HospitalInspections.org

Based on document review, observation and staff interview, it was determined for 7 of 13 patients reviewed for patients' rights (Pt. #s 3, 4, 5, 8, 9 and 13) the Hospital failed to ensure patient care was provided in a safe manner. As a result, the Condition of Participation for Patient Rights 42 CFR 482.13, was not met.

Findings include:

1. The Hospital failed to ensure the HUGS security system was intact to prevent potential infant abduction. See deficiency cited at A144 A.


The immediate jeopardy (IJ) began on 2/2/16 when the HUGS security system was removed on from an infant (Pt. #13) 2/2/16 at 10:40 AM. Pt. #13 remained without a security system for 24 hours. On 2/3/16 from 9:15 AM - 10:20 AM during a tour of the postpartum unit a Code Pink (Baby abduction) was activated at approximately 9:50 AM. The total baby count of seven (7) did not match the total babies (6 babies) in the HUGS computer system. During the recount of babies, it was determined that one of the babies (Pt. #13) did not have a HUGS security device on. This potentially allowed the removal of this baby without alarming the unit.

The Chief Operations Officer, Vice President Ancillary, Chief Executive Officer, Director of Nursing, Director of Quality Management, and the Vice President of Coordination of Care were notified of the Immediate Jeopardy at 2:30 PM on 2/3/16.

On 2/4/16 at 9:15 AM the Hospital presented a plan of correction that included revision of a the Nursing Department policy on "Infant Abduction (Code Pink) With Use of the Hugs System" (rev 2/16) The new policy included, "...the Nursery Staff to remove the tag from the baby and de-activate the system only at discharge time with parents or designee. At time of discharge, reconciliation of newborn will be conducted using two patient identifiers. Two members of the Nursing Staff shall document their signatures on the Newborn Identification form. In the event of delay after a discharge a newborn tag will be reapplied."

The staff education for the revised policy for all Nursery and postpartum staff began on 2/3/16 with a goal of completion of 2/15/16. The education agenda included the updated code pink policy, the 2 signatures on the discharge identification sheet, and census log.

A code pink was activated on 2/4/16 at approximately 9:44 AM. The staff observed during the code pink performed all activities required in the new policy. The discharge documentation for Pt #13's was reviewed on 2/5/16. Pt. #13 was discharged to the mother on 2/3/16 at 8:00 PM with the Newborn Identification form containing the signatures of two staff members and the mother.

Based on the plan of correction presented, and the code pink observation, the IJ is removed as of 2/5/16, however the Condition for Participation for Patient Rights, 42 CFR 482.13 remains out of compliance.

2. The Hospital failed to ensure the patients consented to the administration of psychiatric medications. See deficiency cited at A 131.

3. The Hospital failed to ensure patients were monitored every 15 minutes, as required. See deficiency cited at A 144 B.

4. The Hospital failed to ensure a physician's order was written for restraint device usage. See deficiency cited at A 168 .

5. The Hospital failed to ensure the patient was monitored while in restraints, as required. See deficiency cited at A 175.

Based on document review and interview it was determined that in 3 of 3 (Pt #3, 4, and 5) clinical records reviewed on the psychiatric unit, the Hospital failed to ensure the patients consented to the administration of psychotropic medications.

Findings include:

1. Hospital policy entitled, "Psychotropic Medications," (revised 5/14) required, "Procedure...2. The physician prescribing psychotropic medication will explain the risk and benefits of taking this medication to the patient. The physician will ask the patient for their consent to medicate, documenting agreement or refusal on the Psychotropic Medication Consent Form."

2. On 2/2/16 at approximately 12:45 PM the Hospital presented a list of approved psychotropic/antidepressant medications. The list included: Celexa; Prozac; Haldol; Risperdal; Trazodone; and Seroquel.

3. The clinical record of Pt #3 was reviewed on 2/2/16. Pt #3 was a 32 year old male admitted on 1/26/16 with a diagnosis of major depression with suicidal thoughts. Pt #3's clinical record contained physician's orders dated 1/26 and 1/27/16 for psychotropic medications, which included: Haldol (antipsychotic); Seroquel (antidepressant) and Celexa (antidepressant). The medication administration record for Pt #3 included the administration of the medications on 1/31, 2/1, and 2/2/16 as ordered. Pt #3's clinical record included a Psychotropic Medication Consent Form signed and dated 1/26/16 by the patient and physician. The form indicated the medications were reviewed and the patient agreed to take the medications with an understanding of the risks and benefits. The form failed to include the psychotropic medications that had been ordered and administered to the patient.

