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Based on interview and record review the facility failed to ensure 1 of 10 patients received a safe method of transportation during the discharge process (Patient #5).
This deficient practice had the likelihood to cause harm in all in-patients.
Findings include:

Review of a policy named "Discharge Planning" dated 01/27/2012 revealed:
"Reassessment of the discharge plan should be ongoing in response to the patient's changing condition in order to evaluate whether the plan continues to meet the needs of the patient."
Review of a policy named "Transfers and Emergency Medical screenings" dated 02/2009 revealed :
"Forms to be completed - The following forms must be completed for every patient transferred:
Physician Assessment and Certification - The patient care personnel shall work with the transferring physician to complete all sections of the Physician Assessment and Certification.
The nursing staff shall determine that the required Physician Assessment Certification is completed, including a summary of the risks and benefits."
Review of an undated "Physician Certification Statement for Ambulance Services" revealed:
"Ambulance transport is medically necessary only if other means of transportation are contraindicated or would be potentially harmful to the patient. To meet this requirement, the patient must be either "bed confined" or suffer from a condition such that transport by any other mean is contraindicated by the patient's condition."
Review of a policy named "Skin Assessment" dated 04/2011 revealed:
"Document initial assessment and ongoing assessment on appropriate nursing forms."

Review of a facesheet dated 07/15/2013 revealed Patient #5 was a 75 year old female admitted with diagnoses of acute renal failure, pneumonia, hypotension and altered mental status.
An ED assessment dated 07/15/2013 revealed Patient #5 was confused and had bruising at different stages of healing on the chest and bilateral upper extremities.
Nursing "All Flowsheet Data" notes from 07/15-17/2013 revealed the following:
Patient #5 was high risk for falls, requiring assistance in ambulation, non-weight bearing, required her bed in the low position, in bed on her back, in bed being turned from side to side with staff assist, generalized musculoskeletal weakness and requiring a bed alarm for safety. Underneath the transportation section Patient #5s' method of transportation was a bed with oxygen or stretcher and she was on close observation precautions.
On 07/17/2013 at 8:00 a.m., Patient #5 was considered bedfast with very limited amount/control of body movement. The anticipated transportation needs was a bed with oxygen.
On 07/17/2013 at 8:00 p.m., Patient #5 was considered chairfast with very limited amount/control of body movement. The anticipated transportation needs was a bed with oxygen.
On 7/18/2013 at 7:38 a.m., Patient #5 was high risk for falls, completely dependent and requiring assistance in ambulation, non-weight bearing, required her bed in the low position, in bed on her back, in bed being turned from side to side with staff assist, required a bed alarm for safety. Patient #5 was considered chairfast with very limited amount/control of body movement. Underneath the transportation section Patient #5 method of transportation was a bed with oxygen. Patient #5 was documented as having two prior skin tears to the left arm. There was no documentation of an assessment of the size or the location of the skin tears on the arm.
Review of a progress note dated 07/18/2013 at 7:15 a.m., revealed Patient #5 had multiple bruises noted on arms, hands and chest. There was a dressing on her left arm which was dry and intact. There was no documentation of an assessment of the location, color or sizes of the bruising.
Review of a nursing "All Flowsheet Data" note revealed the following:
On 07/18/2013 at 8:00 p.m., Patient #5 was considered to be chairfast, but the method of transportation was a bed with oxygen. At 8:33 p.m., there was one documentation of Patient #5 being up to the bathroom with assistance since being hospitalized.
On 07/19/2013 at 8:00 a.m., Patient #5 was at high risk for falls, non-weight bearing, and chairfast with very limited amount/control of body movement. There was no documented assessment of the anticipated method of transportation need. There was documentation of ecchymosis but not a detailed description nor any documentation of skin tears.
Review of a progress note dated 07/19/2013 at 11:35 a.m., revealed Staff #4 gave report to nursing home Staff #11. Staff #4 documented she "asked them to bring a wheelchair or geri chair to transport patient."
Review of a nursing "All Flowsheet Data" discharge assessment dated 07/19/2013 at 1:00 p.m., Staff #4 documented that Patient #5s' "LOC ranges from drowsy, but arousable to alert and oriented. Pt verbalizes no greater than 4 on pain scale (or pre-procedure baseline) ..." The transportation method was in a wheelchair.
A physician discharge summary dated 07/19/2013 revealed Patient #5 had been "declining in function lately." The family requested hospice care for rapid decline and poor prognosis due to her dementia, previous CVA.
Review of a nursing home incident report and investigation dated 07/19/2013, 1:00 p.m. revealed the Patient #5 was being transported back to the nursing home via van by two nursing home staff (Staff #12 and 13) when she started sliding out of her wheelchair. During the transport, nursing home staff were instructed to stop the van on the side of the road until nursing home administrative staff arrived to help with the patient. Administrative staff re-secured the patient in the wheelchair. Patient #5 was noted with blood to left ring finger, hand and right elbow, skin tears, as well as dried blood to bilateral arms. Kerlix type dressing was noted to the left lower arm. Bruising was noted as well to bilateral arms. They appeared to be related to venipunctures and intravenous while in the hospital. There was documentation of Staff #12 and 13 reported the hospital nursing staff transferred the patient from the bed to the wheelchair. The injury to the finger was caused by the hospital nursing staff. The hospital nurses dressed the areas.

