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Based on interview and record review the facility failed to ensure an interdisciplinary plan of care was implemented to adequately assess for changes in condition for 1 of 10 sampled patients, Patient #1, as evidenced by failing to intervene in a timely manner when changes in condition were observed for Patient #1.

The Findings Include:

Patient #1 was admitted to the Rehabilitation facility on 04/16/15 status post elective total left knee replacement.

Review of the initial nursing assessment dated 04/16/15 documents the patient is awake, alert and oriented x 3; vital signs are within normal range; and the left knee dressing is dry and intact.

Review of the initial physician orders dated 04/16/15 document services to include, Initiate Plan of Care; Patient/Plan of Care Review; Vital Signs assessment twice daily; Skin/Wound Assessment 3 times daily; Nursing Assessment 3 times daily; Physical Therapy Evaluation and Treatment; Occupational Therapy Evaluation and Treatment; and Care Plan Update every 3 days.

Review of the clinical record revealed an Occupational Therapy (OT) evaluation was completed on 04/17/15 at 1115 with the OT documenting the patient has mild to moderate cognitive deficits.

Review of the Physical Therapy Assistant (PTA) documentation on 04/17/15 at 1300 documents the patient missed 45 minutes of therapy with no documentation for the reason for missing therapy and no evidence nursing was advised that therapy was not completed.

Review of the OT notes dated 04/17/15 at 1430 documents the 'patient requires frequent rest breaks due to complaints of fatigue.'

Review of a Vital Signs log for 04/17/15 at 1530 documents the patient's temperature is 98.2 degrees, heart rate 111 and blood pressure 164/70. Further review of the clinical record revealed these were the only documented vital signs on 04/17/15.

Review of the PTA notes dated 04/17/15 at 1609 documents the 'patient appeared confused today, unable to tolerate weight bearing to left lower extremity.' Review of the clinical record revealed no evidence of documentation nursing staff were alerted to the patient's status in therapy.

Review of Nursing Notes Assessments dated 04/17/15 at 1612 and 1745 reveals no documentation of vital signs or condition of the left knee dressing/incision area.

Review of a Skin Assessment dated 04/18/15 at 0400, nursing documents under Skin Turgor Assessment - 'Elastic.'
Further review of the clinical record revealed the next vital signs entry is dated 04/18/15 at 0500 documenting the patient's temperature was 100.5 degrees orally and heart rate was 110. Further review of the clinical record revealed no evidence the physician was notified the patient had an increased temperature or heart rate.

Review of the PT notes dated 04/18/15 at 1345 documents 'Patient sat in wheelchair group for 45 minutes but was not able to stay awake. I tried several times to wake him and he just was not able to keep his eyes open.' Review of the clinical record revealed no evidence the patient's nurse was apprised of the patient's response during therapy.

Review of nursing documentation dated 04/18/15 at 1508 states 'CN (Charge Nurse) made aware of left knee redness warm to touch, temp 99.8'. There is no evidence the physician was notified of the low grade fever or knee redness and warm to touch.

Review of the Vital Signs Log dated 04/18/15 at 1553, nursing documents the patient's temperature is 97.7 degrees and blood pressure is 90/40. There is no evidence of documentation the physician was notified the blood pressure was low.

Review of an OT note dated 04/18/15 at 1619, the Occupational Therapy Assistant (OTA)documents 'Patient with minimal response to treatment, required frequent redirection to task.' Review of the clinical record revealed no evidence of documentation nursing staff were alerted to the patient's status in therapy.

Review of a physician Progress Note dated 04/18/15 completed at 2126 states in part, 'Patient was seen and examined earlier today at bedside. I have been called to the patient's bedside due to concern about left knee edema. Healing left knee incision with associated erythema but no drainage. There is associated local edema but not more than expected. Neuro slightly lethargic but appropriate with questions. Assessment/Plan - left lower limb edema, consistent with left total knee arthroplasty. Leukocytosis (elevated white blood cell count) - unclear etiology. Patient is afebrile. Consider consultation to infectious disease should there be further concern. May simply represent an acute phase reactant. However platelet cell count is normal. The physician documents the patient's lab work as of 04/17/15- WBC (white blood cells) 15.1 (norm 4.5-13.5); Hemoglobin 8.4 (norm 13-18); Hematocrit 26 (norm 40-52).

Review of a Skin Assessment dated 04/18/15 at 2342, nursing documents under Skin Turgor Assessment - 'Non-Elastic.'(Possible indication of dehydration when skin is pinched it remains in the pinched position and does not lay flat.)

On 04/19/15 at 0446 nursing documents the patient's temperature was 99.2, heart rate 106, and blood pressure was 112/56. There is no evidence of documentation in the clinical record the physician was notified of the low grade fever.

04/19/15 at 0710 nursing note documents 'Receive patient from night RN; night RN stated patient needs cuing; patient was sleeping.'

On 04/19/15 at 1241 nursing notes document 'Patient refused to eat lunch. Patient complains of pain to left knee. Pain medication given. Patient is able to communicate basic need. Patient stated he is very tired and just wants to sleep'.

On 04/19/15 at 1354 nursing notes document ' Reassess patient pain. Patient open his eyes stated decrease in pain. Patient still sleeping. Patient refused to wake up. Offer patient to eat lunch. Patient stated not hungry and closed back his eyes'.