4. The clinical record of Pt #4 was reviewed on 2/2/16. Pt #4 was a 56 year old male admitted on 1/28/16 with a diagnosis of acute psychosis with suicidal thoughts. Pt #4's clinical record contained a physician's order dated 1/28/16 for psychotropic medications, which included: Prozac (antidepressant); Trazodone (antidepressant); and Haldol (antipsychotic). The medication administration record for Pt #4 included the administration of the medications on 1/29, 1/30, and 2/1/16 as ordered. Pt # 4's clinical record included a Psychotropic Medication Consent Form that was unsigned and undated by the patient and/or physician.

5. The clinical record of Pt #5 was reviewed on 2/2/16. Pt #5 was a 32 year old female admitted on 1/25/16 with a diagnosis of acute psychosis. Pt #5's clinical record contained a physician's order dated 1/25/16 for psychotropic medications, which included: Risperdal (antipsychotic) and Ativan (anti-anxiety). The medication administration record for Pt #4 included the administration of the medications on 1/29, 1/30, 1/31, 2/1, and 2/2/16 as ordered. Pt # 5's clinical record included a Psychotropic Medication Consent Form that included the ordered medications but was not signed by the physician.

6. The Manager of the 2 West mental health unit stated during an interview on 2/2/16 at approximately 10:30 AM that the consent forms were not completed as required.

A. Based on document review, observation and interview, it was determined for 1 of 7 (Pt. #13) babies, the Hospital failed to ensure the HUGS security system (Infant Protection System) was intact to prevent a potential infant abduction.

Findings include:

1. The Hospital Policy titled, "Infant Abduction (Code Pink) with use of the HUGS System (revised 12/15)" was reviewed on 2/3/16. The policy required, "The Nursery staff is responsible for applying the tag on the lower extremity of the baby and activating the HUGS system by entering the necessary information for the Newborn. When the baby is discharged, it will also be the responsibility of the Nursery staff to remove the tag from the baby and de-activate the system".

2. An observational tour of the Postpartum and Nursery areas was conducted on 2/3/16 from 9:15 AM - 10:20 AM. A Code Pink (Baby abduction) alarm was activated at approximately 9:50 AM. The total baby count of seven (7) did not match the total six (6)babies in the HUGS computer system. During the recount of babies, it was determined that one of the babies (Pt. #13) did not have on a HUGS security device.

3. The nurse (E#8) in the Nursery stated, "The band was already off when I came in at 7:00 this morning and the baby was discharged from the system because the mom was supposed to come get the baby this morning".

4. The HUGS log was reviewed on 2/3/16. Pt. #13's HUGS security system was removed on 2/2/16 at 10:40 AM (approximately 24 hours earlier).

5. During an interview on 2/3/16 at 10:15 AM, the Nurse Manager (E#7) stated, "The band should never have been removed before the mom came to take the baby home".




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B. Based on document review, observation, and interview, it was determined, for 2 of 2 patients (Pts. #8 and 9) on the telemetry unit being monitored under close observation for fall precautions, the Hospital failed to ensure the patients were monitored every 15 minutes, as required.

Findings include:

1. Hospital policy #6-1000-181, titled, "Close Observation", revised 4/2013, was reviewed on 2/2/16 at 2:45 PM. The policy required, "It is the policy of Nursing Services to institute close observation of a patient when... 3. The patient has been assessed as being 'at risk to fall'... Procedure... 3. The patient will be informed that she/he is on Close Observation and that he/she will be directly observed by staff every 15 minutes..."

2. On 2/2/16 between 9:30 AM and 11:20 AM, an observational tour was conducted on the telemetry unit. At 10:00 AM, 2 patients (Pts. #8 & 9) were in room 308, with a one to one sitter (E #3).

