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Based on interview and record review, the facility failed to ensure that registered nurses developed individualized care plans for two patients (P-1 and P-4) of 10 patients reviewed, resulting in the potential for unidentified patients' care needs/changes in care, incomplete care plan documentation and possible negative outcomes for these two patients. Findings include:

P-1

Review of the P-1's medical record, on 04/14/25, revealed that she was a 81-year-old female admitted to the facility on 12/07/24 with chief complaints of increasing fatigue and infected chest wound. P-1 had a history of a suprasternal wound, breast cancer, coronary artery disease, diabetes, chronic anemia, hypertension (elevated blood pressure), atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots, stroke and heart failure), and chronic kidney disease stage III- IV. During hospitalization patient had two surgical procedures: on 12/10/24- chest wound debridement, and on 12/17/24- chest wound debridement with a muscle flap, wound vac (device that assists with negative pressure wound therapy) and JP drain (a closed-suction medical device that is commonly used as a post-operative drain for collecting bodily fluids from surgical sites) application and wound closure. P-1 was transferred to the inpatient rehabilitation unit (IPR) on 12/18/24 for recovery. On 12/30/24 she was discharged from facility to a subacute rehab (SAR).

During the patient's stay at IPR she continued to be consulted by Infectious Disease (ID) for her extensive history of chest wound infections and for IV (intravenous) antibiotic therapy. Plastic surgery was following the patient regarding post-surgical wound care, wound VAC and JP drain.
The physician's note dated 12/27/24 at 2112 had the following: "Positive for chest pain. Patient discussed with nursing staff as well as IPR physician. Assessment/ Plan. 1. Osteomyelitis of the sternum status post sharp excisional debridement. Continue antibiotics as per ID and wound care as per plastic surgery."

On 04/16/25 during further P-1 medical record review the following nursing-initiated care plans were identified during patient's stay in IPR from 12/18/24 to 12/30/24: Self-care deficits, Rehab impaired mobility and Nutritional deficit. No plans of care were established for P-1 regarding her post-operative chest pain, wound care needs or infection prevention.

On 04/16/25 at approximately 1200 during patients' medical record review, Manager of Patient care services, Staff M, was asked if her expectations were that staff nurses were addressing patient specific needs in the care plans. She stated "yes".

P-4

Review of the P-4's medical record, on 04/16/25, revealed that he was a 77-year-old male with a past medical history of ESRD (end stage renal disease) on peritoneal dialysis (for 3 years), A-fib (atrial fibrillation), heart failure, type 2 diabetes, chronic hypertension (elevated blood pressure), COPD (chronic obstructive pulmonary disease), urethral strictures, history of seizures and anemia who presented to the facility's emergency department on 3/19/24 after a fall. Patient was admitted to the facility on 03/19/24, underwent nephrology, infectious disease, urology, endocrinology, cardiology and neurological evaluations throughout his stay. He was stabilized and transferred to the inpatient rehabilitation unit (IPR) on 03/26/25 for recovery. Patient transitioned from peritoneal dialysis to hemodialysis during his stay at IPR on 04/13/25.

Neurology consulting physician's note dated 04/11/25 1347 indicated: rapid response stroke alert was called this morning when patient was noted to have a seizure-like episode. Apparently, patient stated he complained of a headache and then his wife stated that his eyes rolled back and he was noted to have some intermittent tremors. He was unresponsive for a brief period of time.
Physician's note dated 04/15/25 1333 revealed: "Seen and examined up in bed. Patient (P-4) was placed in a 4-point restraints last night. Sitter at bedside. Patient was given Haldol and 2 doses of Seroquel. Spoke with internal medicine, patient is not appropriate for IPR. Patient will be transferred to acute care. Patient did have dialysis yesterday and again today".

Further P-4 medical record review for patient's stay in IPR from 03/26/25 to 04/15/25 revealed no documented care plans and teaching for the patient/family regarding new dialysis modality (hemodialysis) and a change in condition due to new "seizure-like episode". Though the care plan for the use of restraints for P-4 was established, there was no plan of care in place and/or education for patient/family regarding use of antipsychotic medications (like Seroquel and Haldol) and their side effects.

