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Based on record review and interview, the hospital failed to identify opportunities for improvement. This deficient practice was evidenced by failing to track and/or trend the ten patients in the last 4 months that had left the facility against medical advice in QAPI. Findings:

Review of the list of patients that had left the hospital against medical advice (AMA) in the last 4 month (provided by S5OfficeMger) revealed the following patients and dates:

Patient #R1- 10/06/2021
Patient #R2-10/08/2021
Patient #R3-10/13/2021
Patient #R4-10/19/2021
Patient #5-10/20/2021
Patient #R5-11/07/2021
Patient #R6-11/22/2021
Patient #R7- 12/20/2021
Patient #4- 01/04/2022
Patient #R8-01/08/2022

Review of the Medicare Data Worksheet from 04/07/2021 revealed the hospital's average daily census is 5 patients.

An interview was conducted with S4HIM/QA on 01/24/2022 at 2:20 p.m. S4HIM/QA reported with review of the current QAPI plan, she reported the hospital was not tracking and/or trending the number of patients leaving the hospital against medical advice (AMA).

Based on record review and interview, the RN failed to supervise and evaluate the nursing care of each patient. This deficient practice is evidenced by:
1. Failure of the RN to change the patient's PICC line dressing every 7 days per the hospital policy for 1 (#1) out of 2 (#1, #5) patients reviewed for PICC line care;
2. Failure of the RN to assess and document the PICC line site with the dressing change for 2 (#1, #5) out of 2 (#1, #5) patients review for PICC line care;
3. Failure of the RN to ensure a nutritional assessment was completed on 1 (#3) out of 5 (#1,#2, #3, #4, #5) patients reviewed for nutritional assessments; and
4. Failure of the RN to document a patient leaving AMA in an incident report for 1(#4) out of 2 (#4, #5) patients reviewed for leaving the hospital AMA.
Findings:




1. Failure of the RN to change the patient's PICC line dressing every 7 days

Review of the hospital's policy, titled Nursing PICC Lines, revealed in part, dressing changes are to be done using sterile techniques (including mask) every 7 days for transparent dressing every 48 hours if gauze is under transparent dressing.

Review of the EMR for Patient #1, navigated by S3CNO, revealed on 01/13/2022 Patient #1's PICC line dressing was last changed on 01/06/2022 and was due to be changed on 01/13/2022. With further review of EMR revealed the PICC line dressing was not changed until 01/15/2022 at 2:51 p.m.

An interview was conducted with S3CNO on 01/24/2022 at 11:15 a.m. S3CNO reported Patient #1's PICC line dressing was not changed within 7 days and should have been changed on 01/13/2022.


2. Failure of the RN assess and document the PICC line site with the dressing change

Review of the hospital's policy, titled Nursing PICC Lines, revealed in part, assess patient's arm along the vein tract every 2 hours for any erythema, edema, pain or tenderness.

Patient #1
Review of the EMR for Patient #1, navigated by S3CNO, revealed the PICC line dressing was changed on 01/22/2022. With further review of the documentation, no assessment of the PICC line site was documented when the PICC line dressing was changed.

Patient #5
Review of the EMR for Patient #5, navigated by S3CNO, revealed the PICC line dressing was changed on 10/17/2021. With further review of the documentation, no assessment of the PICC line site was documented when the PICC line dressing was changed.

An interview was conducted with S3CNO on 01/24/2022 at 11:00 a.m. She reported the hospital's expectation and the standard of care is for the nurses to document the PICC line site every 2 hours and once a PICC line dressing is changed.

3. Failure of the RN to ensure a nutritional assessment was completed on each patient per hospital policy

Review of the hospital's policy, titled Nutrition Assessment, revealed in part, nutritional assessment completed within 14 days of admission.

Review of Patient #3 EMR, navigated by S3CNO, revealed no dietician assessment was conducted on Patient #3 during his hospital stay from 12/10/2021 to 01/11/2022.

An interview was conducted with S3CNO on 1/24/2022 at 10:30 a.m. S3CNO reported she was unable to locate a nutritional assessment by the dietician on Patient #3. She further reported the patient should have had a nutritional assessment while in the hospital, the nurses are to notify the dietician with each newly admitted patient.

4. Failure of the RN to document a patient leaving AMA in an incident report.

Review of the hospital policy, titled Incident Report, revealed in part, all incidents, accident and injuries will be documented on an approved incident/occurrence report form. An incident includes but is not limited to:...deviations from company policies, procedures, operating practices and professional standards of practice.

Review of the EMR for Patient #4, navigated by S3CNO, revealed a Narrative Note dated 01/04/2022, Pt states "I'm ready to go now." Instructed pt that she is putting her health in jeopardy. Pt continues to say "I'm ready to go, I'll go across the street and wait on my ride." ...Pt then got dressed and started walking out of door with walker. Pt left the premises against medical advice.

Review of the Incident Reports for the last 4 months provided by S2DON failed to reveal an incident report for Patient #4 leaving the hospital AMA.

An interview was conducted with S2DON on 01/24/2022 at 2:00 p.m. She reported an incident report should had be completed for the patient leaving AMA.