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Based on interview and record review the facility failed to ensure nursing staff developed and kept current, a nursing care plan that responded to identified nursing care needs from admission through discharge for one (#19) of five patients reviewed for pressure ulcer risk or wounds, resulting in the potential for unmet care needs for patients and less than optimal outcomes. Findings include:

On 9/5/2018 at 04:00 PM, review of Patient #19's medical record revealed he was a 82 year old male admitted on 7/28/2018 with a diagnosis of altered mental status, urinary tract infection, and failure to thrive. Upon admission, Patient #19 was assessed for risk of developing pressure sores using the Braden Scale (tool used to measure pressure ulcer risk). Patient #19 scored a 13 out of a possible 23 indicating that the patient was at high risk for developing pressure sores and one early pressure ulcer was identified in the admission assessment. Two wound care assessments were present by the wound care team; however, there was no evidence that report had been made to the physician and there was no recommendation for care. The Nursing care plan did not address the patients pressure ulcers and at the time of discharge there was no documentation of plans for continued wound care after discharge. The patient was discharged on 08/09/2018, there was no documentation of discharge instructions regarding wound care to the family, adult foster care facility, or home care agency.

On 09/06/2018 at 09:00 AM Staff S the Registered Nurse (RN) documented as the discharging nurse was interviewed. Staff S was asked why there was no documentation related to the patients on going need for wound care after being discharged. Staff S stated "I thought that was all handled by the wound care nurse and by the case manager."

On 09/06/2018 at 10:00 AM Staff V the RN wound care nurse was interviewed. Staff V was asked if she was responsible for the care planning related to pressure ulcers and wounds. Staff V stated "I only do an assessment and make recommendations, the physician writes the orders and the RN taking care of the patient does everything else."

On 09/06/2018 at 10:30 AM Staff M the case manager on the record for patient #19 was asked about the lack of documentation on the plan of care related to the patients pressure ulcers requiring care when discharged. Staff M stated "The plan of care for the pressure ulcers is shared by the RN and the Physician."

On 09/06/2018 at 1:35 PM Staff R, the nursing director for the facility, was asked what her expectation was regarding the discharge of a patient with pressure ulcers and who would be responsible. Staff R stated, "Any type of clinical care nursing would be responsible to do that...I would expect that the nurse would catch any gaps in physician orders..."

On 09/06/2018 11:00 AM, the policy titled "Nursing Plan of Care" #3182189 dated revised 06/2014 was reviewed. On page 1 of 2 under Policy: 2. it states "The RN is responsible for the coordination, delivery and evaluation of care through the nursing process. The RN will facilitate an interdisciplinary, collaborative approach as the patients plan of care is managed."

Based on interview and record review, the facility failed to fully implement it's discharge planning process to ensure that discharge needs were accurately assessed, updated as necessary, and discharge needs met for 1 (#19) of 19 patients reviewed for discharge planning, out of a total sample of 19, resulting in unmet care needs and readmission to another acute care hospital. See specific tags:

A 0811 - Failure to discuss the results of the discharge planning evaluation with the patient's representative
A 0821 - Failure to perform a comprehensive discharge assessment and update discharge care plan.
A 0837 - Failure to provide necessary medical information to the post acute care facility that would be providing follow up care.

Based on interview and record review, the facility failed to discuss discharge information with the patient's representative for 1 (#19) of 19 charts reviewed for discharge planning resulting in the potential for poor patient outcomes and the potential for readmission. Findings include:

Review of Patient #19's medical record on 9/5/2018 at 1446 revealed legal documentation naming his daughter as the durable power of attorney (DPOA).

During an interview with the DPOA on 8/31/2018 at 1134, the DPOA stated that she was at the facility the day before discharge and requested information on Patient #19's discharge. She stated, "I didn't expect them to have everything printed and ready to go, I just wanted to know basically what to expect and if I needed to go to the pharmacy and that kind of thing...They told me no and that everything would be in the written instructions and that it would be sent with him to (the adult foster care-AFC)."

Further review of Patient #19's medical record revealed no mention of the DPOA's presence at the bedside the day prior to discharge, the request for discharging information, or that the DPOA had been called with discharge information during the discharge process.

On 9/6/2018 at 0850, Staff S, the nurse identified as caring for the patient the day before discharge and the day of discharge, was interviewed and queried as to if she had refused to give the DPOA information regarding Patient #19's discharge and if she had contacted the DPOA to give the discharge information to which she stated "I don't recall. Based on my documentation, I don't know if someone was here or not for discharge."