On 04/19/15 at 1500 nursing documented the patient's temperature was 101.1 degrees. The last temperature check is documented as 99.2 degrees at 0446 on 04/19/15, 10 hours prior. Review of the clinical record revealed no evidence of documentation the physician was notified the patient's temperature had spiked from 99.2 degrees to 101.1 degrees.

On 04/19/15 at 1529 nursing documented 'Report given to oncoming RN about patient mental status. Patient needs cuing. Patient sleeps most of the day. Patient is lying in bed sleeping. Seen by oncoming RN'.

On 04/19/15 at 16:00 nursing documented 'Patient in bed very lethargic but respond to verbal stimuli. VS temperature 101.1 oral, pulse 104, respirations 22, oxygen saturation on room air 87%, will continue to monitor, place patient on oxygen per protocol at 2 liters via nasal cannula; oxygen saturation up to 94%'.

On 04/19/15 at 1655 nursing documented 'Patient lethargic, temperature 101.1. Physician notified. Orders received for blood cultures x 2 stat /urine stat'.

On 04/19/15 at 1800 nursing documented in the Vital Signs Log, the patient's temperature is 100 degrees.

On 04/19/15 at 2300 nursing documented 'Patient still lethargic but respond to verbal stimuli; left knee incision glue dressing in place dry and clean; cold compress to forehead due to temp 99.0 axillary; BP 116/56, pulse 90, respirations 20, oxygen saturation 96% on 2 liters nasal cannula; POC (plan of care) reviewed with oncoming nurse'.

Review of a physician order taken by the RN on 04/20/15 at 0741 documenting 'Change in orientation, transfer 911. Low hemoglobin 5.3 (norm 13.0-18.0), change in mental status; given Narcan with some improvement but not baseline call (name of doctor) in ER'.

Review of a Physician Progress Note dated 04/20/15 dictated at 1052 states in part, 'I came in the room to evaluate patient who I found to be confused and difficult to awaken from sleep. I was able to awaken him but he could not tell me his name. He could not follow simple commands... Pending labs ..... Question raised about how alert and oriented the patient actually was this morning, and it was suggested that there could have been some changes going on throughout the entire weekend. Lab results revealed elevated WBC 26.2 from 15.1; Hemoglobin 5.3 from 8.4; Platelet count from 231 to 309,000 (norm 150-400); BUN (Blood Urea Nitrogen) from 27 to 91 (norm 6-22); dehydration with a creatinine from 1.1 to 1.9 (norm 0.43-1.13). The patient is transferred back to the acute care hospital.'

On 01/25/16 at 3:20 p.m. in an interview with the Chief Nursing Officer (CNO), the time line was reviewed regarding no nursing documentation the physician was notified of changes in the patient's condition and no therapy documentation nursing was notified of changes in the patient's condition while in therapy. The CNO stated she was not CNO at that time but she will look in the nursing care plans and other clinical documentation that may be able to show communication among the disciplines.
In an interview with the Director of Rehabilitation on 01/25/16 at 3:30 p.m., she stated nursing have access to the therapy notes but probably do not look at them however the therapy looks through the nursing notes for changes and new orders. She stated the therapists look constantly at the orders and check them before the therapy session is started and if there was a change in the patient's condition the therapist would tell the nurse.

On 01/25/16 at approximately 3:45 p.m. a request was made to the CNO and Risk Manager (RM) to review the facility policy for the procedure to follow if there is a change in patient's condition.

On 01/25/16 at approximately 4:10 p.m. the RM stated they could not find a specific policy on change in patient condition however she stated during the annual Risk Management training they discuss Risk Reduction and Change in Patient's condition. The RM stated this training is mandatory for all staff. Review of the power point presentation slide the RM stated she uses in the training states in part, 'Change in Patient Condition - Assess patient including vital signs; Review pertinent diagnostic findings; Notify physician immediately; Document events and interventions. Remember you are ultimately responsible for notifying the physician.'
Additionally the CNO stated during the interview on 01/25/16 at approximately 4:10 p.m., in March 2015, 100% of the nursing staff took a course covering the topic Recognizing and Responding to Changes in Condition.

On 01/25/16 at 4:18 p.m. during an interview with the CNO she stated she was not able to find the documentation requested regarding physician notification of changes in the patient's condition. She stated she reviewed the nursing care plans however they only reflected the patient's status on the initial admission assessment. During the interview with the CNO and RM on 01/25/16 at 4:18 p.m. they confirmed that all disciplines have access to all documentation in the computerized clinical record so nursing can look at therapy and therapy can look at nursing documentation.

On 01/25/16 at 4:50 p.m. an inquiry was made to the CNO about the protocol for dressing changes and wound care to which she stated Patient #1's physician does not like the dressing removed and will do it himself at the first follow up visit. Nursing documentation was reviewed with the CNO at this time showing on 04/18/15 the nurse documented skin adhesive to the left knee and on 04/19/15 the nurse documented the edges were well approximated. The CNO stated she will review the clinical record for the order for dressing changes.
On 01/25/16 at 5:05 p.m. the CNO stated she reviewed the patient's record and did not find an order for dressing changes. She stated during the interview on 01/25/16 at 5:05 p.m. 'if the nurses were changing the dressings there is no documented evidence of it'.

Review of the facility Nursing Policy on Standards of Nursing Care documents in part, 'The patient can expect an interdisciplinary approach to their plan of care through efforts of the rehabilitation team; The Patient can expect that the nursing process will be utilized to prepare and implement their plan of care during hospitalization.'