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Based on interview and record review the hospital failed to ensure information was provided regarding 1 patient's (Patient #1 of 1) worsening pressure injury status to the patient's family. This failure could have prevented the family in making informed decisions regarding the patient's care.

Findings included:

Interviews:
During an interview with Personnel #3 on 8/20/2020 at 12:00 PM she said staff nurses are ultimately responsible for wound care. The nurses don't inform the patient's family of pressure injury changes. She said the nursing staff informs patient's families of changes in condition. The surveyor asked why the families wouldn't be informed of a worsening of a pressure injury since that would be a change in condition. Personnel #3 said she didn't know.

During an interview on 8/20/2020 at 1:28 PM with Personnel #6 she said she didn't talk to Patient 1's family about his worsening pressure injury. The sacral pressure injury was unstageable at admission and continued to be unstageable during his stay due to slough obstructing the wound's base. The pressure injury had become larger since his admission. She assessed and measured the wound every Friday. The staff nurses were responsible for changing the wound's dressing.

A review of Patient #1's medical record indicated the patient was a 50-year-old male admitted to the LTAC (long term acute care) hospital from an ACH (acute care hospital) on 3/21/2020 with diagnoses of Leukocytosis, Anoxic encephalopathy, PEA (pulseless electrical activity) and cardiac arrest, MRSA (methicillin-resistant staphylococcus aureus pneumonia, Acute Respiratory failure status post tracheostomy, Intraventricular hemorrhage, Acute renal failure (on hemodialysis), Sacral Pressure Injury, and a low-grade fever. The patient was on a ventilator. He was awake, but did not follow commands very well. He had muscle wasting in his extremities. He was on dialysis on Tuesday, Thursday, and Saturday. He was on vasopressors. The patient had a tracheostomy and a feeding tube (PEG). Patient #1 had a full thickness stage 3 sacral pressure injury. He was admitted for continuity of care, medical management, as well as wound care.

Wound Care
Physician's Notes. The wound care physician's notes indicated the physician visited and assessed Patient #1 3 times weekly.
Date 3/23/2020.
The note reflected Patient #1 had a sacral wound that was a full thickness stage 3 opened wound, complicated.
The wound measured (in cm.) 5.2 X 3.2 X 0.1 "cluster."
Patient #1 was placed on a low-air loss mattress, and a Roho cushion was placed in his chair. He was to be turned and repositioned every 2 hours. He was placed on aggressive wound care and was to be monitored closely.


Date 4/27/2020.
The note reflected Patient #1 had a sacral wound that was a full thickness stage 3 opened wound, complicated.
The wound measured (in cm.) 6.5 X 4 X 0.1.
"Pt remains high risk for further decubs and monitored closely. Wound bigger ordered dolphin mattress for better offloading. On daily dressing changes and started on Dolphin mattress ... Discussed with nurse in detail ..."

Date 5/27/2020
The note reflected Patient #1 had a sacral wound that was a full thickness stage 3 opened wound, complicated.
The wound measured (in cm.) 10 X 13 X 0.1 cluster. Rt. buttock shear wound joined to the sacral wound.
"On HD MWF and remains high risk for decub and prognosis remains poor ... Pt to continue using dolphin mattress. Sacral wound is bigger and slow to improvement. Will continue aggressive wound care therapy. Continue turning q 2 hours. Will continue to monitor.

Date 6/29/2020
The note reflected Patient #1 had a sacral wound that was a full thickness unstageable wound.
The wound measured (in cm.) 8.9 X 11.5 X 0.1.
"Dolphin mattress. Turn q2hrs. Wounds are showing improvement. Pt high risk for further decubs. Pt off vent."

Date 7/29/2020
The note reflected Patient #1 had a sacral wound that was a full thickness unstageable wound.
The wound measured (in cm.) 8 X 9.8 X 1.9.
"On Dolphin mattress. Long term prognosis remains guarded. Patient is at high risk for further decubs. Some marginal granulation seen. Wounds are stable but slow improvement. Turned q2 hours."

Date 8/12/2020
The note reflected Patient #1 had a sacral wound that was a full thickness unstageable wound.
The wound measured (in cm.) 8 X 9.3 X 1.9.
"On Dolphin mattress. Patient is high risk for further decubs. Some marginal granulation seen. Patient back on vent today. Will plan debridement if pt stabilizes. Pt more responsive now. Pts get HD. Turned q 2 hours. Long term prognosis remains guarded. Wounds are stable but slow improvement."

There was no documentation of Patient #1's family being informed of the patient's pressure injury progression in the Physician's Wound Care notes.

Grievance
A grievance dated 7/07/2020 from Patient #1's family indicated a family member had visited the patient around mid-June. The family member asked staff to change the patient because he had soiled himself. She overheard staff talking about the patient's pressure injury. The family member walked into the patient's room to inquire about what the staff were referring to. They showed her pictures of the sacral pressure injury. The family member indicated the wound was the size of "2 fists" on his backside. The family had not been informed about the pressure injury.

