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Based on review of the facility policy, record review and interview, the facility failed to ensure that a Registered Nurse assessed a patient, based on the patient's needs, but at least every12 hours after the initial comprehensive nursing assessment in 1 (#A) of 1 sampled patient records with skin issues.

Findings include:

Review on 06/25/2024 of the facility's current policy titled Nursing Documentation Standards Dated 8/1/22 revealed the following information: " Each patient is reassessed by the nurse every shift. The reassessments are completed on a daily nursing assessment/ progress note. Significant patient changes are documented in the multidisciplinary progress notes with appropriate clinician notification."

Record review of patient (#A) admitted on 03/04/24 discharged 03/29/24 had diagnoses of depression, hypertension, diabetes, stage 2 bilateral heal ulcers and chronic lower extremity lymphedema. Reason for admitting was suicidal ideation due to pain in her legs.

Daily Nursing Assessments for patient (#A) from the day after admission 03/05/24 through discharged 03/29/24 revealed that no daily assessment or other nursing note assessed, described the lymphedema. There was mention of it in the nursing notes.


When Interviewed 06/25/23 at 14:50 the Director of Quality Management confirmed the findings and stated, "There's nothing I can say".

Based on record review and interview, the facility failed to provide an effective discharge planning program that facilitates the provision of follow-up care for 2 of 2 discharged patients reviewed (A and B) who did not have complete discharge information.

Patient A was senior citizen admitted for aggression with diagnoses of bipolar disorder a with brief psychotic disorder was discharged 10/19/23. The record documented the patient was not allowed to move back into the home she shared prior to discharge and alternates including long term care were explored. Social Worker (#17) note 10/19/24 at 10:20 am to the patient's family, inquired about two different discharge addresses provided to clarify which was correct, transportation to home, obtaining medications, living alone or not and obtaining food/ groceries.

Discharge Summary by Psychiatric Nurse Practitioner #18 on 10/19/23 at 3:15 pm "Discharge Plan & Disposition" checked boxes reading:
Outpatient patients, symptoms can be appropriately managed in a community setting through outside counseling and/or medication management.
X- Return to Home
X- Needs a Private Psychiatrist
7 discharge medications were listed including psychiatric and other medications.
X- Medication risks, benefits, and options have been reviewed with the patient.
x- Discharge information has been communicated to the patient.
Discharge follow-up plans/recommendations: Patient to follow-up with outpatient psychiatrist for further mental health needs.
Follow-up care for identified medical problems: patient to follow-up with primary care physician for future medical needs.

Discharge plan does not include information needed for a safe discharge including: the address patient is going to, name of a psychiatrist to follow up with or an appointment for further care, if medication prescriptions were provided or called into a pharmacy. There was no evidence of patient receipt of complete discharge instructions.

Patient B was a wheelchair bound (some days bed bound) patient admitted 3/6/24 for polyneuropathy, suicidal ideation with diagnoses of major depressive disorder severe with psychotic features, anxiety disorder, diabetes (on sliding scale insulin), hypertension, chronic lower limb lymphedema and stage 2 bilateral heal ulcers. She lived alone at home with intermittent family assist visits and home health 2-3 hours daily. The patient did not want to discharge and appealed to stay longer stating she was alone at home and wanted home care 8 or more hours daily and interaction with others like she had in the facility. The patient appealed a pending discharge 3/18/24 to Kepro Quality Improvement Organization/ Humana/ Medicare Administrator Contractor Novitas which agreed with her appeal. Patient was discharged to home 3/29/24.

Discharge Summary 3/29/24 at 8:20 pm by #16 a Doctor of Osteopathy with Psychiatric Certification "Discharge Plan & Disposition" checked boxes reading:
Outpatient patients, symptoms can be appropriately managed in a community setting through outside counseling and/or medication management.
X- Return to Home
X- Outpatient therapy at (left blank)
13 discharge medications were listed including psychiatric and other medications. Did not include insulin order.
X- Medication risks, benefits, and options have been reviewed with the patient.
x- Discharge information has been communicated to the patient.
Discharge follow-up plans/recommendations: Patient to follow-up with outpatient psychiatrist for further mental health needs.
Follow-up care for identified medical problems: patient to follow-up with primary care physician for future medical needs.

Discharge plan does not include information needed for a safe discharge including: the address patient is going to, name of a psychiatrist to follow up with or an appointment for further care, if medication prescriptions were provided or called into a pharmacy, diabetic medication and blood sugar monitoring, dietary recommendations, wound care/ treatment how/supplies/ by whom. There was no evidence of patient receipt of complete discharge instructions.

When interviewed 6/26/24 at 1:00 pm Dr. ##16 a Doctor of Osteopathy with Psychiatric Certification stated she thought the medical doctor was responsible for the medical part of the discharge information.

When interviewed 6/26/24 at 12:10 Medical Doctor #19 stated he is not routinely informed, prior to discharge of medically followed patients.

When interviewed 6/26/24 at 2:20 pm #2 Director of Quality Management confirmed the discharge plans did not include the afore mentioned information.