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Based on record review and interview the facility failed to insure the physician who initiated placement of a PICC (Peripherally Inserted Central Catheter) line for 1 of 18 (#1) patients identified in the hospital, was accountable to insure the medical safety of the same patient upon discharge.

On 11/12/2014 the medical record (MR) for patient (Pt/pt) #1 was reviewed and revealed the following: Pt #1 was an 81 year old male patient who was initially seen as a new patient in the Wound Care Center (WCC) on 11/21/2013. Pt #1 initially presented to the WCC with an open wound to his sacral area. Wound culture of the sacral wound was completed on the initial visit.

On 11/12/2014 at 11:30 AM in the WCC, office of the Program Director, an interview with staff #7 revealed the following; On the initial visit a culture of pt #1's sacrum was obtained. At that time it was explained to both pt #1 and his daughter that the wound bed appeared infected. The WCC physician gave pt #1 orders for oral antibiotic therapy (ABT) and further explained to pt #1 and his daughter that if the culture came back indicating a drug resistant bacteria that oral ABT might not be effective and it would become necessary to place a PICC (Peripherally Inserted Central Catheter) line in pt #1 for IV (Intravenous) ABT. Pt #1 and his daughter were instructed to return to the WCC in two weeks. In the following days the culture results became available. The WCC staff notified pt #1 and his daughter they would need to see them back in the WCC to discuss the plan for PICC insertion and extended IV therapy.

Continued review of pt #1 MR revealed the following documentation: On 11/25/2013 at 0900 hours, Pt #1's daughter called the WCC requesting MD increase visits (Home Health Visits, HHV) to daily for management of the Foley catheter and deterioration of the sacral wound". "SN (skilled nurse) requested pt #1 to present for evaluation related to reports of wound deterioration, daughter refused". The SN instructed the daughter to contact pt #1's PCP (Primary Care Physician) for changes in daily HHV where the Foley catheter was concerned and pt #1's daughter hung up phone without commenting. The WCC nurse notified the PCP's staff of what had just taken place and requested the PCP be given the information. Next the WCC physician spoke via the phone with the PCP indicating the WCC would follow pt #1 for wound care, that included the plan of care for the course of ABT but pt #1 would need to be seen in the WCC first so the plan could be discussed with the patient and his family prior to beginning any ABT or placing a central line. Documentation from the WCC reflected the PCP was in agreement with the the plan and that pt #1 would follow-up with the WCC.

On 11/25/2013 at 10:00 AM the WCC physician spoke via telephone with pt #1's daughter and instructed her that pt #1 needed to be seen at 10:45 AM in the WCC. Pt #1's daughter stated "No, I'm not going to bring him there. It will cost $750 dollars and that is not what the doctor said". On 11/25/2013 at 1310 the WCC physician's comments were documented as follows: "No, I said for her to come here (WCC) and then we would see what needs to be done, if they even need to go to the ER (Emergency Room)". This information was relayed to pt #1's daughter who replied "No, I refuse to do this. This is malpractice and its recorded". "I refuse this. I'll run it by my parents but this isn't right. I'll run this by my lawyer".

The WCC did not provide orders for IV ABT or placement of the PICC line when pt #1's daughter refused to bring him back to the WCC for discussion of the treatment plan.

On 11/12/2014 review of pt #1's MR for the ED visit of 11/25/2013 revealed the following: on 11/25/2013 at 1715 (5:15 PM), pt #1 arrived via stretcher by the county ambulance services. The Chief complaint credited to pt #1 and his family was "PCP/WCC sent to get PICC line" Further review of the ED physician notes revealed the following: "Pt states he was sent by his wound care specialist and his PCP for PICC line placement for IV ABT for a decubitus wound with Klebsiella and Pseudomonas...

The ED physician's progress of treatment note revealed the following: "1800 hours spoke with Dr. #3 related to plan of care", however no description of the plan of care was documented other than: 1) multi drug resistant wound, 2) follow-up outpatient therapy, disposition to observation status at 1820 in stable condition.

On 11/25/2013 the intake nurse documented the patient's own words as follows "wound care center called and for patient to go to the ER because he had abnormal lab values." Pt #1 received the PICC line and was discharged from the hospital at 11/26/2013 at 1814 hours.

On 11/12/2014 at 4:30 PM in the physician private office an interview with physician #3 revealed he never saw pt #1 on 11/25/2013 or 11/26/2013. He confirmed he never gave orders for ABT for pt #1. Physician #3 confirmed he had been contacted by the ED physician about pt #1 and gave the order because he felt sorry for pt #1. Physician #3 had received the preliminary laboratory culture reports and the report confirmed resistant bacteria in the pt #1's wound. Further physician #3 confirmed he thought the WCC physician would be following the PICC line. Physician #3 was unaware that pt #1's daughter refused to return to the WCC or follow the recommended plan of care. Physician #3 was unaware the WCC physician had refused to give orders without seeing the patient. He further was unaware no order for ABT was found in pt #1's MR from WCC, the hospital ED or the observation status record. Pt #1 was discharge without ABT.

Physician #3, who gave verbal orders over the phone to the ED physician for the PICC line placement failed to follow through with a plan of care for pt #1, who was released to his home, after PICC line placement. Pt #1 and his daughter refused to follow the WCC physician's plan of care and provided inaccurate information to the ED physician. Upon being contacted by the ED physician, physician #3 acted upon the inaccurate information provided by the pt and his daughter. Because physician #3 failed to be accountable for his actions pt #1 was discharge home without an order for IV ABT.

Based on record review and interview the facility failed to provide discharge planning for 1 of 18 (#1) patient's reviewed, who had PICC (Peripherally Inserted Central Catheter) line placement.

On 11/12/2014 review of pt #1's MR or the ED visit of 11/25/2013 revealed the following: on 11/25/2013 at 1715 (5:15 PM), Patient (pt) #1 arrived via stretcher by the county ambulance services. The chief complaint credited to pt #1 and his family was "PCP/WCC sent to get PIC line" Further review of the Emergency Department (ED) physician notes revealed the following: "Pt states he was sent by his wound care specialist and his PCP for PIC line placement for IV ABT for a decubitus wound with Klebsiella and Pseudomonas...

The ED physician's progress of treatment note revealed the following: "1800 hours spoke with Dr. #3 related to plan of care". No description of the plan of care was documented other than the following: 1) multi drug resistant wound, 2) follow-up outpatient therapy.

Pt #1 was transferred to an observation room and scheduled for PICC line placement. He was discharged home on 11/26/2013 at 1814. Review of the medical record (MR) for Pt #1 revealed the "Discharge Summary and Patient Instruction" dated admission 11/25/2013 and Discharge 11/26/2013 documented the final diagnosis as "Need for IV access", destination "home", follow-up appointment WCC. There was no IV ABT orders noted, no home health care, or infusion company noted.

On 11/12/2014 interview with the hospitals Director of Discharge Planning reviewed the discharge documentation and confirmed there was no entry by any hospital discharge planner. Further she stated "she could not explain why no entry had been documented". The Director confirmed PICC line placement normally required a discharge plan with community based resources to follow-up and patient education. None was provided prior to pt #1 discharge.