According to the nursing home investigation, Staff #13 called from the hospital and voiced being uncomfortable with the transfer. The primary physician was at the hospital and said it was safe to transfer the patient in a wheelchair. The primary doctor's NP was in the nursing home when the patient arrived. The NP was informed of the transportation incident.
Review of a nursing home report sheet dated 07/19/2013 revealed Staff #11 took report from Staff #4. There was documentation that Staff #4 provided information of the patient being weight bearing as tolerated.
An "Admission Skin Assessment Form" dated 07/19/2013 revealed Patient #5 had the following skin problems:
*Multiple bruising around the front of her neck that was 5 x 15 centimeters (cms);
*Multiple bruising to the bilateral arms;
*Right elbow 2 x 2 cms skin tear;
*Two digits on the left hand and skin tear measuring 0.5 x 0.5 cms;
*Left lower arms with a skin tear measuring 2 x 2 cms;
*Left elbow a skin tear measuring 2.5 x 1 cms;
*Left upper arm with multiple scratches measuring 5 x 0.5 cms;
*Coccyx/sacral area had redness which measured 7 x 4 cms.

During an interview on 09/18/2013 at 2:23 p.m., Staff #4 confirmed she was the discharge nurse and made the notes on 07/19/2013. She did not know why she gave nursing home staff the option of a wheelchair or geri chair. Staff #4 confirmed two nursing home staff came to pick up the patient, but she could not remember anything else. Staff #4 checked the record to see if she had ever taken care of the patient before 07/19/2013. She reported this was her first time taking care of the patient on 07/19/2013.
During an interview on 09/18/2013 at 2:45 p.m., Staff #3 confirmed Patient #5 did not have a Physician Certification Statement for Ambulances and confirmed the assessment problems in the chart.
During an interview on 09/18/2013 at 4:30 p.m., Staff #1 confirmed the problems with the descrepancies in assessment in the chart. She confirmed not knowing anything about the assessment or transfer problems before 09/18/2013.
Review of September 2013 quality assurance minutes made no mention of the identified discharge and skin assessment problems.
During an interview on 09/19/2013 at 9:53 a.m., Staff #9 reported she informed the NP who worked for the primary doctor of the inaccurate report they received from the hospital.
During an interview on 09/19/2013 at 11:25 a.m. with Staff #12 and at 12:03 p.m. with Staff #13 confirmed they picked up Patient #5 from the hospital. A family member was at the hospital and told them the patient was not able to sit up in a wheelchair and she needed to be transported by ambulance. They felt uncomfortable with it because she appeared so weak and could not support herself. They confirmed the injury to the Patient' s hand occurred at the hospital.

Based on interview and record review the facility failed to ensure 1 of 10 patients care plan was kept current addressing skin problems and discharge needs ( Patient #5).
This deficient practice had the likelihood to cause harm in all in-patients.
Findings include:

