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Based on record review and interview, facility staff failed to report hospital-acquired pressure injury for 1 of 5 patients (Patient #1), in a total sample of 19 patients.

Findings include:

Per medical record review, Patient #1 was admitted to the facility from 2/15/2019 through 3/1/2019, then readmitted on 3/2/2019. Review of Patient #1's skin assessments dated 2/15/2019 through 3/1/2019 did not reveal any documentation of pressure injury. Patient #1 was discharged from the facility to home on 3/1/2019 at 5:41 PM and readmitted approximately 18 hours later on 3/2/2019 at 12:12 PM. Patient #1's admission skin assessment revealed the following pressure injuries as present upon admission: wound ankle left medial pressure injury; wound ankle left lateral pressure injury; wound toe, great left medial pressure injury; wound hip/trochanter right lateral pressure injury; wound buttock circumferential pressure injury; and the following pressures injuries were documented as "probable" present upon admission: wound foot left lateral/distal pressure injury; wound right foot medial/distal pressure injury.

A wound care consult was ordered on 3/4/2019. Review of the initial wound care consultation notes, dated 3/5/2019 at 11:00 AM, revealed Patient #1 "was recently admitted at [Hospital Location S]... came back to [Hospital Location T] ER and subsequently admitted... was found to have multiple areas of deep tissue injury for which wound care was consulted to evaluate and treat. Per review of notes [Patient #1's family member] states that they developed while [Patient #1] was at [Hospital Location S]. ...There are multiple pressure injuries noted to right hip, bilateral buttocks extending to bilateral ischium, bilateral feet, bilateral ankles. ...numerous areas of deep tissue injury and what appears to be traumatic wound on the left anterior lower leg. [Patient #1] is thin and slightly contracted. Likely due to positioning has pressure points pressing together."

Review of the facility's hospital-acquired pressure injury report did not include Patient #1's pressure injuries noted between 3/2/2019 and 3/5/2019.

During an interview on 7/31/2019 at 10:00 AM, Quality Director M stated pressure injuries are reported and "an investigation is done if it's a hospital onset. The department leader and nurse educator review to make sure the standards of care were followed. There's an investigation tool that we use for stage 3 or greater."

During an interview on 7/31/2019 at 10:35 AM, Wound Nurse O stated "based on how extensive they [Patient #1's wounds] were, it is our opinion that they developed during the hospitalization [between 2/15/2019 and 3/1/2019 at Hospital Location S]." When asked why the injuries weren't reported as hospital acquired, O stated "either the wound nurse or the floor nurse can enter" the pressure injury into the facility's reporting system, but "they were present on admission here at [Hospital Location T]" so they were not identified as hospital-acquired.

During an interview on 7/31/2019 at 3:25 PM, when asked for aggregate pressure injury reporting data for the hospital, Wound Care Supervisor U stated the pressure injury reports are reviewed and acted upon separately between hospital locations.

Based on record review and interview, facility staff failed to ensure patients are provided accurate and relevant information upon discharge for 4 of 5 discharged patients reviewed (Patient #1, Patient #11, Patient #12, Patient #13), in a total sample of 19 patients.

Findings include:

Review of facility policy "Discharge Planning" dated 3/30/2017 revealed "5.4 Implementation: k) Prior to discharge, the patient and/or family/patient representative is given written discharge instructions which are legible, in plain language and tailored to the patient's identified needs. The discharge instructions may include: ...iii.) instructions outlining what to do when concerns arise as well as signs and symptoms to watch for and when to seek emergency assistance; iv.) instructions for follow up care. ...m) Any transfers or referrals to other health care facilities, agencies or outpatient services for follow up or ancillary care will be summarized in a transition document."

Per medical record review, Patient #1 was discharged from the facility to home on 3/1/2019 after a 13 day inpatient stay for a diagnosis of pneumonia. Review of Patient #1's physician notes on 3/1/2019 revealed a follow up plan for a chest xray "in a few days" or if Patient #1 develops a fever. Review of Patient #1's After Visit Summary, provided to Patient #1 at discharge, did not include instructions for a follow up chest xray or instructions for signs and symptoms of infection.

