The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SAINT THOMAS RUTHERFORD HOSPITAL 1700 MEDICAL CENTER PARKWAY MURFREESBORO, TN 37129 Oct. 11, 2011
VIOLATION: LIST OF HOME HEALTH AGENCIES Tag No: A0823
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews the facility failed to provide a list of available Home Health Agencies upon discharge to one patient (#5) of eleven patients reviewed.

The findings included:

Medical record review revealed Patient #5 was admitted to the facility on on [DATE], with diagnoses which included: Uncontrolled Diabetes, Hypertension, [DIAGNOSES REDACTED], Anemia, Osteoarthritis, Anxiety/Depression, and Questionable History of Dementia. Further review of the medical record revealed the patient was homeless and had no family or social support.

Review of the Discharge Summary revealed the patient was discharged to a shelter on September 21, 2011. The Discharge Summary also stated, "We put in place a consult for home health services seeing if they could go out to the women's safe house to help her with the medical problems or medications ...". Review of the medical record revealed no documentation of a home health consult or referral.

Review of Case Worker notes dated September 21, 2011, revealed, " ...Pt home environment not safe ...referred to Domestic Violence Shelter..Pt also sent to shelter with Home Health script, per Shelter Request, in case they need assistance."

Medical Record review revealed Patient #5 returned to the hospital via ambulance on September 22, 2011, at 1:41 p.m. The Emergency Department (ED) record revealed Patient #5 stated, " ...was discharged from the hospital yesterday to the domestic violence shelter but has been unable to care for herself or take her insulin shots there." Further review of the ED record revealed blood sugar level was 334 mg/dl (normal 80-120), and the patient was readmitted to the hospital with diagnoses of [DIAGNOSES REDACTED]

Interview with the Case Manager on October 11, 2011, at 10:55 a.m., in the Administration Conference Room, confirmed no home health agency consult or referral was provided for Patient #5. Further interview with the Case Manager revealed a written prescription for home health services was provided to the shelter staff, but a list of available Home Health Agencies was not provided to the patient or care givers.

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VIOLATION: ORGANIZATION OF SURGICAL SERVICES Tag No: A0941
Based on record reviews, interviews, and review of manufacturer's guidelines, the facility failed to provide surgical equipment needed for one patient (#2) of eleven patients reviewed.

The findings included:

Medical record review revealed Patient #2 was admitted to the facility's Same Day Surgery unit on, with diagnoses of: Chronic Wound Infection of the Abdominal Wall, Chronic Renal Failure, and Morbid Obesity. Review of the Operative Note dated August 23, 2011, revealed the patient had a "Wide excision of an infected chronic abdominal wall wound and debridement, classification 4", on that date. Further review of the Operative Note revealed "A wound vac (a dressing which has a tube attached to suction, which provides negative pressure in the wound bed to promote healing) was placed in the usual manner and secured."

Review of the Informed Consent for Surgery/Treatment/Procedure form dated August 22, 2011, revealed the patient consented to a procedure described as, "Incision and drainage of abscess of abdominal wall with debridement and wound vac placement".

Review of Physician Order Form, dated August 23, 2011, at 3:55 p.m. revealed, "Discharge ...wound vac continue ...fu office 7-10 days ..."

Review of discharge instructions, dated August 23, 2011, at 5:38 p.m. revealed, "see md in am, md will provide further instructions per wound vac ...Report to MD office in the AM for wound vac."

Review of Post-Procedure/Post-op Education dated August 23, 2011, at 5:30 p.m. revealed, "Comment: wound vac per md office on 8/24/11".

Review of Home Health records revealed Patient #2 was referred to the agency on August 24, 2011, at 10:10 a.m. by the physician's office. Further review of the home health record revealed the patient was assessed at home on August 24, 2011, at 11:00 a.m. and the initial assessment note stated, "Pt with wound vac dressing in place not connected to vac on arrival. Pt with blood on shirt, pants, and socks ..."


Review of Emergency Department (ED) Record revealed Patient #2 presented on August 24, 2011, at 2:55 p.m. with history stating, " ...when wound care was about to place wound vac, bleeding noted, packed and to ED ..."


Interview with Physician #1, on October 11, 2011, at 12:40 p.m. in the administrative conference room, revealed Patient #2 had a wound vac applied and started in the operating room, on August 23, 2011. Physician #1 stated ...does not remember what type of wound vac was used. Physician #1 stated the patient's dressing was changed to a "wet to dry dressing" and home health was supposed to apply the wound vac the next day (August 24, 2011). Physician #1 stated the home health services were arranged through the physician's office.

Interview with Registered Nurse (RN) #1, on October 11, 2011, at 10:35 a.m. in the administration conference room, revealed RN #1 remember taking care of Patient #2 post-operatively on August 23, 2011. RN #1 stated the patient was attached to a wound vac when returned from surgery with the vacuum device labeled, "do not send home with patient". RN #1 stated ...contacted the surgeon and was told to disconnect the vacuum and clamp the tube from the dressing, and have the patient see the physician at the office the next morning (August 24, 2011) to arrange for a vacuum device. RN #1 stated ...disconnected the dressing tube from the vacuum device and clamped it shut. RN #1 stated she discharged the patient with instructions to see the physician the next day.

Interview with the Nurse Manager of the Same Day Surgery unit, on October 11, 2011, at 10:20 a.m. in the administration conference room revealed the facility does not have a written policy or procedure for outpatients receiving wound vacs. The Nurse Manager stated the facility's practice was for a Representative (Rep) from the wound vac supplier to deliver a wound vac for each individual patient. The Nurse Manager stated the Rep would deliver the wound vac prior to surgery, and the wound vac would be taken to surgery with the patient, attached in surgery, and then sent home with the patient when discharged .

Interview with the facility's Wound/Ostomy Care Nurse (RN #2), on October 11, 2011, at 12:05 p.m. confirmed the facility did not have a written policy or procedure for obtaining wound vacs for outpatients. RN #2 stated the facility's practice was for the surgeon to order the wound vac from the supplier, and the supplier's Representative (Rep) would deliver the wound vac before surgery. RN #2 stated the wound vac would then be taken to the operating room where it would be attached by the surgeon, and then go home with the patient when discharged .

Review of the wound vac's manufacturer's clinical guidelines revealed, "Never leave a V.A.C. (Vacuum Assisted Closure) dressing in place without active V.A.C. Therapy for more than 2 hours. If therapy is off for more than 2 hours, remove the old dressing ...either apply a new V.A.C. dressing ...and restart V.A.C. Therapy, or apply an alternative dressing". Further review of the manufacturer's clinical guidelines revealed, "Keep V.A.C. Therapy on for at least 22 hours in a 24 hour period. Do not leave the V.A.C. Dressing in place if the therapy unit is switched off for more than 2 hours in 24."

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