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Based on the nature of the deficiency, it was determined the Condition of Participation §482.54, OUTPATIENT SERVICES, was out of compliance.

A-1076 If the hospital provides outpatient services, the services must meet the needs of the patients in accordance with acceptable standards of practice.

Based on interviews and document review, the facility failed to ensure staff in the outpatient clinic assessed a new injury reported by a patient and notified the provider of abnormal assessment findings in 1 of 3 medical records reviewed (Patient #3) for patients who required emergent transfer from the clinic.

Findings include:

Facility Policies:

The Nursing Services Scope of Care policy read, Scope of Care: Registered nurses identify, assess, plan, implement and evaluate nursing care of all inpatients and outpatients identified with nursing care needs. Services Provided: Initial nursing evaluation and assessment, the determination of a treatment plan, monitoring of the patient response to intervention so the treatment plan can be reassessed, provision of feedback regarding the patient's response to treatment to the interdisciplinary team, and documentation of nursing services rendered. The policy referenced the American Nurses Association Code of Ethics, and the Association of Rehabilitation Nursing Standards and Scope of Rehabilitation Nursing Practice, as resources.

The Nursing Assessment/ Reassessment policy read, Data is gathered on admission or first contact and on an ongoing basis to ensure patient safety. Formal reassessment will also occur when significant changes in the patient's condition or diagnosis warrant reassessment.

The Standards of Nursing Care policy read, Routine nursing assessment will be completed as needed per patient status. Every patient will have further assessment completed based on associated needs.

The Nursing Documentation policy read, nursing staff will provide timely and complete documentation on each patient. It is the responsibility of the RN to gather all pertinent information and ensure that this data is entered into the EHR (electronic health record) each shift. All documentation that takes place during the day needs to be charted by midnight for it to reflect appropriately in the medical record.

Facility References:

American Nurses Association 2015 Code of Ethics for Nurses with Interpretive Statements, provided by the facility, read, Collaboration: The complexity of health care requires collaborative effort that has the active participation of all health professions. Nurses should foster collaborative planning to provide safe, high-quality, patient centered health care. Authority, Accountability, and Responsibility: Nurses bear primary responsibility for the nursing care that their patients receive and are accountable for their own practice. Nursing practice includes independent nursing care activities; care coordination; and evaluation of interventions.

The Association of Rehabilitation Nursing 2014 Standards & Scope of Rehabilitation Nursing Practice, provided by the facility, read, The rehabilitation registered nurse collects comprehensive data pertinent to the patient's health; involves the patient and other healthcare providers as appropriate; prioritizes data collection activities based on the patient's immediate condition or anticipated needs; documents relevant data. The rehabilitation registered nurse derives and prioritizes diagnoses or issues from the assessment data, validates diagnoses with the patient and other healthcare providers, and documents diagnoses.

1. The facility failed to ensure nursing staff in the outpatient clinic assessed a patient's condition according to standards of practice when the patient reported new bruising and exhibited low oxygen saturations.

a. Patient #3's medical record was reviewed. A history and physical (H&P) completed by Nurse Practitioner (NP) #2 on 11/19/19 at 1:32 p.m. read, Patient #3 had a diagnosis of paraplegia (paralysis of the legs and lower body) and presented to the facility for an interdisciplinary outpatient evaluation and consultation with neurosurgery.

The H&P further read, on arrival Patient #3's vital signs were checked and she was found to have oxygen saturation of 74%. The patient was placed on oxygen with improvement in her vital signs. NP #2 documented Patient #3's right lower extremity was swollen, bruised, erythematous (exhibiting redness of the skin) and hot. Patient #3 reported she may have hit her leg on the bed during a transfer.

NP #2 documented, given Patient #3's acute symptoms of oxygen desaturations and leg swelling she was concerned for possible PE, fracture, DVT (deep vein thrombosis, a blood clot in a deep vein of the body), pneumonia or heart failure. NP #2 activated emergency medical services and notified the emergency department of an outside hospital of her findings and plan to transfer Patient #3.

b. Review of documentation entered in Patient #3's medical record on 11/18/19, the day prior to her transfer to the emergency department, revealed multiple staff were aware the patient exhibited leg bruising and low oxygen saturations. However, there was no evidence in the medical record these findings were further assessed by the outpatient RN.

i. On 11/18/19 at 9:11 a.m. an Occupational Therapy Outpatient Initial Assessment was completed by Occupational Therapist (OT) #4. The skin assessment read, Patient #3 had bruising on her right lower leg and hip. There was no evidence OT #4 notified the RN of the identified bruising.

ii. On 11/18/19 at 11:34 a.m. an Outpatient Nurse's Progress Note was completed by Rehab Technician (Tech) #3. The note read, Patient #3's pulse oxygenation was low at 88% on room air. Tech #3 documented he notified RN #1 of the low pulse oxygenation reading.

iii. On 11/18/19 at 11:29 a.m. an Outpatient Nursing In Person Interview note was entered by Registered Nurse (RN) #1. The note included assessment of Patient #3's needs and medical history, including mobility needs, history of cardiovascular diagnoses, ability to complete activities of daily living, and bowel and bladder needs. The nursing note did not include documentation of any noted or reported skin issues, or of the low oxygen saturations documented by Tech #3.