Per medical record review, Patient #11 was discharged from the facility to home on 4/26/2019 after a 19 day inpatient stay for a diagnosis of critical illness myopathy. Review of Patient #11's Physician Discharge Summary revealed "Patient Instructions: Activity: activity as tolerated; Wound Care: keep wound clean and dry." Review of Patient #11's After Visit Summary, provided to Patient #11 at discharge, revealed "Activity: No driving. Assistance needed with ambulation. Wound Care Instructions: Per wound care." There were no instructions to keep the wound clean and dry on the After Visit Summary.

Per medical record review, Patient #12 was discharged from the facility to home on 5/28/2019 after a 36 day inpatient stay for a diagnosis of C. difficile diarrhea, status post fecal transplant. Review of Patient #12's Physician Discharge Summary revealed "...will discharge home with home PT [physical therapy], OT [occupational therapy]." Review of Patient #12's After Visit Summary, provided to Patient #12 at discharge, did not include instructions or information for home PT/OT.

Per medical record review, Patient #13 was discharged from the facility to home on 7/4/2019 after an 11 day inpatient stay for a diagnosis of respiratory failure. Review of Patient #13's Physician Discharge Summary revealed "Discharge Instructions: Diet: Consistent carb moderate, 1.8 L fluid restriction." Review of Patient #13's After Visit Summary, provided to Patient #13 at discharge, revealed "Discharge Instructions: Low Salt (Sodium) Diet..." The After Visit Summary did not include instructions related to carb or fluid intake.

During an interview on 7/30/2019 at 1:45 PM, Social Services Manager K stated "home health care is arranged by the social worker, the social worker puts the details into the AVS [after visit summary]." Regarding the lack of home health care information on Patient #12's AVS, K stated "I wonder if the physician didn't order it."

During an interview on 7/30/2019 at 2:00 PM, Clinical Nurse Specialist Q stated "things like medications and appointments flow into the AVS [after visit summary]. Things like activity and diet have to be entered by either the RN or physician." Per Q, "things the RN enters into the AVS are done in collaboration with the physician." When asked about the discrepancies between the medical record and patient discharge instructions, Q stated "we are looking at trying to make things more uniform."

Based on medical record review and interview, facility staff failed to track and trend readmissions within the same hospital with multiple locations for 1 of 1 patient readmitted to another location (Patient #1), out of 5 readmission reviewed in a total sample of 19 patients.

Findings include:

Review of facility policy "Discharge Planning" dated 3/30/2017 revealed "5.5 The hospital QAPI program tracks readmissions to their hospital, at least quarterly. Once the QAPI program has identified potentially preventable readmission, it is expected to reassess its discharge planning process. ...Reassessment includes: ...iii.) Tracking of readmission rates (at least one interval) and potentially preventable readmissions."

Review of Patient #1's medical record revealed Patient #1 was admitted to the facility on 2/15/2019 through 3/1/2019 for a diagnosis of pneumonia. Patient #1 was discharged to home on 3/1/2019, then readmitted on 3/2/2019 with a diagnosis of sepsis. Review of the facility's list of readmissions did not include Patient #1.

During an interview on 7/30/2019 at 2:50 PM, Director of Quality M stated Patient #1 was discharged from one hospital location [Building S] and readmitted to another [Building T]. Director M stated the facility is not tracking readmission within the hospital for the different buildings/locations of the hospital.

During an interview on 7/30/2019 at 2:55 PM, Case Management Manager R stated "Case Management does readmission interviews for patients readmitted with certain diagnoses, but all readmissions within 0 to 14 days are reviewed by quality." When asked about the readmission for Patient #1 from Building S to Building T, Manager R stated "we would not look into that, more often than not patients come [back] to the same" location when they are readmitted.