3. The clinical record of Pt. #8 was reviewed on 2/2/16 at 10:55 AM. Pt. #8 was a 75 year old male, admitted on 1/26/16, with diagnoses of acute exacerbation of chronic heart failure, chronic obstructive heart disease, and leukocytosis. A physician's order dated 1/27/16 at 9:04 PM, required close observation for fall precaution. Pt. #8's close observation record dated 2/1/16, lacked checks every 15 minutes between 11:00 PM and 12:00 AM and also on 2/2/16 between 7:00 AM and 8:15 AM.

4. The clinical record of Pt. #9 was reviewed on 2/2/16 at 11:00 AM. Pt. #9 was a 60 year old male, admitted on 1/31/16, with a diagnosis of multiple breakthrough seizures. A physician's order dated 2/1/16 at 1:57 AM, required close observation for fall/ seizure precautions. Pt. #9's observation record dated 2/2/16, lacked checks every 15 minute between 7:00 AM and 8:15 AM.

5. On 2/2/16 at 10:00 AM, an interview was conducted with a Sitter/Certified Nursing Assistant (E #3). E #3 stated the previous Sitter had to leave in a hurry and did not have time to complete the observation records for both patients on 2/2/16 between 7:00 AM and 8:15 AM.

Based on document review, observation, and interview, it was determined, for 1 of 1 patient (Pt. #8) wearing bilateral hand mitts, the Hospital failed to ensure a physician's order was written for restraint device usage.

Findings include:

1. Hospital policy #6-1000-145, titled, "Utilization of Human Restraint", revised 12/2015, was reviewed on 2/4/16 at 11:15 AM. The policy required, "Restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his/her arms, legs, head or body freely... Initiation of Restraint or Seclusion: 1. Each use of physical restraint or seclusion requires a written physician's order. Patients placed in soft wrist and ankle restraints ...gauze mittens...shall be observed...."

2. On 2/2/16 between 9:30 AM and 11:20 AM, an observational tour was conducted on the telemetry unit. At 10:00 AM, Pt. #8 was in bed, in room 308, with both hands in bulky hand mitts. Pt. #1 was unable to use his hands in activities of daily living.

3. The clinical record of Pt. #8 was reviewed on 2/2/16 at 10:55 AM. Pt. #8 was a 75 year old male, admitted on 1/26/16, with diagnoses of acute exacerbation of chronic heart failure, chronic obstructive heart disease, and leukocytosis. A nursing progress note dated 2/1/16 at 8:00 PM, included, "...patient refuses meds, hit and bit me when I tried to offer meds, mittens on..." Pt #8's clinical record failed to include a physician's order for the use of the hand mitts.

4. On 2/2/16 at 11:00 AM, an interview was conducted with the Telemetry Unit Manager (E #4). E #4 stated the hand mitts were not considered restraints, because they were "not tied down" and did not require a physician's order.

Based on document review, observation, and interview, it was determined, for 1 of 1 patient (Pt. #8) wearing bilateral hand mitts, the Hospital failed to ensure the patient was monitored while in restraints, as required.

Findings include:

1. On 2/4/16 at 10:20 AM, the E.M. Adams Company instructions for hand mitt application was reviewed. The instructions required: "Warning: 1. Caution: Patient should be checked per facility's policy...4. Caution: Do not cut off circulation - check circulation often..."

2. Hospital policy entitled, entitled, "Utilization of Human Restraints," (revised 12/15) required, "...Care of the Restraint Patient...3. Patients placed in soft wrist ...gauze mittens...shall be observed and assessed a minimum of every 2 hours. 4. The restrained patient's pulse and respiration will be assessed every two hours. 5. The patient placed in restraint shall be offered fluids...and toileting every two hours...11. The care of the patient in human restraint shall be documented on the 'Observation/Restraint Flow Sheet'. "

3. On 2/2/16 between 9:30 AM and 11:20 AM, an observational tour was conducted on the telemetry unit. At 10:00 AM, Pt. #8 was in bed in room 308, with both hands in bulky hand mitts.

4. The clinical record of Pt. #8 was reviewed on 2/2/16 at 10:55 AM. Pt. #8 was a 75 year old male, admitted on 1/26/16, with diagnoses of acute exacerbation of chronic heart failure, chronic obstructive heart disease, and leukocytosis. A progress note dated 1/31/16 at 8:00 PM, included, "...with mittens at both hands..." Another progress note dated 2/1/16 at 8:00 PM, included, "...mittens on..." Pt #8's clinical record lacked the required observation/check every 2 hours.