Review of a policy named "Skin Assessment" dated 04/2011 revealed :
"Document initial assessment and ongoing assessment on appropriate nursing forms."
Review of a policy named "Discharge Planning" dated 01/27/2012 revealed:
"Reassessment of the discharge plan should be ongoing in response to the patient' s changing condition in order to evaluate whether the plan continues to meet the needs of the patient."
Review of a policy named "Transfers and Emergency Medical screenings" dated 02/2009 revealed:
"Forms to be completed -The following forms must be completed for every patient transferred:
Physician Assessment and Certification - The patient care personnel shall work with the transferring physician to complete all sections of the Physician Assessment and Certification.
The nursing staff shall determine that the required Physician Assessment Certification is completed, including a summary of the risks and benefits."
Review of an undated "Physician Certification Statement for Ambulance Services" revealed:
"Ambulance transport is medically necessary only if other means of transportation are contraindicated or would be potentially harmful to the patient. To meet this requirement, the patient must be either "bed confined" or suffer from a condition such that transport by any other mean is contraindicated by the patient's condition."
Review of a facesheet dated 07/15/2013 revealed Patient #5 was a 75 year old female admitted with diagnoses of acute renal failure, pneumonia, hypotension and altered mental status.
An ED assessment dated 07/15/2013 revealed Patient #5 was confused and had bruising at different stages of healing on the chest and bilateral upper extremities.
Nursing "All Flowsheet Data" notes from 07/15-17/2013 revealed the following:
Patient #5 was high risk for falls, requiring assistance in ambulation, non-weight bearing, required her bed in the low position, in bed on her back, in bed being turned from side to side with staff assist, generalized musculoskeletal weakness and requiring a bed alarm for safety. Underneath the transportation section Patient #5s' method of transportation was a bed with oxygen or stretcher and she was on close observation precautions.
On 07/17/2013 at 8:00 a.m., Patient #5 was considered bedfast with very limited amount/control of body movement. The anticipated transportation needs was a bed with oxygen.
On 07/17/2013 at 8:00 p.m., Patient #5 was considered chairfast with very limited amount/control of body movement. The anticipated transportation needs was a bed with oxygen.
On 7/18/2013 at 7:38 a.m., Patient #5 was high risk for falls , completely dependent and requiring assistance in ambulation, non-weight bearing, required her bed in the low position, in bed on her back, in bed being turned from side to side with staff assist, required a bed alarm for safety. Patient #5 was considered chairfast with very limited amount/control of body movement. Underneath the transportation section Patient #5 method of transportation was a bed with oxygen. Patient #5 was documented as having two prior skin tears to the left arm. There was no documentation of an assessment of the size or the location of the skin tears on the arm.
Review of a progress note dated 07/18/2013 at 7:15 a.m., revealed Patient #5 had multiple bruises noted on arms, hands and chest. There was a dressing on her left arm which was dry and intact. There was no documentation of an assessment of the location, color or sizes of the bruising.
Review of a nursing "All Flowsheet Data" note revealed the following:
On 07/18/2013 at 8:00 p.m., Patient #5 was considered to be chairfast, but the method of transportation was a bed with oxygen. At 8:33 p.m., was the only documentation of Patient #5 being up to the bathroom with assistance since being hospitalized.
On 07/19/2013 at 8:00 a.m., Patient #5 was at high risk for falls, non-weight bearing, and chairfast with very limited amount/control of body movement. There was no documented assessment of the anticipated method of transportation need. There was documentation of ecchymosis but not a detailed description nor any documentation of skin tears.
Review of a progress note dated 07/19/2013 at 11:35 a.m., revealed Staff #4 gave report to nursing home Staff #11. Staff #4 documented she "asked them to bring a wheelchair or geri chair to transport patient."
Review of a nursing "All Flowsheet Data" discharge assessment dated 07/19/2013 at 1:00 p.m., Staff #4 documented that Patient #5s' "LOC ranges from drowsy, but arousable to alert and oriented. Pt verbalizes no greater than 4 on pain scale (or pre-procedure baseline) ... " The transportation method was in a wheelchair.
A physician discharge summary dated 07/19/2013 revealed Patient #5 had been "declining in function lately." The family requested hospice care for rapid decline and poor prognosis due to her dementia, previous CVA.
Review of a nursing home incident report and investigation dated 07/19/2013, 1:00 p.m. revealed the Patient #5 was being transported back to the nursing home via van by two nursing home staff (Staff #12 and 13) when she started sliding out of her wheelchair. During the transport nursing home staff were instructed to stop the van on the side of the road until nursing home administrative staff arrived to help with the patient. Administrative staff resecured the patient in the wheelchair. Patient #5 was noted with blood to left ring finger, hand and right elbow, skin tears, as well as dried blood to bilateral arms. Kerlix type dressing was noted to the left lower arm. Bruising was noted as well to bilateral arms. They appeared to be related to venipunctures and intravenous while in the hospital. There was documentation of Staff #12 and 13 reported the hospital nursing staff transferred the patient from the bed to the wheelchair. The injury to the finger was caused by the hospital nursing staff. The hospital nurses dressed the areas.