On 04/15/25 at 1030 during an interview with the registered nurse, Staff L, she was asked regarding patient centered plan of care documentation. Staff L stated that she "would not double chart" care plans when she already takes care of patients and documents it.

Facility's policy "Nursing Process and Documentation" effective 06/02/18 and revised 12/13/22, was reviewed and revealed:

"1. Purpose
1.1. To document the assessment, diagnoses, planning, interventions and patient
response to care in acute and critical care settings via the ONE [facility name] electronic health record (EHR) at subsidiaries utilizing this system.
4.3. The RN is responsible for patient assessment, data interpretation, diagnoses, and development of plan of care through establishment of related nursing care interventions.
4.3.1. To identify patient needs and care priorities, the RN integrates information from various assessments, history, and other disciplines. The family and/or significant others are included as a source of information related to assessment and planning of care, when appropriate.
4.3.2. Assessment is initiated on presentation to the health care setting and is
continuous throughout the episode of care.
4.3.3. The RN formulates diagnoses and interacts with patient and/or caregivers to establish goals and develop a plan of care.
4.3.4. Discharge planning is initiated on admission and is ongoing throughout the
episode of care."

Based on interview and record review, the facility failed to ensure that registered nurses adhered to the facility's policies and procedures regarding patients' discharge documentation for two patients (P-1 and 8) of 10 patients reviewed, resulting in the potential for unidentified patient care needs, incomplete discharge records, and possible negative outcomes for these two patients. Findings include:

P-1

Review of the P-1's medical record, on 04/14/25, revealed that she was a 81-year-old female admitted to facility on 12/07/24 with chief complaints of increasing fatigue and infected chest wound. P-1 had a history of a suprasternal wound, breast cancer, coronary artery disease, diabetes, chronic anemia, hypertension (elevated blood pressure), atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots, stroke and heart failure), and chronic kidney disease stage III- IV. Patient was transferred to inpatient rehab on 12/18/24 and discharged to SAR (subacute rehabilitation facility) on 12/30/24.

Further review of P-1 medical record revealed no nursing documentation on 12/30/24 that discharge instructions were provided to patient/family and their understanding of it. Also, there was no evidence of nursing transfer/discharge note with documentation of patient destination, time of discharge, necessary communication (report) to the receiving facility and if all required records were sent with the patient.

On 04/15/25 at 1030 during an interview with a registered nurse, Staff L, she was asked if she remembers taking care of the P-1 on 12/30/24. The nurse stated that she remembered the patient but could not recall that day. Staff L was asked to describe her responsibility regarding patients' discharge. Staff L stated that she usually goes over the patient's discharge paperwork, making sure all the medications were reconciled, also checks the provider's orders. When asked if she reviewed the discharge instructions/paperwork with P-1, she said she did not remember. She also added that usually she would not do that if a patient was discharged to the other facility, she would just call the facility and give report. When asked if she documents who she spoke to at the receiving facility, she said, "not the name, just document that I called". Further, Staff L was queried if she called receiving facility for P-1. She stated she did not remember.

On 04/15/25 at 1050 inpatient rehabilitation unit Nurse Manager, Staff K, was interviewed. She was asked if her expectations were for staff nurses to follow facility's policies and procedures. She stated yes.

P-8

Medical record review on 04/16/25 for P-8 revealed that patient was a 53-year-old male with no past medical history who presented to facility on 12/16/24 as a stroke alert. Patient had acute onset of balance issues, right sided weakness and aphasia (a language disorder that affects communication after a stroke or brain injury) while at work. He was found to have left-sided basal ganglion intraparenchymal hemorrhage (stroke). PT/OT (physical and occupational therapy) and speech were consulted. IPR (inpatient rehabilitation) was also consulted and upon their evaluation deemed P-8 a good candidate for inpatient rehab. He was transferred to the rehab unit on 12/22/24. P-8 was discharged to SAR (subacute rehabilitation facility) on 01/15/25 at 1915.

Further review of the patient medical record did not reveal a nursing transfer/discharge note with documentation of patient destination, time of discharge, necessary communication (report) to the receiving facility and if all required records were sent with the patient.

On 04/16/25 at 1403 during an interview with the facility's Chief Nursing Officer, Staff B, she was asked if her expectations were that all staff nurses followed facility's policies and procedures. She stated yes.