5. On 2/2/16 at 10:00 AM, an interview was conducted with the Sitter/Certified Nursing Assistant (E #3) caring for Pt. #8. E #3 stated Pt. #8 had been in hand mitts since she received the patient (7:00 AM) and the mitts had not been removed.

6. On 2/2/16 at 11:00 AM, an interview was conducted with the Telemetry Unit Manager (E #4). E #4 stated Pt. #8 was being assessed every 15 minutes under close observation. Close observation did not include circulation assessment.

7. On 2/4/16 at 2:05 PM, an interview was conducted with the Quality Director (E #16). E #16 stated there was no policy for hand mitt assessment.

A. Based on document review, observation, and interview, it was determined for 1 of 5 patients (Pt #7) receiving oxygen therapy, the Hospital failed to ensure physician's orders were carried out.

Findings include:

1. On 2/3/16 at 8:45 AM, Hospital policy #1-3000-11, titled, "Verbal and Telephone Orders", revised 2/2013, was reviewed. The policy required, "No treatment, medication or diagnostic test shall be administered to a patient except upon the written order of a member of the Medical Staff, a house staff member under the supervision of a member of the Medical Staff or allied health personnel..."

2. On 2/2/16 between 9:30 AM and 11:20 AM, an observational tour was conducted on the telemetry unit. At 9:40 AM, (Pt. #7) was in room 302, with oxygen at 5.5 liters per minute via nasal cannula, according to the wall gage. An oxygen saturation measurement device was not being used to measure Pt. #7's oxygen level.

3. The clinical record of Pt. #7 was reviewed on 2/2/16 at 10:45 AM. Pt. #7 was a 49 year old female, admitted on 1/31/16, with a diagnosis of status asthmaticus. A physician's order dated 1/31/16 at 10:19 AM, required 2 liters per minute as needed, titrate with pulse ox to keep oxygen saturation greater than 92%. Pt #7's clinical record lacked documentation of Pt #7's oxygen level that required the oxygen rate to be increased to 5.5 liters per minute.

4. On 2/2/16 at 9:40 AM, an interview was conducted with Pt. #7's Registered Nurse (E #5). E #5 stated he did not know why the oxygen flow valve was set to 5.5 liter per minute.



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B. Based on document review and interview it was determined that for 1 (Pt #11) of 2 clinical records reviewed for pain management on the 1 west unit, it was determined that the Hospital failed to reassess the patient's response to the pain medication as required per policy.

Findings include:

1. Policy entitled "Pain Management" (Reviewed 2/15) indicated, "...5. Pain assessment is documented on the Nursing Admission profile and Progress Note...Reassessment of the patient's pain, is done following implementation of pain management interventions...If pain medication is given the patient will be re-assessed within one (1) hour of administration."

2. Pt #11 was an 86 year old female admitted on 1/30/16 with a diagnosis of infection of the left big toe. Pt #11's clinical record contained a physician's order dated 1/31/16 for Ultram (pain medication) 50 milligram tablet every 8 hours as needed for pain. On 2/1/16 at 9:03 AM Pt #11 was administered a dose of Ultram. Pt #11's clinical record lacked documentation of a pain reassessment following the administration of the pain medication, as required.

3. On 2/2/16 at approximately 11:00 AM the nurse educator reviewed Pt #11's clinical record and indicated the required pain reassessment had not been done following the administration of the Ultram on 2/1/16 at 9:03 AM.

Based on document review and interview it was determined that in 1 of 2 (Pt #1) clinical records reviewed on the Medical Detox unit, the Hospital failed to ensure complete documentation of the administration of subcutaneous medications.

Findings include:

1. Hospital policy entitled, "Medication Administration Record," (reviewed 4/13) required, "Policy...6. When an injectable medication is administered, the nurse shall document the injection site..."

2. The clinical record of Pt #1 was reviewed on 2/2/16. Pt #1 was a 43 year old male admitted on 1/30/16 with diagnoses of alcohol withdrawal and major depression. Pt #1's clinical record contained physician's orders dated 1/30/16 that included: Lovenox (anticoagulant) 40 mg subcutaneous daily; Novolog Insulin with every meal; Lantus (long acting insulin) subcutaneous at bedtime; and sliding scale insulin every 6 hours. Pt #1's medication administration administration record included that Pt #1 received the medication as required however, the documentation failed to include the site of administration.