According to the nursing home investigation, Staff #13 called from the hospital and voiced being uncomfortable with the transfer. The primary physician was at the hospital and said it was safe to transfer the patient in a wheelchair. The primary doctor ' s NP was in the nursing home when the patient arrived. The NP was informed of the transportation incident.
Review of a nursing home report sheet dated 07/19/2013 revealed Staff #11 took report from Staff #4. There was documentation that Staff #4 provided information of the patient being weight bearing as tolerated.
An "Admission Skin Assessment Form" dated 07/19/2013 revealed Patient #5 had the following skin problems:
*Multiple bruising around the front of her neck that was 5 x 15 centimeters (cms);
*Multiple bruising to the bilateral arms;
*Right elbow 2 x 2 cms skin tear
*Two digits on the left hand and skin tear measuring 0.5 x 0.5 cms;
*Left lower arms with a skin tear measuring 2 x 2 cms;
*Left elbow a skin tear measuring 2.5 x 1 cms;
*Left upper arm with multiple scratches measuring 5 x 0.5 cms;
*Coccyx/sacral area had redness which measured 7 x 4 cms.

During an interview on 09/18/2013 at 2:23 p.m., Staff #4 confirmed she was the discharge nurse and made the notes on 07/19/2013. She did not know why she gave nursing home staff the option of a wheelchair or geri chair. Staff #4 confirmed two nursing home staff came to pick up the patient, but she could not remember anything else. Staff #4 checked the record to see if she had ever taken care of the patient before 07/19/2013. She reported this was her first time taking care of the patient on 07/19/2013.
During an interview on 09/18/2013 at 2:45 p.m., Staff #3 confirmed Patient #5 did not have a Physician Certification Statement for Ambulances and confirmed the assessment problems in the chart.
During an interview on 09/18/2013 at 4:30 p.m., Staff #1 confirmed the problems with the descrepancies in assessment in the chart. She confirmed not knowing anything about the assessment or transfer problems before 09/18/2013.
Review of September 2013 quality assurance minutes made no mention of the identified discharge and skin assessment problems.
During an interview on 09/19/2013 at 9:53 a.m., Staff #9 reported she informed the NP who worked for the primary doctor of the inaccurate report they received from the hospital.
During an interview on 09/19/2013 at 11:25 a.m. with Staff #12 and at 12:03 p.m. with Staff #13 confirmed they picked up Patient #5 from the hospital. A family member was at the hospital and told them the patient was not able to sit up in a wheelchair and she needed to be transported by ambulance. They felt uncomfortable with it because she appeared so weak and could not support herself. They confirmed the injury to the Patient #5's hand occurred at the hospital.

Based on interview and record review the facility failed to ensure 1 of 10 patients received a safe method of transportation during the discharge process (Patient #5).
This deficient practice had the likelihood to cause harm in all in-patients.
Findings include:

Review of a policy named "Discharge Planning" dated 01/27/2012 revealed:
"Reassessment of the discharge plan should be ongoing in response to the patient's changing condition in order to evaluate whether the plan continues to meet the needs of the patient."
Review of a policy named "Transfers and Emergency Medical screenings" dated 02/2009 revealed :
"Forms to be completed - The following forms must be completed for every patient transferred:
Physician Assessment and Certification - The patient care personnel shall work with the transferring physician to complete all sections of the Physician Assessment and Certification.
The nursing staff shall determine that the required Physician Assessment Certification is completed, including a summary of the risks and benefits."
Review of an undated "Physician Certification Statement for Ambulance Services" revealed:
"Ambulance transport is medically necessary only if other means of transportation are contraindicated or would be potentially harmful to the patient. To meet this requirement, the patient must be either "bed confined" or suffer from a condition such that transport by any other mean is contraindicated by the patient's condition."
Review of a policy named "Skin Assessment" dated 04/2011 revealed:
"Document initial assessment and ongoing assessment on appropriate nursing forms."

