng (ambulating) in hallway 4 laps 800 ft (feet) w/ SBA (stand-by-assistance)/Supervision ... Cognition: Overall Cognitive Status: Impaired (PT unable to participate in skilled PT; ..." Review of the Physical Therapist Consult dated 09/11/2021 at 1212 revealed "Precautions: ... Other Therapy Precautions: Fall risk ... Activity Tolerance: ... Endurance: Tolerates 10-20 min exercise with multiple rests; Sitting Balance: Supports self with one upper extremity; Activity Tolerance Comments: Requires sitting balance assistance for safety ... Cognition, Sensation, Proprioception, & Perception: ... Overall Cognitive Status: Impaired ... Orientation Level: Oriented to person, Disoriented to place, Disoriented to time, Disoriented to situation; Safety Judgment: Decreased awareness of need for assistance Bed Mobility: ... Rolling: Contact guard assistance; Supine to Sit: Min assist to left; Sit to Supine: Min assist to right Transfers: ... Sit to Stand: Contact guard assistance; Bed to Chair: Min assist to right, Mod assist to right, Min assist to left, Mod assist to left; Activity Aid: Rolling walker Mobility: ... Ambulation: (CGA [contact guard assistance] for direction); Ambulation Distance (Feet): 220 Feet; Activity Aid: Rolling walker Gait: ... Pattern: Ataxic (impaired balance or coordination); Gait Assistance: Minimal, Moderate; Assistive Device: None; Distance: 25 feet and 82 feet; Gait Additional Comments: Pt has poor LE proprioception (body's ability to perceive its own position in space) and required therapist to constantly uncross feet prior to standing Balance: ... Sitting - Static: Fair; Sitting - Dynamic: Poor; Standing - Static: Poor ... Assessment: ... Assessment: Decreased cognition; Prognosis: Good, 24 hour supervision recommended PT Prognosis: ... Problem List: Decreased cognition, Impaired judgement, Decreased safety awareness; Barriers to Discharge: None; Barriers to Discharge Comments: Husband works all day and pt will require 24 hour assistance due to cognition PT Plan & Recommendation: Plan; Patient and Family Goals: Return home with family; Treatment/Interventions: Functional transfer training, Equipment eval/education, Bed mobility, Gait training, Neuro re-education, Therapeutic exercise; PT Frequency: 3-5 x/wk; PT Duration: For 2 weeks; ... PT Recommendation: Home with family, 24 hour supervision/assist, No skilled PT; No Skilled PT: Safe to return home (with family) ... Review of the Discharge Summary dated 09/13/2021 (not timed) revealed "I certify taht (sic), based on my findings, the following services are medically necessary home health services. Skilled Nursing Education/Teaching and Medication Management; Physical Therapy WBAT (weight bearing as tolerated) Strength/Endurance, Weakness, and Debility; Occupational Therapy Strength/Endurance, Weakness, and Debility; Home Health Aide Assistance with ADL's/IADL's (activities of daily living/instrumental activities of daily living) ... Home PT to evaluate and treat; Home OT to evaluate and treat; Home health for skilled nursing evaluation; Med management; Ambulatory referral to Psychiatry ..." Review of the After Visit Summary printed on 09/13/2021 at 1257 revealed no appointments scheduled on a date after discharge and no referrals for Patient #3. Review of the Progress note dated 09/13/2021 at 1627 revealed " ... DISCHARGE TO: Home; HOME HEALTH SKILLED SERVICES (s) ARRANGED FOR DISCHARGE: Occupational Therapy, Physical Therapy, Skilled Nursing Evaluation and Other Med management referrals sent out to all (county name) HH agencies based out of (name of town), per patient's mom (name) request ... ADDITIONAL DISCHARGE INFORMATION: Patient to dc home on this date ..." Review of the Nursing note dated 09/13/2021 at 1807 revealed "Awaiting family to arrive for pt discharge. Mother arrived at 1600. Nurse informed mother she would be in shortly with the discharge papers. Mother, (name), stated she had no clue patient was being discharged. Mother .... Left the floor and Nurse called mother back to floor so Hospitalist and case worker could talk to her. Hospitalist and case worker informed husband and mother that she would be discharged today. Mother agreed for ambulance to take daughter home. All discharge instructions, med's, diet and f/u home health instructions explained to mother, mother verbalized an understanding ...." Review of the Progress note dated 09/13/2021 at 2129 revealed " ... (Patient's mom's name) stated to "try (Named Provider)and the other providers based out of (town name) and that she absolutely did not want anyone from (name of county). CM (case manager) voiced understanding and informed (patient's mom's name) she would send it out ..."Medical record review revealed Patient #3 was discharged on 09/13/2021 at 2129. Review revealed Patient #3 was transported on a stretcher by EMS (emergency medical services - ambulance).

Interview on 09/22/2021 at 1303 with Registered Nurse (RN) #2 revealed she remembered Patient #3. Interview revealed there was miscommunication about Patient #3's discharge. Interview revealed Patient #3's sister was upset she had just found out Patient #3 was being discharged that day. Interview revealed MD #3 and RN #2 spoke with Patient #3's mom and daughter about the discharge. Interview revealed RN #2 was not clear on the date the discharge discussion took place. Interview revealed Patient #3 did not get out of bed and could not feed herself. Interview revealed Physical Therapy was working with Patient #3.

Interview on 09/22/2021 at 1416 with RN #4 revealed she remembered Patient #3. Interview revealed Patient #3 had a 1:1 sitter because of behavior until discharge. Interview revealed MD #5 made Patient #3's mom and husband aware Patient #3 was being discharged on 09/12/2021. Interview revealed RN #4 was not sure if the discussion was documented. Interview revealed on the day of discharge Patient #3's mom arrived to the floor around 1600 and RN #4 asked Patient #3's mom if she was ready to take Patient #3 home. Interview revealed Patient #3's mom looked confused.. Interview revealed Patient #3's mom stepped off the floor and then reappeared. Interview revealed Patient #3's "mom made out like there had been no talk about home health, physical therapy, etc." Interview revealed the case manager went in to talk with Patient #3's mom and RN #4 was not involved in the conversation. Interview revealed the MD #3 told Patient #3's mom if she was not comfortable taking Patient #3 home in her vehicle, that she (Patient #3) could go by transport. Interview revealed at the time for Patient #3 to be discharged she was considered to need "minimal assistance." Interview revealed RN #4 "gave Patient #3's mom the discharge papers, she agreed, she had no questions, and she signed the AVS (after visit summary)." Interview revealed Patient #3 did not leave the hospital during RN #4's shift (0700 to 1900). Interview revealed Patient #3 had a sitter unitl she was discharged from the hospital.

Interview on 09/22/2021 at 1550 with Administration #6 revealed the case manager is not available for interview.

Telephone interview on 09/23/2021 at 1013 with Medical Doctor (MD) #5 revealed he remembered Patient #3. Interview revealed Patient #3 was a difficult placement and social worker had to get involved and help get Patient #3 Medicaid. Interview revealed MD #5 had the understanding Patient #3 was "going home with home health." Interview revealed Patient #3 could ambulate minimally and that she was in the bed most of the time. Interview revealed MD #5 did not know Patient #3 was discharged without services set up. Interview revealed Patient #3 was "kept in the hospital 120 days to get everything set up" that she needed.

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