An addendum to the nursing note was entered two days later on 11/20/19 at 12:23 p.m. by RN #1. The addendum read, after assessment Patient #3 reported having a skin tear on her right forearm and a bruise on her right knee, with etiology of transfer to toilet at the facility apartments. The addendum did not reveal evidence RN #1 conducted any further assessment of the reported injuries.

c. On 2/13/20 at 1:00 p.m. an interview was conducted with Tech #3. Tech #3 stated if there were concerns with the initial assessment of a patient, he would notify a nurse. He stated this was important because a more qualified practitioner would need to know so they could assess the patient.

Tech #3 stated a patient's oxygen saturation should be above 90%, and for any saturation lower than 90% he would notify a nurse. He stated he would do so because if a patient's oxygen saturation was low, it could indicate poor ventilation to other parts of the body.

Tech #3 reviewed Patient #3's medical record. He confirmed on his assessment of Patient #3's vital signs on 11/18/19, her oxygen saturation was 88%. He stated he notified RN #1 of this.

d. On 2/13/20 at 11:30 a.m. an interview was conducted with RN #1. RN #1 stated her initial assessment of a patient would focus on the patient's needs related to bowel, bladder, and skin. RN #1 stated any applicable information collected during an initial assessment was documented in a nursing flowsheet. She stated the rehab technician would do an initial check of a patient's vital signs, and if there was a concern with vitals she would see the patient, check a repeat set of vital signs, and then notify a provider of the findings.

RN #1 reviewed Patient #3's medical record. She stated on 11/18/19 after she had completed her initial assessment, Patient #3 reported the bruising on her leg and skin tear on her arm and a possible injury during a transfer. She confirmed she did not enter documentation of this until two days later on 11/20/19, and stated she did so because she had closed out her assessment but wanted to ensure this information was in the patient's medical record.

RN #1 stated she recalled looking at the skin tear on Patient #3's arm, but she did not recall looking at the bruising on the patient's leg. She stated she knew about the bruising on Patient #3's leg because the patient reported it to her.

RN #1 stated an oxygen saturation of 88% would be considered low. She did not recall whether Patient #3's oxygen saturations were reported to her. She stated she hoped she received this information because she would then have to look at the patient's other vital signs, assess whether the patient needed to be on oxygen, and involve the nurse practitioner for further evaluation.

RN #1 was unable to locate evidence in Patient #3's medical record she assessed either the bruising on Patient #3's leg or her low oxygen saturations.

RN #1 stated bruising or swelling of the leg could indicate a DVT, internal bleeding, or possibly a fractured limb. RN #1 stated low oxygen saturations could indicate respiratory complications, the patient not receiving enough oxygen, difficulty acclimating to altitude changes, or a PE.

e. On 12/13/20 at 3:35 p.m. an interview was conducted with Vice-President of Clinical Services and Risk Management (VP) #5. VP #5 stated if a patient raised a concern to a staff member, it was the staff's responsibility to assess this concern. She stated she would expect staff to look at an area of concern if it was reported to them. She stated if a patient reported they fell at home and their leg was swollen, staff should inform the patient they would not continue therapy and counsel the patient to have the leg evaluated.

f. On 2/13/20 at 3:54 p.m. an interview was conducted with Vice-President of Patient Care Services (VP) #6. VP #6 stated if a patient reported a concern to their nurse, the nurse should evaluate the patient. She stated if there was a concern with a new skin injury the nurse should assess the skin, either independently or in the presence of a provider. She stated if a patient reported new bruising, the nurse should visualize it and document their assessment.

VP #6 stated new bruising could indicate internal bleeding or a new injury, and was important to assess because patients with spinal cord injuries did not have sensation in their lower extremities. She stated a new wound or swelling could be worrisome due to a patient's lack of mobility and the potential for blood clots.

VP #6 stated if a rehab technician noted abnormal vital signs to include low oxygen saturation, the technician would report this finding to the nurse. She stated the nurse was then responsible to provide oxygen to the patient if needed, and notify either the provider or respiratory therapy for further assessment. VP #6 stated it was the nurse's responsibility to take care of the patient's needs.

g. An incident report entered on 11/19/19 was reviewed. The report read, the patient arrived in the outpatient clinic for an H&P (History and Physical). The patient's pulse oxygenation was in the 70's and oxygen was applied. The lower right extremity was edematous (abnormally swollen) and 911 was called due to desaturation and potential for PE (pulmonary embolism, a blockage in an artery of the lung caused by blood clots which travel from deep veins in the legs). The patient was transported via ambulance with first responders to an outside hospital.