Review of a facesheet dated 07/15/2013 revealed Patient #5 was a 75 year old female admitted with diagnoses of acute renal failure, pneumonia, hypotension and altered mental status.
An ED assessment dated 07/15/2013 revealed Patient #5 was confused and had bruising at different stages of healing on the chest and bilateral upper extremities.
Nursing "All Flowsheet Data" notes from 07/15-17/2013 revealed the following:
Patient #5 was high risk for falls, requiring assistance in ambulation, non-weight bearing, required her bed in the low position, in bed on her back, in bed being turned from side to side with staff assist, generalized musculoskeletal weakness and requiring a bed alarm for safety. Underneath the transportation section Patient #5s' method of transportation was a bed with oxygen or stretcher and she was on close observation precautions.
On 07/17/2013 at 8:00 a.m., Patient #5 was considered bedfast with very limited amount/control of body movement. The anticipated transportation needs was a bed with oxygen.
On 07/17/2013 at 8:00 p.m., Patient #5 was considered chairfast with very limited amount/control of body movement. The anticipated transportation needs was a bed with oxygen.
On 7/18/2013 at 7:38 a.m., Patient #5 was high risk for falls, completely dependent and requiring assistance in ambulation, non-weight bearing, required her bed in the low position, in bed on her back, in bed being turned from side to side with staff assist, required a bed alarm for safety. Patient #5 was considered chairfast with very limited amount/control of body movement. Underneath the transportation section Patient #5 method of transportation was a bed with oxygen. Patient #5 was documented as having two prior skin tears to the left arm. There was no documentation of an assessment of the size or the location of the skin tears on the arm.
Review of a progress note dated 07/18/2013 at 7:15 a.m., revealed Patient #5 had multiple bruises noted on arms, hands and chest. There was a dressing on her left arm which was dry and intact. There was no documentation of an assessment of the location, color or sizes of the bruising.
Review of a nursing "All Flowsheet Data" note revealed the following:
On 07/18/2013 at 8:00 p.m., Patient #5 was considered to be chairfast, but the method of transportation was a bed with oxygen. At 8:33 p.m., there was one documentation of Patient #5 being up to the bathroom with assistance since being hospitalized.
On 07/19/2013 at 8:00 a.m., Patient #5 was at high risk for falls, non-weight bearing, and chairfast with very limited amount/control of body movement. There was no documented assessment of the anticipated method of transportation need. There was documentation of ecchymosis but not a detailed description nor any documentation of skin tears.
Review of a progress note dated 07/19/2013 at 11:35 a.m., revealed Staff #4 gave report to nursing home Staff #11. Staff #4 documented she "asked them to bring a wheelchair or geri chair to transport patient."
Review of a nursing "All Flowsheet Data" discharge assessment dated 07/19/2013 at 1:00 p.m., Staff #4 documented that Patient #5s' "LOC ranges from drowsy, but arousable to alert and oriented. Pt verbalizes no greater than 4 on pain scale (or pre-procedure baseline) ..." The transportation method was in a wheelchair.
A physician discharge summary dated 07/19/2013 revealed Patient #5 had been "declining in function lately." The family requested hospice care for rapid decline and poor prognosis due to her dementia, previous CVA.
Review of a nursing home incident report and investigation dated 07/19/2013, 1:00 p.m. revealed the Patient #5 was being transported back to the nursing home via van by two nursing home staff (Staff #12 and 13) when she started sliding out of her wheelchair. During the transport, nursing home staff were instructed to stop the van on the side of the road until nursing home administrative staff arrived to help with the patient. Administrative staff re-secured the patient in the wheelchair. Patient #5 was noted with blood to left ring finger, hand and right elbow, skin tears, as well as dried blood to bilateral arms. Kerlix type dressing was noted to the left lower arm. Bruising was noted as well to bilateral arms. They appeared to be related to venipunctures and intravenous while in the hospital. There was documentation of Staff #12 and 13 reported the hospital nursing staff transferred the patient from the bed to the wheelchair. The injury to the finger was caused by the hospital nursing staff. The hospital nurses dressed the areas.

