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Based on record review and interview the governing body failed to ensure services furnished in the hospital under contract (dialysis-removal of waste products and fluid) met the standards of practice for the contracted services for 2 (P#s 3 and 4) of 10 records reviewed. The deficient practice has the potential to result in adverse outcomes, including fluid overload and respiratory failure when patients are dialyzed without adherence to professional standards. The findings are:

A. Record review of [name of facility] dialysis website undated revealed, "Fluid is removed during dialysis to return the patient to his or her dry weight by the end of the treatment. Ideally, the goal is to target a weight where the patient will be normally hydrated (not feel thirsty) and feel comfortable. In most cases, dry weight is an estimate determined by your doctor, based on his or her experience and your input."

B. Record review of P#s 3 and 4's dialysis treatment records revealed no weights were obtained prior to or after dialysis treatment. P#3 was admitted 08/10/19 and dialyzed on 08/13, 08/15, 08/17, and 08/20/19. P#4 was admitted on 08/16/19 and dialyzed on 08/16/19 and 08/19/19.

C. Record review of contract dialysis documentation revealed P#3's "Inpatient Services Dialysis Treatment Summary" dated 08/10/19, 08/13/19, 08/13/19 and 08/15/19 revealed 1000 cc (approximately 2 pounds of fluid) was ordered to be removed during treatment. All of the treatment records from the contract dialysis organization documented "Unable to Obtain: Floor to weigh" (no weight was used to determine fluid removal goals).

D. Record review of P#4's "Inpatient Services Dialysis Treatment Summary" dated 08/16/19 revealed the amount of fluid to be removed was "UF (ultrafiltration/fluid removal) Range 2-3". 2-3 (unknown amount).

E. Record review of P#3's vital sign record revealed P#3 was weighed twice since admission to the facility. Weight was recorded on 08/09/19 as 60.1 kg (kilograms) and on 08/11/19 as 60 kg (weight obtained after dialysis treatment).

F. On 08/14/19 at 3:30 during interview, S#1 Administrator stated that the patients are taken off site during dialysis and believed the weights were done at the offsite location.

G. On 08/20/19 at 3:00 pm during interview, S#3 Nurse Manager confirmed dialysis patients should be weighed daily to determine weight gain due to fluid intake and to determine dialysis fluid removal goals and confirmed that procedures need to be established with the contract dialysis provider.

Based on record review and interview the facility failed to administer medications in accordance with acceptable standards of practice, by not assessing pain location for 2 (P#s 2 and #5) of 10 patient records reviewed. This deficient practice has the potential to result in failure to properly assess pain medication requirements, addiction or over-utilization of pain medications or inadequate pain control. The findings are:

A. Record review of "American Society for Pain Management Nursing Guidelines on Monitoring for Opioid-Induced Sedation and Respiratory Depression, Pain Management Nursing Vol 12, No3 (September) 2011 pages 118-145 revealed, "Nurses play an important role in intervening to prevent the worsening of adverse events." and "Effective pain management is a priority of care and a patient right (Joint Commission, 2010). Appropriate assessment and monitoring of patients are essential components of care."

B. Record review of P#5's "Pain Monitoring" dated 08/04/19 through 08/08/19 revealed no pain location documentation and patient received Acetaminophen 650 mg. on 5 occasions in the time period.

C. Record review of P#2's "Pain Monitoring" dated 08/06/19 through 08/07/19 revealed no pain location documentation, patient experienced moderate to severe pain (5-8 on a scale with 10 being the worst pain possible) and received Oxycodone (opioid pain medication sometimes called a narcotic) 8 times and Tramadol (narcotic-like pain reliever used to treat moderate to severe pain) 1 time. In addition the documentation did not include the "Patient's Stated Pain Goal".

D. On 08/21/19 at 12:00 during interview S#3 Nurse Manager confirmed documentation of pain location should be recorded in the pain monitoring documentation to meet the standard of practice for medication administration.

Based on record review and interview the hospital failed to ensure the medical record contained information to describe the patient's progress and response to services including wound care for 2 (P#2 and 6) of 10 patient records reviewed. This deficient practice does not allow the medical provider to review the entire record for patient's progress or degree of changes which could result in increase in wound size, wound infection or lack of wound healing. The findings are:

A. Record review of P#2's medical record revealed patient had a diabetic ulcer (skin breakdown) fourth toe anterior, right and a diabetic ulcer toe second anterior right as of 08/20/19. P#2 was admitted on 07/16/19. P#2 had venous stasis ulcer (non healing wound) on the right lower extremity. No wounds were documented in the admission history and physical and the only wound care orders were for "Evaluate and treat" as of 07/16/19.

B. Record review of P#2's nursing documentation during hospitalization does not include measurements of wounds or status of wound healing.

C. Record review of P#6's wound documentation flowsheet for the "Great Toe" describes the wound as "approximated" (close together). P#6 was admitted 08/02/19. No wound measurements are included. In addition, the wounds described in the "Review of Systems" dated 08/02/19 on the front of the neck and right shin are not addressed in nursing documentation (no measurements, dressing change documentation or status of healing).