The incident report included records of imaging conducted at the outside hospital. An X-ray was taken of Patient #3's right lower leg on 11/19/19 at 1:36 p.m. The X-ray revealed a nondisplaced tibial shaft fracture (a fracture along the length of the shinbone). A computerized tomography (CT) angiogram (a test using X-rays to provide pictures of the heart and lungs) was performed on 11/19/19 at 3:10 p.m. The CT angiogram revealed pulmonary edema (excess fluid in the lungs) and atelectasis (a partial collapse of a section of the lung).

2. The facility failed to ensure staff in the outpatient clinic reported abnormal assessment findings of new bruising and low oxygen saturations to a provider in order for the provider to evaluate the patient's condition and needs.

a. Patient #3's medical record did not reveal evidence staff notified a provider of the leg bruising and possible injury reported by Patient #3 on 11/18/19, or of Patient #3's low oxygen saturations on the same day.

i. On 11/18/19 at 9:11 a.m. an Occupational Therapy Outpatient Initial Assessment was completed by OT #4. The skin assessment read, Patient #3 had bruising on her right lower leg and hip.

ii. On 11/18/19 at 11:34 a.m. an Outpatient Nurse's Progress Note was completed by Tech #3. The note read, Patient #3's pulse oxygenation was low at 88% on room air. Tech #3 documented he notified RN #1 of the low pulse oxygenation reading.

iii. On 11/18/19 at 11:29 a.m. an Outpatient Nursing In Person Interview note was entered by RN #1. An addendum to the nursing note was entered two days later on 11/20/19 at 12:23 p.m. by RN #1. The addendum read, after assessment Patient #3 reported having a skin tear on her right forearm and a bruise on her right knee, with etiology of transfer to toilet at the facility apartments.

iv. On 11/19/19 at 1:32 p.m. NP #2 completed an H&P which read, on arrival Patient #3's vital signs were checked and she was found to have oxygen saturation of 74%. Patient #3's right lower extremity was swollen, bruised, erythematous and hot.

None of the above documentation revealed evidence NP #2 was notified of concerns documented on 11/18/19 regarding Patient #3's leg bruising and oxygen saturations, or was aware of these findings prior to her assessment of the patient the following day.

b. On 2/13/20 at 12:34 p.m. an interview was conducted with NP #2. NP #2 stated if other staff saw a patient prior to her assessment, she would expect to be notified of anything the staff member found concerning.

NP #2 reviewed Patient #3's medical record. NP #2 stated she saw Patient #3 in clinic on Tuesday, the day after she admitted to the inpatient program. She stated she was worried because the patient's leg was swollen, bruised and hot, and her oxygen saturation was low. She stated she was concerned Patient #3 had a PE.

NP #2 stated her assessment of the patient was the first time she was aware of both the oxygen saturations and the swollen leg. She stated she did not recall other staff members speaking with her about Patient #3, or whether she was told about the patient's condition prior to her assessment.

c. On 2/13/20 at 3:02 p.m. an interview was conducted with OT #4. OT #4 reviewed Patient #3's medical record and stated she looked at Patient #3's leg during her initial assessment. She stated the leg was swollen and hot, and the patient reported she fell off of or hit some equipment in the facility apartment. OT #4 stated she was concerned with the condition of Patient #3's leg, but did not recall whether she notified other staff so the leg could be evaluated further.

OT #4 stated she would notify a provider if a patient exhibited skin issues. She stated she also would counsel the patient to speak with a nurse in the outpatient clinic regarding any new concerns.

OT #4 stated based on the condition of Patient #3's leg when she looked at it, her concerns would include a possible DVT or a broken leg.

d. On 2/13/20 at 11:30 a.m. an interview was conducted with RN #1. RN #1 stated if she saw a patient prior to the nurse practitioner, she would notify the provider of unusual assessment findings or concerns including abnormal vital signs, open wounds, or issues with voiding and bowel function. She stated the provider needed to know of unusual assessment findings to ensure there was not something more serious which needed to be addressed.

RN #1 stated she notified NP #2 Patient #3 had reported leg bruising and a possible injury, however she could not recall whether she did so on the same day it was reported or the next day. RN #1 was not able to locate evidence in Patient #3's medical record of communication with the provider regarding these concerns, nor was she able to locate any documentation outside of the medical record to verify this communication occurred.

e. On 12/13/20 at 3:35 p.m. an interview was conducted with VP #5. VP #5 stated if a staff in the outpatient clinic discovered a concerning finding while assessing a patient, the staff member should tell the provider or refer the patient to the emergency department. She stated if staff noticed bruising with swelling she would definitely believe the staff would notify the nurse practitioner or physician. VP #5 stated if a patient had new swelling, she would expect staff would not continue with therapy until the patient followed-up with a provider.

f. On 2/13/20 at 3:54 p.m. an interview was conducted with VP #6. VP #6 stated basic nursing practice was to notify the provider of anything unusual noted during a patient assessment. She stated a new wound or swelling and low oxygen saturations would be reasons to contact a provider. She stated the nurse should document the information given to the provider. VP #6 stated documentation of communication with a provider was standard nursing practice, and if it was not documented then it did not happen.