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Based on review of documentation and interviews with staff, the facility failed to ensure that patients receive care in a safe setting, as 1 of 1 patient whose record was reviewed fell on several occasions without proper intervention or documentation.

Findings were:

Review of the medical record of Patient #1 revealed that the patient was admitted to the facility on 12/19/2011 following surgery on the right upper extremity related to a fracture of the upper bone of the arm. The patient was admitted for Physical Therapy (PT) and Occupational Therapy (OT) in order to return home. According to the History and Physical report dictated by the attending physician, Staff #4, the patient's past medical history and diagnoses included severe Parkinson's disease, a progressive disease that affects the smooth control and coordination of the movement of voluntary muscle groups, reducing the ability to move muscles voluntarily. The patient also had an amputated right leg, and with surgery performed on the right arm, had use of the left side only. Review of Progress Notes written 1/3/12 by the attending physician, Staff #4, revealed that the patient "had fallen once again." (There was no documentation of a fall prior to this either in progress notes, nursing notes, or incident reports.) On 1/4/12, the physician wrote that the patient "has been, again, impulsive and, again, had tried to transfer on...own and sustained another fall yet today." Minor scrapes and bruises were the result of the falls. Two incident reports regarding Patient #1's falls were provided. The two incidents were recorded on the forms utilized by Quality Assurance to track and trend falls in the facility. These incident reports were dated 1/4/12 and 1/7/12. Review of the medical record, however, revealed more than the 2 falls. Attached to one of the incident reports was a "Post Fall Incident Report Addendum" that documented a fall that occurred 1/3/12. This was not documented on an incident report separately; therefore, it was not included in the QA tracking documentation. No injury was noted. Written on the form was a statement that the patient's spouse requested a recliner wheelchair; noting that the upright chair was a fall risk. There was no further documentation that a reclining wheelchair was obtained. The patient experienced 2 more documented falls with only minor scrapes and bruises.

An in-person interview was conducted with the facility Chief Operations Officer (COO), Staff #2, the afternoon of 1/17/2012. According to Staff #2, team members meet for an operations meeting each morning. The COO indicated these meetings are not documented; they are informal and are for discussing the current patients and what needs they may have. Staff #2 recalled that they discussed Patient #1's falls and determined that the patient may need a wedge or some other intervention in his chair, as the patient is "top heavy" and tended to fall forward from the chair. There was no action taken in this matter, however. Staff #2 confirmed the documentation and intervention findings during the interview.

Based on review of documentation and interview with staff, the facility Chief Nursing Officer failed to ensure nursing supervision of the transfer of Patient #1 to a higher level of care per facility policy.

Findings included:

Review of Facility Policy Number NSG-114 entitled, "Emergency Patient Transfer," stated, "Policy: The hospital provides guidelines for emergency patient transfers to acute care facilities." The procedure stated, "The Nursing Supervisor shall oversee the transfer ...assuring contact with the administrator on-call. "

1) A Memorandum of Transfer (MOT) was found to be incomplete and inaccurate for patient #1. The MOT revealed the following areas were left blank: Religion, Physical handicap, Initial contact with the receiving hospital administration, Transferring physician secured receiving physician (also the transferring physician's name was in the receiving physician name blank), Accepting hospital secured by transferring hospital, Transferring hospital administration who contacted the receiving hospital did not have a signature, Type of vehicle and company used, and the Personnel needed.

2) A review of patient #1's medical record from North Austin Medical Center revealed an emergency room record dated 1/9/2012 at 8:33am. The Emergency Department (ED) dictation stated that patient #1 arrived by ambulance to the ED and the historian was an EMS (Emergency Medical Services) personnel. Patient #1 remained in the ED until transferred to ICU (Intensive Care Unit) at 11:30 am.

3) A review of the medical record of patient #1 from North Austin Medical Center revealed a fax cover sheet sent from Reliant Rehabilitation on 1/9/2012 at 12:15pm which had 18 pages. Some of the pages faxed were the face sheet, labs dated 1/5/2012, history and physicals dated 12/08/2011 and 12/19/2011, and the current medication list.

