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Based on record reviews and interviews, the facility 1) Failed to provide wound care instruction upon discharge to one (Patient #2) of ten sampled patients and 2) Failed to complete a discharge planning assessment for one (Patient #14) of ten sampled patients. (SP)

The findings included:

Review of the facility's " Discharge Planning Policy," reviewed 05/14, showed that the care manager/social worker assessed all patients prior to discharge to determine post hospitalization needs. The policy also stated that when applicable, the care manager or social worker will provide medical information to the post-acute provider in order to coordinate services.

Review of Nursing documentation for Sampled Patient (SP)#2, on 10/23/14 at 6:49PM showed that the patient did not have any wounds. Nursing documentation on 10/27/14 at 5:00PM showed that the patient had skin tears to the right scapula and right elbow with A dry dressing in place. Xeroform dressing was placed. On 10/27/14, wound care orders for the right scapula and right elbow was as follows: cleanse with normal saline and cover with sterile xeroform dressing. On 10/29/14 showed that the patient had A stage II wound to the right hip. Treatment was triple antibiotic and mepilex foam dressing. The patient also had A skin tear/small ulcer to right buttock. On 10/29/14, wound care orders for the right scapula, right elbow and right hip was as follows: cleanse with normal saline, apply triple antibiotic ointment and cover with sterile xeroform dressing. Nursing documentation on 11/03/14, when the patient was discharged showed that the patient had skin tears to the right scapula and right elbow with a dry dressing in place. The patient had a stage II wound to the right hip with foam dressing. The patient also had a skin tear/small ulcer to the right buttock with dressing. Review of the patient's discharge instruction on 11/03/14 showed that discharge medications included neomycin-bacitracin-polyxin ointment. Instructions were to apply one application daily. The patient's medical record did not show any discharge instructions for wound care.

On 04/15/15 at 9:40AM, Staff C, a Registered Nurse (RN for SP#2), stated that SP#2 was non-compliant with medications and care. He stated, the Neosporin was used for the patient's wound and that it was explained to SP#2 to continue the same treatment upon discharge.


On 04/15/15 at 10:00AM, Staff D, a Case Manager for SP#2, stated that the assisted living facility (ALF) was contacted for SP#2. She stated that the ALF representative spoke Spanish and that the call was referred to the social worker because she did not speak Spanish. She stated, if a patient who had wounds was being discharged, the physician would be contacted to write wound care orders.


On 04/15/15 at 12:50PM, the Staff E, a Social Worker, stated that she was not informed by the case manager of any wounds. She stated that the patient had a bandage on the shoulder and when she asked the nurse about it, she was told that the patient scratched himself.


2) Review of the facility's "Discharge Planning Policy," reviewed 05/14, showed that in accordance with state regulations, all patients will have an initial assessment completed with 24 hours of admission.


Review of sampled patient (SP)#14 medical records showed that the patient was admitted to the facility from 04/08/15 to 04/10/15. Case manager documentation on 04/09/15 stated that the patient was in the Operating Room for cardiac catheterization and percutaneous transluminal coronary angioplasty (PTCA). During cardiac catheterization a code blue called and cardiopulmonary resuscitation (CPR) for asystole performed on the patient. After CPR, the patient was awake, alert and complained of nausea and vomiting. the PTCA was deferred for 04/09/15. A Case management note on 04/09/15 stated that the patient was in the OR for PTCA. A Nursing note on 04/10/15 at 11:31AM stated, " patient given discharge instructions, prescriptions given. Patient right and left groin intact, no hematoma noted. Patient transported to main lobby. Review of the discharge instruction showed that the patient was discharged home by self. Discharge Summary on 04/10/15 showed that on 04/09/15, the patient had a temporary pacemaker and stent of the left anterior descending artery (LAD). Review of the patient's medical record did not show that the patient was assessed by a case manager/social worker.


On 04/15/15 at 12:50PM, the Director of Case Management stated that case managers do an initial assessment on all patients within 24 hours of admission. She stated that the case manager attempted to do SP#14's initial assessment. However, the patient was in the OR and then left the next day.

Based on record reviews and interviews, the facility failed to provide a one to one sitter for four (Patient #1, 3, 4,and 5) of eleven sampled patients, per physician orders.

Based on observation, record reviews and interview, the facility failed to administer medication at scheduled times, per the facility's policy, for one (Patient #12) of ten sampled patients.



The findings included:

1) On 04/15/15 at 10:10AM, Sampled Patient (SP)#1 stated that a few weeks ago, he fell in the facility. SP#1 stated that someone was supposed to be there in the room with him however, no one was there. He stated that he was not trying to get up out of the bed. He stated that he was just lying down and the next thing he knew he was lying on the floor. He stated that he doesn't remember if the side rails were up. He stated that he cannot walk because he had weakness in both legs.