According to the nursing home investigation, Staff #13 called from the hospital and voiced being uncomfortable with the transfer. The primary physician was at the hospital and said it was safe to transfer the patient in a wheelchair. The primary doctor's NP was in the nursing home when the patient arrived. The NP was informed of the transportation incident.
Review of a nursing home report sheet dated 07/19/2013 revealed Staff #11 took report from Staff #4. There was documentation that Staff #4 provided information of the patient being weight bearing as tolerated.
An "Admission Skin Assessment Form" dated 07/19/2013 revealed Patient #5 had the following skin problems:
*Multiple bruising around the front of her neck that was 5 x 15 centimeters (cms);
*Multiple bruising to the bilateral arms;
*Right elbow 2 x 2 cms skin tear;
*Two digits on the left hand and skin tear measuring 0.5 x 0.5 cms;
*Left lower arms with a skin tear measuring 2 x 2 cms;
*Left elbow a skin tear measuring 2.5 x 1 cms;
*Left upper arm with multiple scratches measuring 5 x 0.5 cms;
*Coccyx/sacral area had redness which measured 7 x 4 cms.

During an interview on 09/18/2013 at 2:23 p.m., Staff #4 confirmed she was the discharge nurse and made the notes on 07/19/2013. She did not know why she gave nursing home staff the option of a wheelchair or geri chair. Staff #4 confirmed two nursing home staff came to pick up the patient, but she could not remember anything else. Staff #4 checked the record to see if she had ever taken care of the patient before 07/19/2013. She reported this was her first time taking care of the patient on 07/19/2013.
During an interview on 09/18/2013 at 2:45 p.m., Staff #3 confirmed Patient #5 did not have a Physician Certification Statement for Ambulances and confirmed the assessment problems in the chart.
During an interview on 09/18/2013 at 4:30 p.m., Staff #1 confirmed the problems with the de

Based on interview and record review the facility failed to ensure 1 of 10 patients care plan was kept current addressing skin problems and discharge needs ( Patient #5).
This deficient practice had the likelihood to cause harm in all in-patients.
Findings include:

Review of a policy named "Skin Assessment" dated 04/2011 revealed :
"Document initial assessment and ongoing assessment on appropriate nursing forms."
Review of a policy named "Discharge Planning" dated 01/27/2012 revealed:
"Reassessment of the discharge plan should be ongoing in response to the patient' s changing condition in order to evaluate whether the plan continues to meet the needs of the patient."
Review of a policy named "Transfers and Emergency Medical screenings" dated 02/2009 revealed:
"Forms to be completed -The following forms must be completed for every patient transferred:
Physician Assessment and Certification - The patient care personnel shall work with the transferring physician to complete all sections of the Physician Assessment and Certification.
The nursing staff shall determine that the required Physician Assessment Certification is completed, including a summary of the risks and benefits."
Review of an undated "Physician Certification Statement for Ambulance Services" revealed:
"Ambulance transport is medically necessary only if other means of transportation are contraindicated or would be potentially harmful to the patient. To meet this requirement, the patient must be either "bed confined" or suffer from a condition such that transport by any other mean is contraindicated by the patient's condition."
Review of a facesheet dated 07/15/2013 revealed Patient #5 was a 75 year old female admitted with diagnoses of acute renal failure, pneumonia, hypotension and altered mental status.
An ED assessment dated 07/15/2013 revealed Patient #5 was confused and had bruising at different stages of healing on the chest and bilateral upper extremities.
Nursing "All Flowsheet Data" notes from 07/15-17/2013 revealed the following:
Patient #5 was high risk for falls, requiring assistance in ambulation, non-weight bearing, required her bed in the low position, in bed on her back, in bed being turned from side to side with staff assist, generalized musculoskeletal weakness and requiring a bed alarm for safety. Underneath the transportation section Patient #5s' method of transportation was a bed with oxygen or stretcher and she was on close observation precautions.
On 07/17/2013 at 8:00 a.m., Patient #5 was considered bedfast with very limited amount/control of body movement. The anticipated transportation needs was a bed with oxygen.
On 07/17/2013 at 8:00 p.m., Patient #5 was considered chairfast with very limited amount/control of body movement. The anticipated transportation needs was a bed with oxygen.
On 7/18/2013 at 7:38 a.m., Patient #5 was high risk for falls , completely dependent and requiring assistance in ambulation, non-weight bearing, required her bed in the low position, in bed on her back, in bed being turned from side to side with staff assist, required a bed alarm for safety. Patient #5 was considered chairfast with very limited amount/control of body movement. Underneath the transportation section Patient #5 method of transportation was a bed with oxygen. Patient #5 was documented as having two prior skin tears to the left arm. There was no documentation of an assessment of the size or the location of the skin tears on the arm.
Review of a progress note dated 07/18/2013 at 7:15 a.m., revealed Patient #5 had multiple bruises noted on arms, hands and chest. There was a dressing on her left arm which was dry and intact. There was no documentation of an assessment of the location, color or sizes of the bruising.
Review of a nursing "All Flowsheet Data" note revealed the following:
On 07/18/2013 at 8:00 p.m., Patient #5 was considered to be chairfast, but the method of transportation was a bed with oxygen. At 8:33 p.m., was the only documentation of Patient #5 being up to the bathroom with assistance since being hospitalized.
On 07/19/2013 at 8:00 a.m., Patient #5 was at high risk for falls, non-weight bearing, and chairfast with very limited amount/control of body movement. There was no documented assessment of the anticipated method of transportation need. There was documentation of ecchymosis but not a detailed description nor any documentation of skin tears.
Review of a progress note dated 07/19/2013 at 11:35 a.m., revealed Staff #4 gave report to nursing home Staff #11. Staff #4 documented she "asked them to bring a wheelchair or geri chair to transport patient."
Review of a nursing "All Flowsheet Data" discharge assessment dated 07/19/2013 at 1:00 p.m., Staff #4 documented that Patient #5s' "LOC ranges from drowsy, but arousable to alert and oriented. Pt verbalizes no greater than 4 on pain scale (or pre-procedure baseline) ... " The transportation method was in a wheelchair.
A physician discharge summary dated 07/19/2013 revealed Patient #5 had been "declining in function lately." The family requested hospice care for rapid decline and poor prognosis due to her dementia, previous CVA.
Review of a nursing home incident report and investigation dated 07/19/2013, 1:00 p.m. revealed the Patient #5 was being transported back to the nursing home via van by two nursing home staff (Staff #12 and 13) when she started sliding out of her wheelchair. During the transport nursing home staff were instructed to stop the van on the side of the road until nursing home administrative staff arrived to help with the patient. Administrative staff resecured the patient in the wheelchair. Patient #5 was noted with blood to left ring finger, hand and right elbow, skin tears, as well as dried blood to bilateral arms. Kerlix type dressing was noted to the left lower arm. Bruising was noted as well to bilateral arms. They appeared to be related to venipunctures and intravenous while in the hospital. There was documentation of Staff #12 and 13 reported the hospital nursing staff transferred the patient from the bed to the wheelchair. The injury to the finger was caused by the hospital nursing staff. The hospital nurses dressed the areas.