Facility's "Continuum of Care: Discharge Planning" policy, effective 08/01/21 and reviewed 09/24/24, was reviewed and revealed:
"1. Purpose
1.1. To provide an integrated multidisciplinary approach to the specific continuing needs of patients post hospitalization for patients receiving care in a subsidiary utilizing the ONE [facility name] electronic health record (EHR) system.
5.2. Discharge Process
5.2.1. All patients discharged are provided with written instructions created via the discharge process in the EHR for post hospital care which may include, but are not limited to:
5.2.1.1. Medications, including new prescriptions
5.2.1.2. Food/drug interaction
5.2.1.3. Treatment and dietary instructions
5.2.1.4. Pain and symptom management
5.2.1.5. Supplies and equipment
5.2.1.6. Diagnostic testing
5.2.1.7. Outpatient therapies
5.2.1.8. Instructions for follow-up care
5.3. Referrals to Community Resources.
5.4. After ascertaining that all discharge instructions are clearly understood and appropriate follow-up plans are determined, the RN documents the patient/responsible caregiver understanding of the discharge instructions, in the EHR.
5.5. Upon discharge or transfer, the RN documents a discharge/ transfer note which
may include the patient's discharge medications, destination, time of discharge, mode of transport, and family accompaniment.
5.11. Registered Nurse/SW/CM will provide/facilitate necessary communication
and forms required for placement of the patient in a nursing home, rehabilitation or sub-acute facility."

Based on interview and record review, the facility failed to provide all necessary/ pertaining medical discharge information to a receiving facility and patient/ family for one patient (P-1) of 10 patients reviewed, resulting in patient, family, and receiving facility not having complete information upon discharge and possible negative outcomes to the patient. Findings include:

Review of P-1's medical record, on 04/14/25, revealed that she was a 81-year-old female admitted to facility on 12/07/24 with chief complaints of increasing fatigue and infected chest wound. Infectious disease provider consulting note dated 12/08/24 2017 indicated that P-1 "is being seen by wound clinic and also ID (Infectious Disease) clinic for sternal bone manubrium osteomyelitis with MRSA (methicillin-resistant Staphylococcus aureus) and Enterococcus faecalis (species of bacteria that is naturally found in the intestines). Per records patient has been following with surgery at [another facility name], she has a history of breast cancer in 1980s which was treated with left-sided mastectomy and afterwards right sided mastectomy too, she had a recurrence of the cancer and did receive radiation therapy, last session was in July, 2023. Patient had a Mediport (an implantable device, placed under the skin, used to give therapy or withdraw blood) in the chest wall for many years and she had erosion in the soft tissue and chest wall, it was removed and she has been following with the surgeon, she underwent excision and debridement of the midline chest wall wound down to the bone and removal of necrotic bone of sternum, the bone culture grew MRSA (Methicillin-resistant staphylococcus aureus)and Enterococcus faecalis (a species of bacteria that is naturally found in the intestines) from 10/25/2024, patient has been following with wound care center at [facility name] they referred the patient to ID clinic for management of IV antibiotics for sternal osteomyelitis. On last office visit she was started on IV Daptomycin (antibiotic) for 6 weeks via PICC line (a long, thin tube that's inserted through a vein in the arm and passed to the larger veins near the heart). Per records, patient supposed to complete therapy on December 12 (2024). Patient currently on Vancomycin, Cefepime and Metronidazole (antibiotics) then [sic] ID consult requested."

During the stay in the facility P-1 underwent two surgical procedures. Plastic surgeon, Staff O, was following up with the patient after her last procedure on 12/17/24.
On the day of patient's discharge from the facility, plastic surgeon, Staff O, documented at 12/30/2024 0711: Orders: "Culture Aerobic with Gram Stain. I changed the dressing from the drain site, I got the culture, I discussed with the patient nurse that she needed to " [sic] infectious disease physician about this".
Review of physicians' orders revealed: Culture Aerobic with Gram Stain, Action Date/Time: 12/30/2024 0711, Electronically Signed By: Staff O (plastic surgeon). Electronically Signed by Staff L, nurse in care for P-1, at 12/30/2024 0725.

Patient was discharged to SAR (subacute rehabilitation facility) later that day, on 12/30/24.