Review of SP#1 medical record showed that the patient was legally blind. The patient's medical record showed that on 03/04/15 at 9:21AM, the physician ordered a one to one (1:1) sitter on a routine basis for SP#1. Nursing note on 03/22/15 at 6:02PM stated that pt had a fall and was taken to a Computed Tomography scan and is positive for bilateral subarachnoid brain bleed. The note stated that the patient was transferred to the Intensive Care Unit. Nursing note on 03/22/15 at at 8:37AM stated, "while I was in another patient's room, pt (patient) found on the floor by PCT (Patient Care Technician). Pt awake, alert and oriented to his name, follows commands. Nursing documentation on 03/22/15 did not show that a sitter was at the patient's bedside.


On 04/15/15 at 9:27AM, Staff A, a Licensed Practical Nurse (LPN for SP#1) stated when the patient fell he was in room 726. She stated that she was in another patient's room when the PCT came and told her that the patient was on the floor. She stated that when she went into SP#1's room, SP#1 was on the floor. The charge nurse and other staff came to help put the patient back into bed. She stated that the physician was notified and a 1:1 sitter was ordered immediately. She stated that there was no order for sitter before the patient's fall. She stated that the patient did not show any previous signs of behavioral problems which could indicate a risk for falls. She stated that the patient was alert and oriented times three.

On 04/15/15 at 11:01AM, Staff B, a Charge Nurse (for SP#1) stated that SP#1 was just transferred from the six floor before he fell. She stated that SP#1 did not have orders for a sitter upon transfer to the floor. She stated that she doesn't know what exactly made the patient fall. She stated that SP#1 did not seem confused as she had a conversation with him that night. She stated that SP#1's fall was unwitnessed. She stated that after SP#1's fall, a sitter was placed at the bedside, and staff huddles were held to discuss fall prevention strategies.



2) Review of SP#3 medical record showed that the patient was admitted to the facility on 03/12/15. The medical record showed that on 03/12/15 at 2:56PM, the physician ordered a 1:1 sitter at bedside on a routine basis. Nursing documentation showed that there was no sitter at the patient's bedside until 03/26/15 at 9:00AM.

3) Review of SP#4 medical record showed that the patient was admitted to the facility on 04/10/15. The medical record showed that on 04/10/15 at 2:47AM, the physician ordered a 1:1 sitter at bedside on a routine basis. Nursing documentation showed that there was no sitter at the patient's bedside until 04/10/15 at 8:00PM.


4) Review of SP#5 medical record showed that the patient was admitted to the facility on 04/10/15. The medical record showed that on 04/12/15 at 4:39PM, the physician ordered a 1:1 sitter at bedside on a routine basis. Nursing documentation showed that there was no sitter at the patient's bedside until 04/13/15 at 8:00AM.

On 04/14/15 at 1:15PM, Staff G, a Sitter, stated that when a sitter is ordered, the sitter has to be in the patient rooms at all times.


5) Review of the facility's " Medication Administration Policy, " reviewed 09/14, showed that daily medications must be administered two hours before or after the scheduled timeframes. The policy also showed that medications that are prescribed more frequently than daily but not more than four hours must be administered one hour before or after scheduled times.


On 04/14/15 at 12:30PM, Staff E, a Registered Nurse (RN) was observed as she gave Sampled Patient (SP)#12's scheduled medications. The medications administered were Heparin, Metoprolol and Insulin. Review of SP#12's Medication Administration Record (MAR) showed that Plavix and Metoprolol were ordered daily at 9:00AM and heparin was ordered every eight hours. Review of the facility's "Medication Administration Policy, " reviewed 09/14, showed that medications that were ordered every eight hours were scheduled daily at 12:00AM, 8:00AM, and 4:00PM. Further review of the MAR showed that the patient ' s 4:00PM dose of heparin was not administered. There was no documentation why heparin was not given at 4:00PM.

Based on record reviews and interviews, the facility failed to provide a one to one sitter for four (Patient #1, 3, 4,and 5) of eleven sampled patients, per physician orders.

Based on observation, record reviews and interview, the facility failed to administer medication at scheduled times, per the facility's policy, for one (Patient #12) of ten sampled patients.



The findings included:

1) On 04/15/15 at 10:10AM, Sampled Patient (SP)#1 stated that a few weeks ago, he fell in the facility. SP#1 stated that someone was supposed to be there in the room with him however, no one was there. He stated that he was not trying to get up out of the bed. He stated that he was just lying down and the next thing he knew he was lying on the floor. He stated that he doesn't remember if the side rails were up. He stated that he cannot walk because he had weakness in both legs.

Review of SP#1 medical record showed that the patient was legally blind. The patient's medical record showed that on 03/04/15 at 9:21AM, the physician ordered a one to one (1:1) sitter on a routine basis for SP#1. Nursing note on 03/22/15 at 6:02PM stated that pt had a fall and was taken to a Computed Tomography scan and is positive for bilateral subarachnoid brain bleed. The note stated that the patient was transferred to the Intensive Care Unit. Nursing note on 03/22/15 at at 8:37AM stated, "while I was in another patient's room, pt (patient) found on the floor by PCT (Patient Care Technician). Pt awake, alert and oriented to his name, follows commands. Nursing documentation on 03/22/15 did not show that a sitter was at the patient's bedside.