D. On 08/21/19 at 12:00 pm during interview, S#3 Nurse Manager confirmed documentation should include wound measurements, healing or non-healing status and changes to wound care including dressing and medication if needed S#3 also confirmed there were no additional wound care orders in the record for P#2 other than "evaluate and treat" and that due to P#2's "morbid obesity-444 pounds" and report of "new lesions on the right foot and blisters of the right plantar surface" the patient required specialized wound care. Nurse Manager also confirmed no wound care expert was currently on staff at the facility.

E. Record review of facility policy "Pressure Ulcer Prevention and Treatment" dated 03/14/19 revealed "Provider, dietician and wound care nurse to be notified-document in nurse's notes. Use dressing product that is appropriate for the wound-consult wound care nurse. Measure wound and document measurement of wound including any undermining and/or tunneling and description of wound in nurse's notes. Patients with a pressure ulcer or open wound should have a provider's order for wound care treatment. Nurses should document their observations and actions and provide clear communication with the provider and wound care team."

Based on record review, observation and interview the facility failed to use the weight for dialysis (clean the blood of waste products and remove excess fluid) treatment of 2 (P#s 3 and 4) of 2 dialysis patient records reviewed as appropriate for the necessary monitoring of the patient's condition. This deficient practice has the potential to result in inadequate fluid removal or excessive fluid removal during dialysis treatment, significant problems with blood pressure and possibly death. The findings are:

A. On 08/20/19 at 9:00 am during observation and record review with S#3 Nurse Manager, no record of the dialysis treatments P#3 received while hospitalized (admission 08/10/19) at the facility could be found in the electronic record.

B. Record review of P#3's vital sign record revealed P#3 was weighed twice since admission to the facility. Weight was recorded on 08/09/19 as 60.1 kg (kilograms) and on 08/11/19 as 60 kg (weight obtained after dialysis treatment).

C. Record review of P#3's "Inpatient Services Dialysis Treatment Summary" dated 08/10/19, 08/13/19, 08/16/19, 08/17/19 and 08/20/19 revealed the weight was not obtained by the dialysis provider before or after treatment. In the pre treatment and post treatment vitals section it was documented "Unable to Obtain: Floor to Weigh".

D. Record review of P#'4's"Inpatient Services Dialysis Treatment Summary" dated 08/16/19 and 08/19/19 revealed the weight was not obtained by the dialysis provider before or after treatment. In the pretreatment vitals section it was documented "Unable to Obtain: Floor to Weigh".

E. On 08/20/19 at 3:00 pm during interview, S#3 Nurse Manager confirmed dialysis patients should be weighed daily to determine weight gain due to fluid intake and to determine dialysis fluid removal goals. Nurse Manager confirmed being unable to find the dialysis treatment records in the electronic record and confirmed that if she was unable to find them, the staff would also not be aware of the location in the record.

Based on observation, record review and interview the facility failed to provide protection from hazards of ionizing radiation for facility personnel in the fluoroscopy (imaging technique that uses X-rays to obtain real-time moving images of the interior of an object) suite. This deficient practice can result in cataracts in the eyes of staff performing procedures in the suite. The findings are:

A. On 08/22/19 at 10:30 am S#5 RN (Registered Nurse) was observed using the fluoroscopy equipment to take Xray films during a bilateral (both) knee procedure. S#5 was not wearing protective leaded eyewear or any eyewear during the procedure. There was no lead screen in the suite.

B. Record review of the "International Atomic Energy Agency Health professionals" website article undated revealed, "Performing a few fluoroscopic procedures per week that require only a few minutes of fluoroscopy time per procedure (i.e. less than 5 minutes), sufficient protection of the eye lens can be achieved by using a lead screen or wearing lead glass eye wear. But if protection is not used, there can be a risk (cataracts).

C. On 08/22/19 at 11:00 am during interview, S#6 (CFO Chief Financial Officer) confirmed staff should be wearing leaded eye protection in the fluoroscopy suite when performing procedures and also confirmed that protective eye wear was purchased for the staff to wear during procedures.

Based on record review and interview, the facility failed to employ a staff person who was appropriately qualified to provide discharge planning evaluations to determine discharge needs which affects all patients. This failed practice has the potential to result in poor discharge planning which may slow or complicate the patient's recovery, lead to readmission to a hospital, or may even result in the patient's death. The findings are:

A. Record review of [name of facility] "Job Description/Evaluation EOY (End of Year) 2018 (one document) dated 02/25/19 revealed, "Education, Minimum: Clinical background with a Bachelor's degree or equivalent experience or combination of ADN (Associates degree in Nursing) and experience in a health related field. Licensure, Valid LSW (licensed social worker) for Hospital, and or valid NM (New Mexico) or multi-state RN (Registered Nurse)."

B. Record review of S#7's resume revealed, no evidence of degree completion or equivalent experience in a health related field.

