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Based on review of medical records, policies and procedures, hospital logs, department of medicine rules and regulations, and staff interview, it was determined that the facility failed to conduct peer review on patient #40 who was readmitted within 30 days of discharge.

Findings include:

Review of "Department of Medicine Rules and Regulations" revealed: "...The Department of Medicine is responsible to...Conduct reviews to analyze and evaluate the quality and appropriateness of care and treatment provided by practitioners with privileges in the department and make recommendations on the results of these reviews...."

Review of the "Hospitalist Indicators by Facility" provided by Director of Quality Management revealed: "...Internal Medical Indicators by Facility...Readmission within 30 days of discharge...."

Review of discharge and emergency room summaries dated 7/24/09, revealed that the patient was admitted to the hospital 6/25/09 through 7/24/09, for a Coronary Artery Bypass Graft (CABG) x 4. The patient was discharged on 7/24/09 at 4:07 pm, and readmitted on 7/25/09 at 1:45 am.

The "Discharge Summary," dated 7/24/09, revealed: "...The patient was admitted on June 26, 2009, for a mechanical aortic valve replacement, mitral valve repair, and (CABG)...tolerated reasonably well...patient was not extubated until July 3, 2009...patient continued to improve...the patient was fairly deconditioned after the prolonged intubation...The patient was discharged to the rehab (rehabilitation) facility on July 24, 2009, at 4:07 pm with appropriate follow and...medications that is on the chart...."

The "Emergency Room Report," dated 7/24/09, at 9:09 pm, revealed: "...the patient was transported via ambulance to the Emergency Room (ER) for hypotension, altered mental status, and renal failure, and admitted to the hospital at 1:45 am.

Employee # 23 verified, during and interview conducted on 10/13/10, that the patient was discharged from Banner Thunderbird Medical Center (BTMC) to the rehab facility on 7/24/10, at 4:07 pm, then readmitted to BTMC with hypotension, altered mental status, and renal failure, on 7/25/09 at 1:45 am.

The Director of Quality Management verified, during an interview conducted on 10/26/10, that the peer review indicators for internal medicine included readmission within 30 day of discharge. The Director of Quality Management confirmed there was no documentation that a peer review was conducted for the readmission of a patient within 30 days of discharge.

Based on review of policies and procedures, medical records, and interviews with staff, it was determined that a registered nurse failed to evaluate the nursing care for patients #1, #2, #40, #41, and #48, as evidenced by the failure:

1. of nursing to document post cardiac catheterization vital signs, and assess the incisional site, according to the physician's order, for 1 of 1 patient (Patient #1);

2. to document clear and consistent descriptions, for 1 of 1 patient's (Pt. #2), with compromised skin integrity;

3. of nursing to administer anxiety medication on 7/18/09 (Pt #40);

4. to ambulate 1 of 1 patients reviewed for ambulation (Pt #40), four times a day (qid) as ordered by the physician; and

5. to provide personal hygiene and peri-care daily for 1 of 1 patients reviewed (Pt #40).

Findings include:

1. Patient #1 was admitted on 05/06/09, for a left and/or right cardiac catheterization with coronary angiogram and left ventriculography, percutaneous transluminal coronary artery stent placement, and coronary artery rotational arthrectomy.

The Physician's Post Percutaneous Coronary Intervention Routine Orders required: "...check vital signs, access site for swelling/bleeding...every 15 minutes x 4 then every 30 minutes x 2, every 1 hour x 2 and after sheath removal. Resume previous vital sign schedule if stable, checking above parameters with each vital sign check for 24 hours...."

The hospital's Cardiac Catheterization procedure report, 05/06/09, revealed that the patient's post procedure vitals signs were assessed at 1800, 1807, and 1820. The nurse documented "no bleeding/hematoma right groin" and transferred the patient to the inpatient nursing unit.

The Post Procedural Flowsheet revealed the nurse assessed the patient's pulses 05/06/09 at 2000, and 05/07/09 at 1002. The Wound Assessment was documented as follows:

05/06/09 at 1835: S/P (status post) heart cath R (right) groin incision with drsg (dressing) no hematoma.
05/06/10 at 2219: puncture wound, right groin, dry/intact.
05/07/10 at 0800: incision/surgical, right groin, dry/intact, drng (drainage) none, wound surrounding tissue pink/soft. The patient was discharged on 05/07/10 at 0911.

