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GULF COAST MEDICAL CENTER LEE HEALTH 13681 DOCTORS WAY FORT MYERS, FL 33912 Aug. 30, 2011
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
Based on staff interview and medical record review, the facility failed to provide a coordination of care to assure discharge planning included communication regarding care instructions for 1 (Patient #3) of 3 patients sampled. The findings include:

A review of the medical record for Patient #3 was conducted on 08/29 and 08/30/11. The medical record reveals the patient has two admissions at this facility. The first admission was on 05/10/11 through 05/31/11. The second hospital stay was 06/23/11 through 07/27/11.

On 05/10/11, the patient was admitted to the hospital after being transferred from a Skilled Nursing facility to the Hospital Emergency Department. The patient presented with a high fever and abnormal laboratory values.

A record review revealed a diagnosis of (including, not limited to) pneumonia, dehydration and acute renal failure. The record includes a history of a Motor Vehicle Accident (MVA) in April, which resulted in multiple trauma (not limited to) closed head trauma,/head wound, cervical spine fracture with quadriplegia (Paralysis-below the neck), artificial feeding (peg tube), pacemaker (implanted device to trigger heart beat) and a tracheostomy (a tube placed in the throat for breathing). The hospital course included antibiotics and wound care on head and right heel. The head wound was with pink healing tissue, the heel wound was unstageable (wound covered with necrotic tissue). These wounds required dressings and pressure relieving measures. The patient also requires an artifical feeding/nutrition through the peg tube.

On 06/23/11, the patient was admitted from the nursing facility to the hospital Emergency Department and into the hospital for a fever. The record documents admission diagnosis including (not limited to) Right Lung Pneumonia and rule out sepsis (Infection-systemic). The physician progress notes document administration of antibiotics, pulmonary consultation with respiratory treatments. The nursing notes documents wounds; including (not limited to) a head wound, coccyx wound, left heel wound and an open area on the big toe, open area on the ankle bone. At discharge, the patient was without signs of pneumonia on the radiologic studies at discharge. The big toe wound was "healed," ankle wound "healing," coccyx wound "resolved" as of 07/16/11, the head wound was with healing pink tissue with an area of eschar (necrotic tissue) with granulation formation and healing.

The medical history was as outlined in the physician progress notes and physician consult documents. These physician notes were consistent with the previous 05/10/11 admission (including the closed head trama, cervical fracture, peg tube, pacemaker, and tracheostomy). The patient would require wound care, artificial feedings through the peg tube, and pulmonary treatments at discharge to the SNF.

An interview was conducted with the discharge planning nurse on 08/30/11 at 3:45 p.m. The Case Management (discharge planning) nurse was asked about the discharge planning that is performed for the patients being discharged to a Skilled Nursing Facility. The nurse commented, the discharge planning is initiated at admission and continues through to discharge. The nurse explained the hospital usually faxes parts of the medical record to the Skilled Nursing Facility (SNF). A packet of those medical records are sent with the patient to the SNF at discharge. The nurse and risk manager gathered this information that would be sent to the SNF. The nurse was asked about the physician orders, which will ensure the patient maintains a continuum for care. The nurse stated "this information would be in the 3008 form (used for communication from the hospital to the SNF), wound care and diet needs would be on this form." The case manager and risk manager provided a packet including the documents that would have been sent to the SNF for each of the two discharges; 05/31/11 and 07/27/11. A review of the packets included an example of the case management checklist.
The 05/31/11 discharge 3008 form was reviewed. The form is divided into sections. The section containing the documents required for the at time of discharge we have a check list entitled "Skin Condition" has a handwritten check mark indicating "Open Wound." The Section for "Diet"contains a handwritten entry "Jevity 1.2 cal" (type of tube feeding liquid). The case management nurse was questioned regarding the vague entries on the form sent to the SNF to provide continuing care. The case management nurse commented additional information would have been optimal. When asked about specifics regarding the sites of the wounds and the treatments for each wound, the case management nurse and risk manager indicated these would be found in the progress notes and physician orders. A review of those documents was conducted with the case management nurse and the risk manager. The Progress Notes dated 05/27/11 documents "Santyl ointment 30 G (grams) 1 Appl (application) BID (Twice a day). TP (Topical)." The information regarding the tube feedings do not identify the amount or the type of tube feeding. The risk manager stated "The nursing home would have their own doctor write orders, once the patient arrives." The case management nurse stated "The nursing home doctor would write his own orders." When asked about the 3008 form, the case management nurse again commented additional information would have been optimal.

The 07/27/11 discharge 3008 form was reviewed. The "Skin Condition Decubitus" section has a hand written entry "(R) heel eschar" a check mark indicates "Intact" indicates other skin is intact. This does not document other skin issues including the head wound status. |
The facility failed to communicate pertinent physical conditions to identify and assure a continuity of care post hospital discharge.