An interview was also conducted with the Chief Nursing Officer,Staff R, on 9/6/2018 at 1335. She was queried as to if the nurse was expected to give discharge instructions to the DPOA when requested even if it was the day prior to actual discharge to which she stated, "Yes. The DPOA should have gotten the discharge information even the day before (discharge)."

Based on record review and interview, the facility failed to reassess the patient's discharge plan for 1 (#19) of 19 patients resulting in the potential for poor patient outcomes. Findings include:

Review of the medical record for Patient #19 on 9/5/2018 at 1446 revealed that upon admission Patient #19 was assessed for risk of developing pressure sores using the Braden Scale (tool used to measure pressure ulcer risk). Patient #19 scored a 13 out of a possible 23 indicating that the patient was at high risk for developing pressure sores and one early pressure ulcer was identified in the admission assessment. Two wound care assessments were present by the wound care team; however, there was no evidence that report had been made to the physician and there was no recommendation for care. The nursing care plan did not address the patients pressure ulcers and at the time of discharge there was no documentation of plans for continued wound care after discharge. The patient was discharged on 08/09/2018, there was no documentation of discharge instructions regarding wound care to the family, adult foster care facility, or home care agency.

Staff S, identified as the nurse giving care on the last two days of the patient admission and the discharge nurse, was interviewed on 9/6/2018 at 0850 and queried as to the lack of discharge information on wound care. Staff S stated that the physician "hadn't ordered wound care instructions to be given." Staff S was then queried as to if she had contacted the physician for wound care orders to which she stated "No. I thought that was all handled by the wound care nurse and by the case manager."

On 09/06/2018 at 1000 Staff V the wound care nurse was interviewed. Staff V was asked if she was responsible for the care planning related to pressure ulcers and wounds. Staff V stated "I only do an assessment and make recommendations, the physician writes the orders and the RN taking care of the patient does everything else."

On 09/06/2018 at 1030 Staff M the case manager on the record for Patient #19 was asked about the lack of documentation on the plan of care related to the patients pressure ulcers requiring care when discharged. Staff M stated "The plan of care for the pressure ulcers is shared by the RN (registered nurse) and the Physician."

Physician Staff X, who served as the attending physician from 8/7/2018-8/9/2018, was interviewed on 9/6/2018 at 1302. Staff X was asked about the process for generating wound care for pressure ulcers. She explained that the wound care nurses could be consulted by staff nurses if they were concerned about a patient and then the wound care would send a note to the physician for orders for the treatment. Staff X was asked if a physician order was required for wound care to be continued when a patient was discharged, and she stated "Yes there should be an order for wound care if a patient is discharged with wounds. Staff X was asked why the patient of concern did not have wound care orders when he was discharged to which she stated, "I do not know how that was missed." She was then queried as to if she were aware that Patient #19 had wounds to which she stated, "I can't remember if I was aware or not of the wounds ...I don't see anything in my notes ..." When told that she had written an order for the Venelex ointment, she stated, "I must have been aware of it then."

An interview was also conducted with the Chief Nursing Officer Staff R on 9/6/2018 at 1335. She was queried as to her expectation regarding discharge information and who would be responsible for it to which she replied, "Any type of clinical care, nursing would be responsible...If the physician missed an order, the nurse should be able to catch those gaps and obtain an order."

On 09/06/2018 at 11:15 AM the policy titled "Discharge of the Patient-Depart Process" #5084663 dated revised 02/2012 was reviewed. On page 1 of 2 under Policy: 5 it states "The RN assigned to the patient at the time of discharge must assess patient, determine level of assistance required of patient for discharge...and document in the Interdisciplinary Discharge Plan section. If the patient is going to another health care facility the RN must also review...the final Discharge summary for information concerning the discharge plan."

Based on record review and interview, the facility failed to provide necessary medical information regarding the presence of wounds and wound care to the adult foster care facility upon discharge for 1 (#19) of 19 patients resulting in the potential for poor patient outcomes. Findings include:

Review of the medical record for Patient #19 on 9/5/2018 at 1446 revealed that Patient #19 had multiple wounds including a skin tear, pressure ulcers, and a blister at the time of discharge. Discharge documentation was found to be missing instructions regarding wound care.

Discharge nurse Staff S was interviewed on 9/6/2018 at 0850 and was queried as to the lack of information regarding wound care to which she stated that the physician "hadn't ordered wound care instructions to be given...When a patient goes to a facility like an adult foster care (AFC), the (unit clerk) puts the discharge packet together to send with the ambulance." Staff S was further queried as to if she had called report to the AFC to which she stated, "No."