Documentation did not demonstrate that the patient's vital signs were assessed, and the incision site checked, according to the physician's orders.

RN #31, confirmed that the post procedure vital signs were not documented, and the wound assessed, per physician order, during the record review and interview conducted on 10/01/10, at 1330.

2. Patient #2 was admitted on 04/05/10, with complaints of weakness and altered level of consciousness, post fall at home. Co-morbidities included diagnosed atrial fibrillation, dehydration, coagulopathy (taking Coumadin), leukocytosis, bronchial asthma, and hypertension.

Wound Care Nurse RN #13, confirmed during the medical record review and interview conducted on 09/23/10 at 1015, that it was unclear of what was happening with the patient's integumentary status as the staff's documentation ranged in "pale...ruddy...pigmented...cellulitis...lesions... weeping areas...bruising...." RN #13 stated, "...Cellulitis should be documented only when doing wound care..." but verified that the staff documented cellulitis on skin assessments also.

RN #13 verified that the patient's skin integrity was not clearly documented, and that there was no documentation that the patient was instructed in wound care prior to discharge

3. Review of Pt #40's medical record revealed the following:

Review of "PHYSICIAN'S ORDERS" dated 6/25/09, revealed: "...Xanax 1 mg (milligram) tid (three times a day)...prn...."

Physician order on the MAR dated 7/6/09, revealed: "... Haldol 1-2 mg IV (intravenous) Q (every) 1H (hour) PRN Agitation...."

7/18/09, Registered Nurse (RN) assessments;

8:00 am, lethargic, agitated and restless;

12:00 pm, lethargic;

4:00 pm; restless and agitated, no medication administered;

8:00 pm, agitated, restless, angry and anxious wanted to go to the room next door and that we were kidnapping him, called his girlfriend and said I think she's cheating on me;

Employee # 23 verified, during an interview conducted on 10/13/10, that patient #40 did not receive the ordered medication on 7/18/09.

Nursing documented Pt #40 was agitated at 0800, 4 pm and 8 pm. Nursing did not administer Xanax or Haldol that were ordered for the patient if needed.

4. Review of Pt # 40's medical record contained a physician order dated, 07/21/09, at 0758 hours...Ambulate qid at least with assist...."

Documentation in the medical record indicated nursing documented the following:

7/20/09, ambulate 300 feet; and

7/21/09, return to chair, ambulate 300 feet (ft), repositioned, up to bathroom.

Employee #23, verified, during an interview conducted on 10/13/10, that the patient was not ambulated QID from 07/21/10, when the physician first ordered ambulation for the patient, through 7/24/09. Nursing documented ambulating the patient only twice in 4 days.

5. Review of policy and procedure "BH Adult Nursing Standards of Care," dated 7/9/09, revealed: "...All patients will be provided an opportunity for personal hygiene at least daily and as a condition warrants and includes but not limited to...Shampoo will be offered as patient condition allows...Pericare will be done at least daily...Oral hygiene will be offered and provided at least 2 times daily and more frequently in the comatose/less responsive...."

Review of Pt #40's medical record revealed the patient was admitted on 06/25/09, and discharged on 07/24/09.

Review of "Hygiene," forms revealed:

07/12/09, bed to chair, up to bathroom, peri care max assist;

07/16/09, complete bed bath, oral care, skin care, up to BS (bedside commode), positioned back, elevate head of bed 30 degrees, 2 person assist;

Employee #23, verified, during an interview conducted on 10/13/10, that documentation in the medical record indicated the patient had peri-care once and one bed bath, for this 30 day hospitalization.

Based on review of medical records, medical staff rules and regulations, and staff interviews, it was determined that the facility did not obtain a fully, completed anesthesia consent form for 1 of 1 (Pt #55) patients.

Findings include:

Review of "MEDICAL STAFF RULES AND REGULATIONS" revealed: "...A patient's informed consent, must be obtained prior to performing any of the operative and/or invasive procedures...the responsible practitioner will discuss with the patient...adequate information about the procedures so that an informed decision can be made, including an explanation of the material risks and anticipated benefits...."