In an in person interview with staff member #1 on 1/17/2012, the above was confirmed including, that the Memorandum of Transfer was incomplete and inaccurate. Staff member #1 also stated the staff needed training.

Based on review of documentation and interview with staff, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for 1 of 1 patient whose record was reviewed. The patient's record indicated that nursing staff did not document evaluation of Patient #1 for five hours on 1/9/2011; the patient was found unresponsive and was transferred emergently to an acute care hospital.

Findings were:

Review of the medical record of Patient #1 revealed that Nursing Progress Notes written on 1/8/2012 at 10 pm state "Pt agitated tonight and pt states inappropriate things and did some actions. Agitation was getting worse and try to get out the bed, so give Haldol 5 mg at 23:55. After 15 mints, pt fell asleep." Another nursing note documented an evaluation of the patient 1:29 am on 1/9/12. At 7 am, the nursing aide documented that Patient #1 had a shower. An entry in the nursing notes for 1/9/12 at 7:56 stated that the patient was "cleaned up for 25ml of coffee ground emesis." Coffee ground emesis indicates internal GI bleeding. There was no documentation that the patient was evaluated between the hours of 1:29 am and 7 am. The nursing physical examination revealed that Patient #1's oxygen saturation was checked and was under normal limits at 89%. It is unknown how long the patient's oxygen saturation was below normal limits. With 2 liters of oxygen, the rate increased to 92%. The attending physician was called and ordered the patient to be sent to a nearby acute care hospital via EMS.

The facility Chief Nursing Officer, Staff #1, was interviewed in person on 1/17/2012 and explained that the nurses round on the patients hourly, but do not document this unless a problem is noted. Staff #1 acknowledged that the there was documentation that Patient #1 was seen by nursing staff at 1:29 am on 1/9/2012 and again at 7 am. The CNO could not provide documentation that the patient was evaluated at any time in between those hours.

Based on review of documentation and interview with staff, it was determined the facility failed to send with patient #1 the necessary medical documentation to provide continuity of care when transferred to a higher level of care.

Findings included:

Review of Facility Policy Number NSG-114 entitled, "Emergency Patient Transfer," stated, "Policy: The hospital provides guidelines for emergency patient transfers to acute care facilities." The procedure stated, "Copies sent with transport: History and physical, current lab test results, recent radiology reports, current medication record, face sheet, most current physician orders, progress notes." Further review revealed, "A Memorandum of Transfer (MOT) shall be completed and sent with the patient ... The nurse shall give a verbal report to the paramedics and telephone a report to the receiving emergency department ...As appropriate the transferring physician/ordering physician shall call report to the receiving Emergency Department or house physician...The Nursing Supervisor shall oversee the transfer ...assuring contact with the administrator on-call. "

1) A Memorandum of Transfer (MOT) was found to be incomplete and inaccurate for patient #1. The MOT revealed the following areas were left blank: Religion, Physical handicap, Initial contact with the receiving hospital administration, Transferring physician secured receiving physician (also the transferring physician's name was in the receiving physician name blank), Accepting hospital secured by transferring hospital, Transferring hospital administration who contacted the receiving hospital did not have a signature, Type of vehicle and company used, and the Personnel needed.

2) A review of patient #1's medical record from North Austin Medical Center revealed an emergency room record dated 1/9/2012 at 8:33am. The Emergency Department (ED) dictation stated that patient #1 arrived by ambulance to the ED and the historian was an EMS (Emergency Medical Services) personnel. Patient #1 remained in the ED until transferred to ICU (Intensive Care Unit) at 11:30 am.

3) A review of the medical record of patient #1 from North Austin Medical Center revealed a fax cover sheet sent from Reliant Rehabilitation on 1/9/2012 at 12:15pm which had 18 pages. Some of the pages faxed were the face sheet, labs dated 1/5/2012, history and physicals dated 12/08/2011 and 12/19/2011, and the current medication list.

In an in person interview with staff member #1 on 1/17/2012, it was confirmed there was no communication between the transferring facility and the receiving facility prior to the transfer. Staff member #1 confirmed the Memorandum of Transfer was incomplete, inaccurate and stated the staff needed training.