3. The Manager of the Medical Detox unit stated during an interview on 2/2/16 at approximately 11:15 AM that the documentation of the injections do not include the site.

Based on document review and interview it was determined, the Hospital failed to ensure that medical records were completed within 30 days after discharge.

Finding include:

1. The "Medical Staff Bylaws and Rules and Regulations (approved 11/20/13) indicated "If after (30) days following discharge, medical records are still incomplete, Administration will notify the attending physician that his admission privileges have been suspended until the delinquent records have been completed."

2. On 2/4/16 at approximately 2:13 PM, the Hospital presented an attestation letter that indicated the Hospital had a total of 51 delinquent records past 30 days.

3. On 2/5/16 at approximately 10:05 AM the Director of Health Information Management stated that there are 51 incomplete medical records and our goal is zero.

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Based on document review, observation, and interview it was determined that in the Surgical Department, the Hospital failed to ensure medications were secured in accordance with policy. This potentially affected all three (3) patients scheduled for surgery on 2/3/16.

Finding include;

1. Hospital policy entitled, "Nursing Medication Policy," (Revised 7/15) indicated, "Special Instructions: 1. B. Medications are properly and safely stored. Medication Carts are to be locked or in a secure are (i.e. Medication Room) when not under the constant surveillance of the nurse."

2. On 2/3/16 at approximately 9:30 AM an observational tour was conducted in the surgery department. In the "Anesthesia Medication Room" (adjacent to the recovery unit and anesthesia office), there was an unlocked refrigerator that contained medications. The doors to the medication room were not locked.

3. On 2/3/16 at approximately 9:32 AM the Surgery Manager (E #9) was interviewed. E #9 stated she was unclear why the refrigerator was kept unlocked.

4. On 2/3/16 at approximately 9:50 AM the anesthesiologist (MD #2) was interviewed. MD #2 stated the refrigerator is unlocked in the morning and remains unlocked until the unit closes at night.

This was found in the male locker room in the Operating Room (OR):

5. On 2/3/16 at 9:00 AM, an observational tour was conducted in the OR. In the male locker room, locker 15's door was partially open. Six unopened medication vials (1 Lidocaine 30 ml, 2 Sensocaine 30 ml, and 3 Lidocaine with Epinephrine 5 ml) were in the unlocked locker.

6. On 2/3/16 at 10:25 AM, the same locker door was still ajar and an interview was conducted with a Surgeon (MD #1). MD #1 stated he placed the medications in locker 15 for later use in the Intensive Care Unit. MD #1 stated the locker door automatically locks when it is closed.

7. The Manager of the surgical department stated during an interview on 2/3/16 at approximately 10:30 AM that she was unaware of medications being kept in physician's lockers. The Manager stated, during an interview on 2/5/16 at approximately 11:30 AM, that medications should not be kept in the physicians locker.

Based on document review, observation, and interview it was determined that for 1 of 7 in-patient units (1 West), the Hospital failed to ensure controlled substances were kept secure as per policy. This potentially affected all 13 patient on census.

Findings include:

1. Policy entitled "Nursing Medication Policy, " (revised 7/15) indicated, "...IV. b.) Narcotics and controlled drug substances will be placed in the double locked safe reserved for these medications. V. Narcotic Policy and Procedure...B.2. a.) Narcotic usage on the patient care units will be audited daily by the Pharmacy. b) Audits will be done from the daily Narcotic Sheet in Pharmacy concerning usage, errors, wastage, and any irregularities..."

2. The "Controlled Substances Inventory" sheet was reviewed on 2/2/16. The sheet included "Ativan (antianxiety) 2 mg/1 ml" as a Schedule IV controlled substance to be counted.

3. On 2/2/16 at approximately 10:10 AM during observational tour of the Medical Unit (1 West), in the refrigerator located in the medication room, there were 2 vials of Ativan (antianxiety medication) 2 mg/1 ml in a bin. The "Daily Narcotic Record" dated 2/2/16 failed to include the Ativan.