On 04/15/15 at 9:27AM, Staff A, a Licensed Practical Nurse (LPN for SP#1) stated when the patient fell he was in room 726. She stated that she was in another patient's room when the PCT came and told her that the patient was on the floor. She stated that when she went into SP#1's room, SP#1 was on the floor. The charge nurse and other staff came to help put the patient back into bed. She stated that the physician was notified and a 1:1 sitter was ordered immediately. She stated that there was no order for sitter before the patient's fall. She stated that the patient did not show any previous signs of behavioral problems which could indicate a risk for falls. She stated that the patient was alert and oriented times three.

On 04/15/15 at 11:01AM, Staff B, a Charge Nurse (for SP#1) stated that SP#1 was just transferred from the six floor before he fell. She stated that SP#1 did not have orders for a sitter upon transfer to the floor. She stated that she doesn't know what exactly made the patient fall. She stated that SP#1 did not seem confused as she had a conversation with him that night. She stated that SP#1's fall was unwitnessed. She stated that after SP#1's fall, a sitter was placed at the bedside, and staff huddles were held to discuss fall prevention strategies.



2) Review of SP#3 medical record showed that the patient was admitted to the facility on 03/12/15. The medical record showed that on 03/12/15 at 2:56PM, the physician ordered a 1:1 sitter at bedside on a routine basis. Nursing documentation showed that there was no sitter at the patient's bedside until 03/26/15 at 9:00AM.

3) Review of SP#4 medical record showed that the patient was admitted to the facility on 04/10/15. The medical record showed that on 04/10/15 at 2:47AM, the physician ordered a 1:1 sitter at bedside on a routine basis. Nursing documentation showed that there was no sitter at the patient's bedside until 04/10/15 at 8:00PM.


4) Review of SP#5 medical record showed that the patient was admitted to the facility on 04/10/15. The medical record showed that on 04/12/15 at 4:39PM, the physician ordered a 1:1 sitter at bedside on a routine basis. Nursing documentation showed that there was no sitter at the patient's bedside until 04/13/15 at 8:00AM.

On 04/14/15 at 1:15PM, Staff G, a Sitter, stated that when a sitter is ordered, the sitter has to be in the patient rooms at all times.


5) Review of the facility's " Medication Administration Policy, " reviewed 09/14, showed that daily medications must be administered two hours before or after the scheduled timeframes. The policy also showed that medications that are prescribed more frequently than daily but not more than four hours must be administered one hour before or after scheduled times.


On 04/14/15 at 12:30PM, Staff E, a Registered Nurse (RN) was observed as she gave Sampled Patient (SP)#12's scheduled medications. The medications administered were Heparin, Metoprolol and Insulin. Review of SP#12's Medication Administration Record (MAR) showed that Plavix and Metoprolol were ordered daily at 9:00AM and heparin was ordered every eight hours. Review of the facility's "Medication Administration Policy, " reviewed 09/14, showed that medications that were ordered every eight hours were scheduled daily at 12:00AM, 8:00AM, and 4:00PM. Further review of the MAR showed that the patient ' s 4:00PM dose of heparin was not administered. There was no documentation why heparin was not given at 4:00PM.


On 04/14/15 at 12:40PM, Staff F, RN stated that she had six patients. She stated that SP#12 was the last patient to whom she had to give morning medications. She also stated that she had a RN orientee with her.

Based on observation, record reviews and interview, the facility failed to administer medications at scheduled times, per the facility's policy, for one (Patient #12) of ten sampled patients.


The findings included:

Review of the facility's "Medication Administration Policy," reviewed 09/14, showed that daily medications must be administered two hours before or after the scheduled timeframes. The policy also showed that medications that are prescribed more frequently than daily but not more than four hours must be administered one hour before or after scheduled times.


On 04/14/15 at 12:30PM, Staff E, a Registered Nurse (RN) was observed as she gave Sampled Patient (SP)#12's scheduled medications. The medications administered were Heparin, Metoprolol and Insulin. Review of SP#12's Medication Administration Record (MAR) showed that Plavix and Metoprolol were ordered daily at 9:00AM and heparin was ordered every eight hours. Review of the facility's "Medication Administration Policy, " reviewed 09/14, showed that medications that were ordered every eight hours were scheduled daily at 12:00AM, 8:00AM, and 4:00PM. Further review of the MAR showed that the patient's 4:00PM dose of heparin was not administered. There was no documentation why heparin was not given at 4:00PM.


On 04/14/15 at 12:40PM, Staff F, RN stated that she had six patients. She stated that SP#12 was the last patient to whom she had to give morning medications. She also stated that she had a RN orientee with her.