According to the nursing home investigation, Staff #13 called from the hospital and voiced being uncomfortable with the transfer. The primary physician was at the hospital and said it was safe to transfer the patient in a wheelchair. The primary doctor ' s NP was in the nursing home when the patient arrived. The NP was informed of the transportation incident.
Review of a nursing home report sheet dated 07/19/2013 revealed Staff #11 took report from Staff #4. There was documentation that Staff #4 provided information of the patient being weight bearing as tolerated.
An "Admission Skin Assessment Form" dated 07/19/2013 revealed Patient #5 had the following skin problems:
*Multiple bruising around the front of her neck that was 5 x 15 centimeters (cms);
*Multiple bruising to the bilateral arms;
*Right elbow 2 x 2 cms skin tear
*Two digits on the left hand and skin tear measuring 0.5 x 0.5 cms;
*Left lower arms with a skin tear measuring 2 x 2 cms;
*Left elbow a skin tear measuring 2.5 x 1 cms;
*Left upper arm with multiple scratches measuring 5 x 0.5 cms;
*Coccyx/sacral area had redness which measured 7 x 4 cms.

During an interview on 09/18/2013 at 2:23 p.m., Staff #4 confirmed she was the discharge nurse and made the notes on 07/19/2013. She did not know why she gave nursing home staff the option of a wheelchair or geri chair. Staff #4 confirmed two nursing home staff came to pick up the patient, but she could not remember anything else. Staff #4 checked the record to see if she had ever taken care of the patient before 07/19/2013. She reported this was her first time taking care of the patient on 07/19/2013.
During an interview on 09/18/2013 at 2:45 p.m., Staff #3 confirmed Patient #5 did not have a Physician Certification Statement for Ambulances and confirmed the assessment problems in the chart.
During an interview on 09/18/2013 at 4:30 p.m., Staff #1 confirmed the problems w