4. On 2/2/16 at approximately 10:13 AM the nurse (E #10) was interviewed. E #10 stated she was not aware Ativan was in the refrigerator, and stated she was not aware Ativan was required to be kept locked or included in the daily count of the controlled substances.

5. On 2/2/16 at approximately 10:15 AM the nurse Educator (E #11) was interviewed. The educator stated the Ativan should have been kept locked in the refrigerator and included in the daily count of controlled substances.

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety code portion of a full survey due to complaint conducted on February 2-3, 2016 the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety portion of a full survey due to complaint conducted on February 2-3, 2016 the surveyors find that the facility does not comply with the applicable provisions of the 2000 edition of NFPA 101 Life Safety Code.

See the life safety code deficiencies identified with the K-tags.

Based on document review, observation, and interview, it was determined, for 2 of 2 Registered Nurses (E #5 & 12) and 1 of 1 Patient Care Attendant (E #15) observed removing gloves, the Hospital failed to ensure staff disinfected their hands after removing gloves. This potentially affected all 32 patients on the Telemetry unit on 2/3/16.

Findings include:

1. On 2/2/16 at 1:30 PM, Hospital policy #1-4500-16, titled, "Exposure Control Plan", revised 3/2014, was reviewed. The policy required, "Work Practice Controls... 2. Employees will clean their hands... as soon as possible after removing gloves..."

2. On 2/2/16 between 9:30 AM and 11:20 AM, an observational tour was conducted on the telemetry unit. At 9:40 AM, a Registered Nurse (E #5), while wearing gloves, gave Pt. #7 an injection of Enoxaparin (anticoagulant) 40 mg, via the subcutaneous route. E #5 removed his gloves, but did not perform hand hygiene and then proceeded to touched a portable computer.

3. On 2/2/16 at 9:45 AM, an interview was conducted with the Telemetry Nurse Manager (E #4). E #4 stated E #5 did not disinfect his hands right after removing his gloves, but did disinfect his hand when he exited Pt. #7's room.

4. On 2/3/16 at 11:40 AM, a central venous catheter dressing change for Pt. #30 was performed by a Registered Nurse (E #12) in room 323, on the Intermediate Care Unit. After E #12 removed the dressing and cleaned Pt. #30's catheter site, E #12 changed her gloves, but did not disinfect her hands. E #12 donned new gloves and applied a new catheter dressing to Pt. #30's catheter site.

5. On 2/3/16 at 11:45 AM, an interview was conducted with E #12. E #12 stated the catheter guidelines did not indicate hand disinfection was required when removing gloves between the site cleaning and dressing application.

6. On 2/3/16 at 2:00 PM, and interview was conducted with the Nurse Manager of Infection Control (E #13). E #13 stated hand washing is always required after glove removal.

7. On 2/4/16 at 9:30 AM, an observation of a blood draw in the Outpatient Laboratory was conducted. A Patient Care Attendant (E #15), while wearing gloves drew blood from another employee for an annual health screening. E #15 removed the gloves, did not disinfect hands, donned new gloves, and labeled the blood tubes. E #15, for a second time, removed the gloves, did not disinfect her hands, and performed data entry on a keyboard.

8. On 2/4/16 at 9:35 AM, an interview was conducted with a Registered Nurse (E #1). E #1 stated E #15 should have disinfected her hands on both occasions, after removing her gloves.

Based on document review and interview, it was determined for 1 (Pt. #25) of 1 patient discharged with home health service, the Hospital failed to ensure discharge instructions were complete.

Findings include:

1. On 2/4/16 at approximately 10:00 AM, the clinical record review for Pt. #25 was reviewed. Pt. #25 was an 89 year old male admitted on 1/31/16 with a diagnosis of infected foot ulcer. Pt #25's clinical record contained a social service note dated 1/19/16 at 2:23 PM that included the name and phone number of a home health agency that would be following the patient after discharge. Pt #25's discharge instructions dated 1/18/16 failed to include the contact information for the home health services.

2. Hospital policy #6-1000-53 titled, "Discharge of Patients," (reviewed 2/15) required, "1. Discharged patients will receive written and verbal instructions by the Registered Nurse, including information regarding...home care and follow-up physician visit."

3. On 2/4/16 at approximately 10:20 AM, an interview was conducted with the Coordinator of Care who stated that the discharge instructions failed to include the name and phone number for the home health service.