Based on interviews and record review the hospital failed to ensure 1 patient's (Patient #1 of 1) discharge plan was re-evaluated and updated to reflect the patient's change in his discharge status. As a result, the patient's family wasn't notified of his impending discharge. Their right to participate in the development and implementation of his plan of care, and to make informed decisions regarding the plan of care and discharge plan, was denied.

Findings included:

During an interview with Personnel #3 on 8/20/2020 at 12:00 PM she said the Case Manager would be the person responsible of informing the patient and their family of an upcoming discharge from the LTAC.

During an interview with Personnel #1 on 8/20/2020 at 12:30 PM he said the LTAC didn't have bed holds. He said when some insurance patients are transferred to an ACH they were considered discharged. The LTAC had a cap of 14 patients for "airway" beds. The LTAC expected for Patient #1 to return after his procedure. An in-patient experienced a problem and had to be placed in an "airway" bed. That patient took Patient 1's bed. On Friday when Patient #1 was to return to the LTAC "we were waiting on a bed to open up and to get insurance authorization. They acted like they [patient's family] didn't know but we had talked to them about it. They didn't want to wait on a bed to open up so they went somewhere else."

During an interview with Personnel #4 on 8/20/2020 at 12:45 PM she said Patient #1 left for a local acute care hospital (ACH) on Wednesday evening of August 12, 2020. His procedure (on his tracheostomy) was for the next day (August 13, 2020). The hospital kept the patient until Friday, August 14, 2020. The patient's wife called Personnel #4 on that Friday asking why he was discharged. She told the wife the LTAC would need to get insurance authorization to allow him back in. Personnel #1 said she was on PTO (paid time off) Monday through Wednesday before Patient #1 went to the hospital. She never explained to the patient or his family that he would be considered discharged from the LTAC when he went to the ACH for his procedure. She said if she had been at the hospital, she would have explained how the insurance company would have considered the patient to be discharged and would have needed authorization to allow the patient to come back to the LTAC.

During an interview on 8/20/2020 at 2:27 PM with Personnel #5 she said she knew that the patient would be going to a hospital for a procedure. She did not discuss insurance or discharge plans with the wife. She assumed Patient #1 would just return to his room following the procedure. She didn't know he would be discharged.

During an interview on 8/20/2020 at 3:25 PM with Physician #8 she said she thought Patient #1 was going to return following his procedure at the ACH. She did not discuss discharge or insurance issues with his family. She didn't know why the patient hadn't returned.

A review of Patient #1's medical record reflected he was a 50-year-old male admitted to the LTAC (long term acute care) hospital from an ACH (acute care hospital) on 3/21/2020 with diagnoses of Leukocytosis, Anoxic encephalopathy, PEA (pulseless electrical activity) and cardiac arrest, MRSA (methicillin-resistant staphylococcus aureus pneumonia, Acute Respiratory failure status post tracheostomy, Intraventricular hemorrhage, Acute renal failure (on hemodialysis), Sacral Pressure Injury, and a low-grade fever. The patient was on a ventilator. He was awake, but did not follow commands well.

Patient #1's Physician's Order
Date: 8/07/2020. " ...Transfer to [local ACH] ICU next week Wednesday for trach procedure ..."

Physician's Pulmonary Progress Note. Date 8/12/2020.
Patient #1 was "being sent to hospital for evaluation of subglottic stenosis ... Transfer to [local hospital] ICU for laser/trach dilation today for procedure on Thursday."

Case Management Progress Notes
There was no documentation regarding Patient #1's impending discharge when he was scheduled to go to the ACH (acute care hospital) on 8/12/2020. There was no documentation of a discussion with the family regarding the patient's discharge to the ACH for his procedure. There were no discharge instructions for his upcoming discharge. There was no documentation to reflect a change in his discharge planning. The last case management note dated 8/06/2020 reflected, " ...pt progressing towards plan of care, cm spoke to family regarding dc planning, pt expected to dc to SNF, barrier included trach/HD ..."

Admit/Discharge/Transfer Log
A review of the log indicated Patient #1 was discharged on 8/12/2020 at 2120.

Hospital Policy
Discharge Planning Revised Date: 7/06/2017 Page 1.
" ...The Case Management Department will have oversight of the Discharge Planning process. The Case Manager will have knowledge of clinical, social, insurance/financial and physical/functional factors that affect how the patients post discharge needs will be met ... Each patient/patient representative has the right to participate in the development and implementation of his/her plan of care and to make informed decisions regarding the plan of care and discharge plan ... Re-assessment and planning for discharge takes place throughout the patient's stay ... Any changes in the patient's condition that may require a change to the discharge plan is discussed through the interdisciplinary process ..."