On 04/15/25 at 1030 during interview with registered nurse, Staff L, she was asked if she remembers taking care of the P-1 on 12/30/24. The nurse stated that she remembered the patient but could not recall that day. Staff L was asked to describe her responsibility regarding patients' discharge. Staff L stated that she usually goes over the patient's discharge paperwork, making sure all the medications were reconciled, also checks the provider's orders. She added that during patients' admission they see specialty physicians and she makes sure that all discharge follow up information was included. When asked if she reviewed the discharge instructions/paperwork with P-1, she said she did not remember. She also added that usually she would not do that if a patient was discharged to the other facility, she would just call the facility and give report. When asked if she documents who she spoke to at the receiving facility, she said, "not the name, just document that I called". Further, Staff L was queried if she called receiving facility for P-1 and communicated pertinent information. She stated she did not remember. Staff L also was asked if she remembered plastic surgeon, Staff O, discussing any culture orders with her on 12/30/24. Nurse stated "no". She added that after patients' discharge nursing staff would not be aware of the results anyway.

Further record review revealed discharge documentation that was provided to the accepting facility. No information was provided in discharge paperwork regarding infectious disease services follow up after patient's hospitalization (P-1 was consulted by the ID providers and had an extensive history of wound infections). Further, no information was provided to the patient, patient's family or receiving facility regarding pending culture that was collected by a provider, Staff O, on 12/30/24 prior to P-1's discharge (denying the patient right to know their own test results). No information was provided to the receiving facility (SAR) regarding the follow up on the culture results and who should be contacted.

P-1 medical record revealed that "wound culture 12/30/2024 - grew Enterobacter cloacae (bacteria can cause many infections in hospital and clinical settings)".

There was a facility's office clinic note dated 01/06/25 1400: "Patient (P-1) is at SNF (skilled nursing facility) [name]. She finished Daptomycin IV as ordered on 12/30/24 for sternal osteomyelitis. Writer received a call from facility Nursing Supervisor saying when the patient admitted 12/30/24 there was a very small scabbed area at the distal end of the chest incision which had a dry wound base. Since admission, this scab came off the incision and there is copious amounts of purulent drainage. Dr. [name] notified and reviewed culture obtained by surgery (Staff O) day of discharge from hospital on 12/30/24. Recommends treatment with PO (oral) Cipro (Ciprofloxacin- antibiotic) 500 mg BID (twice a day) x 14 days and schedule ID follow-up on 01/16/25 to re-evaluate".

P-1 was re-admitted back to the facility on 01/06/25 at 2309.

Facility's "Continuum of Care: Discharge Planning" policy, effective 08/01/21 and reviewed 09/24/24, revealed:
"1. Purpose
1.1. To provide an integrated multidisciplinary approach to the specific continuing needs of patients post hospitalization for patients receiving care in a subsidiary utilizing the ONE [facility name] electronic health record (EHR) system.
5.2. Discharge Process
5.2.1. All patients discharged are provided with written instructions created via the discharge process in the EHR for post hospital care which may include, but are not limited to:
5.2.1.1. Medications, including new prescriptions
5.2.1.2. Food/drug interaction
5.2.1.3. Treatment and dietary instructions
5.2.1.4. Pain and symptom management
5.2.1.5. Supplies and equipment
5.2.1.6. Diagnostic testing
5.2.1.7. Outpatient therapies
5.2.1.8. Instructions for follow-up care
5.3. Referrals to Community Resources
5.3.1. Instructions are provided to the patient/family and/or the organization/outside agency or individuals responsible for the patient's continuing care.
5.11. Registered Nurse/SW/CM (social worker, case manager) will provide/facilitate necessary communication and forms required for placement of the patient in a nursing home, rehabilitation or sub-acute facility.
5.12. Appropriate medical record documentation shall be provided to the receiving
facility. The CM/SW will initiate provision of copied medical records/pertinent
information. Health Information Management (HIM) provides copies of all pertinent
clinical information that accompanies the patient at time of transfer to another facility
which may include, but are not limited to:
5.12.1. Transfer summary
5.12.2. Copy of recent (within last 30 days) chest x-ray report (Skilled Nursing Facility only)
5.12.3. History and Physical
5.12.4. Laboratory results
5.12.5. Surgical reports
5.12.6. Consultation notes."