HospitalInspections.org

Based on medical record review, review of facility policies and procedures and staff interview, the facility failed to ensure adequate supervision by nursing to protect patients by securing the provider transfer order per facility policy. The facility failed to ensure a transfer order was received for 1 of 5 sampled patients (Patient 1) transferred to an acute care hospital. This failed practice had the potential to affect all patients of the hospital requiring a transfer to an acute care hospital. The facility transferred 24 patients in February 2025. On 3/12/25 the inpatient census was 37.

Findings are:

A. Review of the medical record for Patient (Pt) 1 identified the patient was admitted 1/25/25 at 10:35 PM to the Long Term Care Hospital (LTCH are certified acute-care hospitals, but focus on patients who, on average, stay more than 25 days, many are transferred there from an intensive or critical care unit.) for care following a hospitalization for the treatment of a blood infection and infection/abscess of vertebral disc in lower back following surgery.

Review of the medical record discharge summary dated 2/16/25 at 11:12 PM identified the following:
-On 2/16/25 the patient had complained of increasing pain in the lower back and sacrum. An order for an MRI (magnetic resonance imaging-by using magnets and radio waves to produce images on a computer) was received and completed. The MRI showed increased ventral epidural phlegmon (an infection of the soft tissue in the front part of the spine between the spinal cord and the vertebrae) early abscess contributing to mild to moderate spinal canal stenosis (a narrowing of the spaces inside the bones of the spine get to narrow) at L5-S1 (lumbar spine 5 and sacrum 1) and mild spinal canal stenosis at L4-L5 (lumbar spine and sacrum is the most distal part of the spine). The patient was discussed with the Neurosurgeon on-call. The Neurosurgeon agreed the patient should be transferred. Labs on the day of discharge ESR 84 (erythrocyte sedimentation rate-a test to detect inflammation in the body. Normal range 0-20); CRP 16.2 (c-reactive protein-a test to detect inflammation in the body. Normal range less than 10).
-The patient rated (gender) lumbar and sacral back pain anywhere from 8/10 to 10/10 in intensity throughout the day. Vital Signs 107/61, pulse 59, temp 97.7, resp 16, ht 5'10" and weight 231 pounds.
-The patient was discharged to the acute care hospital for services of neurosurgery related to an epidural abscess on 2/16/25 at 4:39 PM.

B. Review of Patient 1's physician orders for the 1/25/25-2/16/25 stay lacked an order for transfer.

C. An interview the Director of Quality on 3/17/25 at 12:00 noon verified the medical record lacked an order for transfer on 2/16/25.

D. Review of the policy and procedure titled Orders (Revised 4/1/23) stated:
-When computerized physician order entry (CPOE) is available, orders should be entered electronically by a Licensed Practitioner.
-Verbal Orders (VO) and Telephone Orders (TO); Verbal and telephone orders should be used only to meet the care needs of the patient when it is impossible or impractical for the ordering Licensed Practitioner to write/enter the order without delaying treatment.
-Entering VO/TO; Staff member taking the VO or TO will either enter it directly into computer system (CPOE) or transcribe it to the order sheet (written); CPOE:Staff member taking the order will select the "Verbal with read back" or Telephone with read back" order mode.