Review of "ANESTHESIA CONSENT FORM" for Pt #55 revealed: "...Anticipated type of anesthetic" was left blank on the consent.

Interview with Employee #38, endoscopy RN, at 1145 hours on 10/13/10, revealed: "...The anticipated type of anesthesia space on the "ANESTHESIA CONSENT FORM" should be filled out as to type of anesthesia to be used prior to the patient signing the form. During the time out, the staff verifies the procedure and signed consents prior to starting the procedure. The anesthesiologist reviews the consent with the patient either in the admitting area or in the procedure room as long as it is before the physician begins the procedure...."

The Director of Quality Management verified on 10/13/10 at 1113 hours, that the consent form was not completely filled out prior to the patient signing the form.

Based on review of hospital policies/procedures, medical records, and staff interviews, it was determined that 1 of 1 patient's (Pt. #2) discharge planning, did not consider the likelihood of the patient needing post-hospital services.

Findings include:

The hospital policy titled Case Management Discharge Planning #9394.1 (last reviewed 07/08) required: "...Discharge planning is based on a patient assessment of physical...needs...involving the patient/family, practitioner...nursing, and other disciplines...planning is accomplished through a coordination of hospital and community providers and support systems to enable the patient to return home safely...Include in a discharge planning evaluation the likelihood of a patient's capacity for self-care...."

The physician documented: "...discharge...home with home health for home PT (physical therapy)...no extremity edema...." The Discharge Instructions Summary indicated the physician ordered: "...continue...Lasix 20 mg oral twice a day...nystatin topical...1 application (application) twice a day x 14 days...Coumadin 5 mg oral once every day...." There was no physician order to include home health nursing visits for wound care and/or coumadin monitoring.

Case Manager RN #14, who was identified in the medical record as one of the case managers involved in the discharge process, confirmed during the medical record review and interview conducted on 09/23/10 at 1330, that s/he was not aware that the patient required wound care, was prescribed Coumadin, that the patient had a history of falls, and lived alone. S/he confirmed the physician's discharge order for home health therapy only.

RN #14 verified that the Medical Power of Attorney (MPOA) expressed concerns on admission, that the patient could not be home alone without help. RN #14 stated that if a patient refused placement in a skilled nursing facility (SNF), the placement could not be forced.

Case management did not interact with the nursing staff or therapist to ensure the home situation was safe and home care services were arranged to meet the needs of the patient post discharge.

Based on review of hospital policies/procedures, medical records, and staff interviews, it was determined that 1 of 1 patients (Pt # 2) was not adequately prepared for discharge.

Findings include:

Patient #2, presented to the Emergency Department (ED) on 04/05/10, with complaints of weakness and altered level of consciousness, post fall at home. Co-morbidities included diagnosed atrial fibrillation, dehydration, coagulopathy (taking Coumadin), leukocytosis, bronchial asthma, and hypertension. The patient was admitted to the inpatient unit for ongoing care and treatment, and discharged on 04/14/10.

The patient revisited the ED on 04/19/10, at 1701, with complaints of increased bilateral lower leg swelling and, reported temperature of 102. The physician documented: "...ulceration from peripheral vascular disease which is chronic...." The patient was treated and released at 2252, with a prescription for Lasix 20 mg orally twice daily. There were no orders addressing wound care for the lower extremity ulcerations.

The hospital policy titled Case Management Discharge Planning #9394.1 (last reviewed 07/08) required: "...Discharge planning is based on a patient assessment of physical...needs...involving the patient/family, practitioner...nursing, and other disciplines...planning is accomplished through a coordination of hospital and community providers and support systems to enable the patient to return home safely...Include in a discharge planning evaluation the likelihood of a patient's capacity for self-care...."

Case Manager RN #14, who was identified in the medical record as one of the case managers involved in the discharge process, confirmed during the medical record review and interview conducted on 09/23/10 at 1330, that s/he was not aware that the patient required wound care, was prescribed Coumadin, that the patient had a history of falls, and lived alone. S/he confirmed the physician's discharge order for home health therapy only.

RN #14 verified that the Medical Power of Attorney (MPOA) expressed concerns on admission, that the patient could not be home alone without help.

The patient/representative was not involved in the discharge process.