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Based on interviews, observations, and documentation review the Hospital failed to ensure that: 1). staff followed the Fall Prevention Policy for five of nine patients (Patient #1, Patient #2, Patient #4, Patient #8, and Patient #9); 2). staff followed the Hospital's policy related to pressure sore prevention or perform skin assessments for three of nine patients (Patient #1, Patient #6, and Patient #9).

Findings included:

1). The Hospital's Policy/Procedure titled Fall Prevention indicated that all patients were assessed upon admission for their fall risk potential (low or high). Assessments will be done daily unless Patient #1's condition changes. The level of risk potential was based on a numerical score; patients scoring 5 or more were considered to be at high risk. Low risk interventions included: bed in the low position with brakes locked; top side rails in the up position; call light in reach, and offer toileting frequently every 2 hours if awake and after meals. High risk interventions included: a colored wrist band; falls precaution sign at the doorway, and a personal alarm as appropriate.

The medical record documentation indicated that Patient #1 was admitted to the Observation Unit on 4/1/10 for failure to thrive and inability to ambulate. Patient #1 had a history of falling. Patient #1 remained on the Unit until 4/6/10 when Patient #1 was discharged to a nursing home.

Review of the medical record documentation indicated that fall risk re-assessment was not completed daily as required per the Policy.

A tour of the Observation Unit was conducted on 4/23/10 with the Director of Patient Safety present. At the time of the tour the Unit census was 7 patients (Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, and Patient #8). Observation and medical record review determined the following:

Patient #2 had an order written for fall precautions however; there was no numerical score to determine whether the Patient was a low or high risk potential. Patient #2 did not have a colored wrist band or a sign at the doorway.

Patient #4 was assessed as high potential for fall risk. At the time of the tour Patient #4 was off the Unit and could not be checked for a wrist band however; there was no sign at the doorway.

Patient #8, admitted on 4/22/10, was not assessed for falls upon admission however; Patient #8 had a colored bracelet and did not have a sign at the doorway.


2). The Hospital's Skin Care Protocols indicated that every patient would have a full skin assessment on admission, each shift, as as their condition changes. A risk assessment tool was used to identify the level of risk for pressure sore development. Levels of risk ranged from no risk to the highest risk.

a). The medical record documentation indicated that Patient #1 was admitted to the Observation Unit on 4/1/10. Admission diagnoses were failure to thrive and unable to ambulate. Patient #1 also had Alzheimer's disease and a history of falling. A risk assessment was performed that scored Patient #1 at no risk for pressure sore development.

Review of the medical record documentation, dated 4/1/10 to 4/6/10, indicated that Patient #1 was never re-assessed for the level of risk for pressure sore development. Patient #1 had episodes of incontinence and used the bedpan. Patient #1 was on bedrest for most of the time and needed assistance to turn.

The medical record documentation indicated that on 4/6/10 Patient #1 was discharged to a nursing home. The Discharge referral indicated that Patient #1 had a reddened area on the buttock.

The Nurse Aide assigned to Patient #1 was interviewed on 4/28/10 at 2:15 P.M. The Nurse Aide reported bathing Patient #1 in preparation for discharge. The Nurse Aide reported Patient #1 complained of pain when the Nurse Aide washed the buttocks. The Nurse Aide reported Patient #1 had a large reddened area with a blister. The Nurse Aide said Patient #1's family members were present, saw the area, and got the nurse.

The nurse assigned to Patient #1 (Nurse #4) was interviewed on 4/28/10 at 10:00 A.M. Nurse #4 confirmed Patient #1 had an opened blister on the buttock to which a dressing was applied prior to discharge.

Documentation from the nursing home, dated 4/6/10, indicated Patient #1 had a Stage II (top layer of skin opened) area measuring 5 by 8 inches that was healed by the time of this survey.

b). The medical record documentation indicated that Patient #6 was admitted to the Observation Unit on 4/21/10. A risk assessment was performed that scored Patient #6 at moderate risk for pressure sore development.

Review of the medical record documentation, dated 4/22/10 to 4/27/10, indicated that skin risk re-assessments were not performed during the remainder of Patient #6's stay. Patient #6 was discharged to a nursing home on 4/27/10.

c). The medical record documentation indicated that Patient #9 was admitted to the Observation Unit on 4/6/10. A risk assessment was performed that scored Patient #9 not at risk for pressure sore development.

Review of the medical record documentation, dated 4/6/10 to 4/13/10, indicated that skin risk re-assessments were not performed during the remainder of Patient #9's stay. On 4/13/10 Patient #9 was noted to have a red, excoriated area on the buttocks to which a cream was applied. Patient #9 was discharged to the Psychiatric Unit on 4/13/10.