C. Record review of wavier memo signed by Chief Executive Director (CEO) dated 07/03/18 revealed, "Waiver for [name of S#7] to be a case manager. [Name of S#7] Due to the nature of the work that [name of S#7] has demonstrated at [name of facility] we are doing a onetime waiver to allow her to be in the job description of a case manger with her training and current skill set. This waiver is only for [name of S#7] to work as a case manager at [name of facility]."

D. On 08/21/19 at 5:00 pm during interview, CEO confirmed he provided S#7 a written waiver to be placed in the Case Manager position as S#7 was working on getting a degree in Social Work. CEO confirmed believing S#7 was in school to get the degree and did not know that S#7 had not been in school to complete the degree since 2004.

E. On 08/22/19 at 12:05 pm during interview, HR (Human Resource) Manager confirmed no evidence of a degree in the HR file to verify degree completion for S#7.

F. On 08/22/19 at 1:45 pm during exit conference, CEO confirmed transcripts of degree completion would be emailed to surveyor by end of day for review. To date, no transcripts have been received.

Based on record review and interview, the facility failed to arrange for the inital implementation of the discharge plan for 1 patient (P#1) of 10 (P#1-P#10) patients sampled by not establishing who will assist the patient in the home setting after discharge from rehabilitation. This failed practice does not prepare the patient for self-care or prepare patient's family or other support person(s) who will be providing care the resources needed to discharge successfully.

The findings are:

A. Record review of [name of facility] Discharge Process undated, next review date: 02/05/2020 revealed, "General Guidelines: 2. Discharge planning may be initiated by the patient, family/support system, case manager, physician, nursing staff, ancillary service staff, or community agency. 4. Discharge plans are discussed by all members of the interdisciplinary team and discussion is documented in the medical record."

B. Record review of P#1's medical chart page 132 revealed, "limited support system: spouse, family members. Caregiver at discharge: Patient will be staying with her spouse and his aunt in [name of city]."

C. Record review of P#1's medical chart page 159 revealed, "limited support system: spouse, family members, Caregiver at discharge: Patient will stay with daughter and brother in [name of city] spouse who was able to verify demographics. Discharge plan is for her to stay with her spouse and his aunt in [name of city]. CM unable to obtain information from patient. CM attempted to reach her sister [name of sister], her brother [name of brother], and her daughter [name of daughter]-none of these contacts have a voice mailbox set up."

E. Record review of email sent from Staff #7 (Case Manager) dated July 30, 2019 revealed, "The family does not want the pt's (P#1) boyfriend coming to the hospital or calling as they believe he is the reason she is in this condition."

F. Record review of Director of Quality Notes from a telephone conversation with boyfriend's aunt dated 08/01/19 revealed, P#1 does not have a spouse as documented.

G. On 08/21/19 at 12:15 pm during interview Director of Quality confirmed the daughter was the person appointed by P#1 to care for her after discharge. Director of Quality also confirmed P#1 did not live in [name of city] did not have a spouse and the aunt was not related to P#1, but was the aunt of the boyfriend of P#1.

Based on record review and interview, the facility failed to reassess the patient's discharge plan if there are factors that may affect continuing care needs or the appropriateness of the discharge plan for 1 patient (P#1) of 10 (P#1-P#10) patients sampled. This failed practice has the potential to affect the patients post care if the resources needed are not provided when significant changes in the patients condition are presented. The findings are:

A. Record review of P#1's discharge plan revealed no evidence of addressing the identified concerns in the "Interdisciplinary Team Priorities."

B. Record review of [name of facility] "Discharge Process" undated, next review date" 02/05/2020, revealed, "3. Complete Discharge Care Instruction form including: All needed follow-up appointments for discharge (include phone numbers), Home Health Care and/or Outpatient therapy (agency or location and phone number with date of first visit).

C. Record review of P#1's medical chart page 136 revealed, "Interdisciplinary Team Priorities, Social Services: social work for community resources." No evidence of community resources identified for coordination.

D. Record review of P#1's medical chart page 145 revealed, "Special Needs: Substance Abuse." No evidence of substance abuse resources identified or provided to P#1.

E. Record review of P#1's medical chart page 164 revealed, "Interdisciplinary Team Priorities, Social Services: social work for community and substance abuse resources." No evidence of resources provided.

F. Record review of physical therapy progress note for P#1 dated 08/05/19 revealed: "No family training done."

G. Record review of Case Management note undated: "She (P#1's representative) also asked to have pt's (P#1) neuro (nervous system) moved up as they will not be able to travel back to [name of city] for the appointment. CM (Case Manager) spoke with [name of Dr] office regarding the appointment and they will call CM if the appointment is able to be moved up. CM also spoke with pt's sister to let her know patient will be going home on tube feeds and someone in the family will need to learn how to do the bolus feeds (syringe to deliver formula through your feeding tube). No evidence to indicate follow-up on appointment rescheduling or family training.

H. On 08/21/19 at 12:20 pm during interview, Chief Executive Officer and Director of Quality confirmed the documentation provided by the case manager could have been better.