Based on documentation review the Hospital failed to implement a care plan for one of nine patients (Patient #6).

Findings included:


The Hospital's Skin Care Protocols indicated that every patient would have a full skin assessment on admission, each shift, as as their condition changes. A risk assessment tool was used to identify the level of risk for pressure sore development. Levels of risk ranged from no risk to the highest risk. Based on the risk category risk factors and nursing interventions that were implemented were entered into the nursing care plan.

Review of the Hospital's care plans indicated that standardized care plans were used.

The medical record documentation indicated that Patient #6 was admitted to the Observation Unit on 4/21/10. A risk assessment was performed that scored Patient #6 at moderate risk for pressure sore development.

Review of Patient #6's care plan indicated that the risk for pressure sore development was not implemented.

Based on interviews and documentation review the Hospital failed to ensure that:

1). there was documentation in the medical record as to why Patient #1 continued on observation status and did not qualify for inpatient status and orders to continue observation status after the 24 hour benchmark period.

2). information related intravenous fluid and oral fluid intake and the reason the intravenous line was discontinued was documented in the medical record for one of nine patients (Patient #1.

Findings included:

1). The Complainant was interviewed on 4/22/10 at 2:30 P.M. and the Complainant's Letter, dated 4/12/10, was reviewed. The Complainant said and the Letter indicated that on 4/1/10 Patient #1 was brought by a family member to the physician and was sent to the Hospital for a direct admission because Patient #1 had an injury somewhere and would need pain control and further testing. The Complainant said and the Letter indicated that the physician told Patient #1/family that Patient #1 needed a 3 day inpatient Hospital stay in order to qualify for nursing home placement and to access Medicare benefits. The Complainant said and the Letter indicated that when the Patient #1 was placed on the Observation Unit for 5 days despite repeated requests that Patient #1 be admitted to an inpatient unit.

The Physician who saw Patient #1 on 4/1/10 was interviewed on 4/29/10 at 1:40 P.M. The Physician said the weakness was most noticeable. The Physician reported sending Patient #1 to the Hospital for an admission and had discussed with family members the need for a 3-day inpatient stay so Patient #1 would be able to access benefits and the family would not be billed as they could not afford it. The Physician reported conveying the intent of Patient #1's admission to the admitting Hospitalist. The Physician reported not being aware of the Observation Unit or admission criteria until after Patient #1 was in the Hospital.

The Clinical Manager of Case Management was interviewed on 4/28/10 at 12:00 P.M. The Manager said when patients were considered for admission to the Hospital it was the admitting physician who made the decision as to whether the patient was observational or inpatient status. The Manager said the Hospital utilized the McKesson InterQual Level of Care (2009) Manual to determine if patients were considered to be observational status or qualified for an acute inpatient stay.

Review of the Observation Unit's Admission Criteria indicated that the Unit was dedicated to caring for patients that required further observation and monitoring. The expectation was that any patient who was cared for on the Unit would either be discharged or admitted to an inpatient status within 24 hours of arrival. Medical necessity to determine inpatient status was based on the severity of the presenting illness, the planned medical treatment, and/or expected resolution within 24 hours. Criteria for admission included elder at risk with nursing home placement secured in the next 24 hours (family unable to care for the patient at home, needing assistance with home care needs, or awaiting nursing home or assisted living placement). The Admission Criteria did not include steps to be taken to address outliers such as the patient who exceeded 24 hours on the Unit and did not qualify for an inpatient status.

Review of the Policy titled Outpatient Observation Status indicated that at the end of the 24 hour benchmark period nursing and/or case management will contact the Attending Physician for orders to admit, discharge, or continue observation of the patient.

The History and Physical Report, dated 4/1/10, indicated that Patient #1 was admitted to the Observation Unit with a plan to obtain x-rays of the ribs and pelvic region, check blood work, attempt to ambulate Patient #1, and obtain rehabilitation consults. If Patient #1 was unable to function independently then placement was needed for rehabilitation.

The Hospitalist assigned to Patient #1 was interviewed on 4/28/10 at 11:00 A.M. The Hospitalist said Patient #1 was sent to the Hospital by the Physician and needed nursing home placement, did not qualify for an acute care length of stay, and therefore was admitted to the Observation Unit. The Hospitalist reported speaking with Patient #1's family member the day after Patient #1's admission and telling family member Patient #1 did not qualify for hospital level of care.

The medical record documentation, dated 4/2/10, indicated that x-rays of the ribs, hips, pelvis, and lumbar spine were performed. The Radiology Reports indicated that there were no acute fractures identified, only diffuse osteoporosis. Blood work was performed that was essentially within normal limits.

The Clinical Manager of Case Management was interviewed and Case Management documentation was reviewed. The Manager said and documentation indicated that on 4/2/10 (Friday) Case Management told the family that Patient #1 did not qualify for a 3 day inpatient stay, discussed nursing home preferences, and placed screens/telephone calls to 3 nursing homes. The Manager said and documentation indicated that on 4/3/10 (Saturday) two case managers who were on duty spoke with Patient #1's family. The Manager said and documentation indicated that the family was requesting that Patient #1 be converted to inpatient services so Patient #1 could access the Medicare benefits. The Manager said and documentation indicated that the case managers discussed at length inpatient verses observation status and discussed why Patient #1 did not qualify for an inpatient stay. The Manager said and documentation indicated that discharge options were discussed (home with private pay assistance verses private pay nursing home placement). The Manager said and documentation indicated that nursing home choices were again reviewed and the family was told that none of the nursing homes would screen Patient #1 until Monday. The Manager said and documentation indicated that the case was referred for a physician review to determine if Patient #1 could be converted to inpatient status and the family was informed of this. The Manager said and documentation indicated that acute rehabilitation was discussed however; the family did not think Patient #1 could tolerate the 3 hour daily Physical and Occupational program required for acute rehabilitation.

The Chief of Medicine was interviewed on 4/28/10 at 1:40 P.M. The Chief reported reviewing the medical record to determine if there was any way Patient #1 could qualify for an inpatient stay and could not find any qualifiers. The Chief said even if Patient #1 had been moved to an inpatient unit Patient #1 would have remained on observation status.

The medical record documentation, dated 4/3/10, indicated that Patient #1 was evaluated by Physical and Occupational Therapies. Patient #1 participated in 30-45 minutes therapy sessions (tolerance of 3 hour sessions required for acute rehabilitation) and her tolerance was poor to fair.

The Clinical Manager said and documentation indicated that on 4/4/10 (Sunday) the case manager on duty met with Patient #1's family who requested a CT scan of the hips, pelvis, and spine and an acute rehabilitation consult for possible transfer to the acute rehabilitation unit.

The Hospital's Social Worker (LCSW) was interviewed on 4/28/10 at 12:35 P.M. with the Clinical Manager present and the medical record documentation, dated 4/5/10, was reviewed. The Social Worker said and documentation indicated that on 4/5/10 a CT scan was performed and was negative for acute fractures. The Social Worker said and documentation indicated that the would not qualify for acute rehabilitation because when attempts were made to get Patient #1 out of bed Patient #1 was too weak and had too much back pain to ambulate. The Social Worker said and documentation indicated that the family was told Patient #1 had been accepted to 2 of the 3 nursing homes to which referrals were made. The Social Worker said and documentation indicated that on 4/6/10 the Case Manager, Patient Relations, the Hospitalist, and Physical therapist met with Patient #1's family member and reviewed Medicare criteria for 3 day qualifying stay. The Social Worker said and documentation indicated that the family member agreed to nursing home placement.

The medical record documentation, dated 4/6/10, indicated that Patient #1 was discharged to a nursing home.

Review of Physician Orders, dated 4/2/10 to 4/6/10, indicated that there were no further orders regarding observation status.

Review of the medical record documentation indicated that there was no documented evidence of re-evaluation of patient status or specifically why Patient #1 continued to not qualify for inpatient status.




2). The Complainant said and the Letter indicated that the ED Physician ordered 2 bags of intravenous fluids for Patient #1 however; the intravenous site backed up and was removed. The Complainant said and the Letter indicated that the ED Physician chose not to start another intravenous line and told Patient #1 to drink fluids.

The medical record documentation, dated 3/30/10, indicated that the ED Physician ordered blood testing. Patient #1's blood test results indicated that the creatinine level was elevated at 1.67 (normal range is 0.7 to 1.4; elevations indicative of dehydration or decreased kidney function). An intravenous line was inserted and intravenous fluids at 200 cubic centimeters an hour were initiated at approximately 6:30 P.M. At 7:50 P.M. the intravenous line was removed and documentation indicated that Patient #1 was given a meal.

Review of the medical record indicated that documentation did not indicate why the intravenous line was removed, how much of the fluids Patient #1 had received, or how much fluids with the meal were consumed.