HospitalInspections.org

Based on medical record review, policy and document review and staff interview, it was determined that the registered nurse (RN) failed to supervise and evaluate the nursing care for 1 of 1 patients (Patient #3) in the sample with wounds. Findings included:

The hospital policy entitled "Wound Care Assessment and Reassessment" stated, "...PAM (Post Acute Medical)...protects patients who have wounds..."

The hospital's Standard of Care entitled "Lippincott Manual of Nursing Practice, 11th Edition" stated, "Pressure Ulcers...Nursing and Patient Care Considerations...Relieve the Pressure...Reposition every 2 hours..."

The hospital "Registered Nurse" Job Description stated, "...Monitors all aspects of care, including...physical activity...Performs...physician orders in a timely manner..."

A. Review of Patient #3's medical record revealed:

1. Admitted on 1/16/20

2. "Initial Assessment" dated 1/16/20: pressure ulcer to coccyx measured as 1.5 cm (centimeter) in length x (by) 1.5 cm in width

3. Physician orders:
dated 1/16/20: turn and reposition patient every 2 hours
dated 1/25/20: turn and reposition patient every 2 hours...Comment: patient now has a tunnel wound in sacrum
dated 1/30/20: turn patient every 2 hours

4. No evidence of patient repositioning every 2 hours as ordered on 1/16, 1/19, 1/20, 1/23, 1/24, 1/26, 1/27, 1/28, 1/29, 1/30, 1/31, 2/1, 2/5 and 2/6/20.

5. "Wound Evaluation Form" dated 2/4/20: pressure ulcer to coccyx measured 7.5 cm x 7.5 cm

On 9/23/20 at 1:50 PM, Chief Nursing Officer A confirmed these findings.

Based on medical record review, policy review and staff interview, it was determined that for 1 of 2 discharged patients (Patient #3) in the sample, the hospital failed to ensure the necessary medical information was provided to the post discharge provider. Findings included:

The hospital policy entitled "Discharge Planning" stated, "...Post Acute Medical provides a collaborative delivery of discharge/transition planning to each patient which includes ...implementation of the discharge plan, evaluation of discharge plan appropriateness with ongoing monitoring and coordination of the final preparations for discharge and/or transitioning of care...Case Managers...confirm all necessary medical information is transferred to post discharge provider...confirm all necessary medical information has been received..."

The hospital policy entitled "Documentation Guidelines for Case Management" stated, "...Case Manager will utilize for all discharges to home environment...Identification of the necessary medical information pertaining to the patient's current course of illness and treatment ...to ensure continuity of care post discharge..."

A. Review of Patient #3's medical record revealed:

1. was admitted on 1/16/20 from another hospital
2. had a sacral wound
3. received tube feedings and medication administration via PEG (percutaneous endoscopic gastrostomy) tube
4. ST (speech therapy) consulted to assist with advancement of diet so patient could work on oral intake
5. had a urinary foley catheter
6. PT (physical therapy) consulted and treated patient throughout hospitalization
7. OT (occupational therapy) consulted and treated patient throughout hospitalization
8. "Case Management Discharge Summary" dated 2/6/20 at 1:03 PM documented Patient #3:
- was discharged home with family
- spouse declined any follow up referrals
- was being transported to another acute rehabilitation facility (Rehab A), closer to home
9. "Discharge Instructions" dated 2/7/20 documented:
- patient to be given PEG tube feeding if eats less than 50% (percent) of meal
- continue to take all medications as prescribed via PEG tube
- cleanse sacral wound with NSS (normal saline solution), apply silver alginate, cover with sacral foam dressing daily
- patient education included medication education on how to manage pain at home, side effects, activities of daily living, safe usage, storage and disposal of pain medications

During an interview on 9/21/20 between 3:00 PM and 3:20 PM, Case Manager A:
- reported that due to Patient #3 not progressing in therapy, patient was a candidate for a SNF (skilled nursing facility)
- reported that family did not want Patient #3 to go to a SNF and wanted patient to have same level of care and they were taking Patient #3 to another acute rehabilitation facility (Rehab A)
- reported that it was not typical for patients to be transferred to another acute rehabilitation facility since it was the same level of care they can provide
- confirmed there was not any coordination of care between the case manager and the receiving facility (Rehab A)

During an interview on 9/23/20 between 10:00 AM and 10:50 A, Medical Director A reported:
- that SNF placement for Patient #3 was recommended to the family and the family declined
- they do not transfer and/or discharge patients to other acute rehabilitation facilities, only to lower levels of care
- Patient #3's family arranged for the patient to be admitted to Rehab A
- authorization for release of medical records was sent to physician on 2/5/20
- had numerous conversations with receiving physician (at Rehab A) regarding Patient #3 but did not document in Patient #3's record

At 11:25 AM on 9/23/20, Medical Director A confirmed that Patient #3's record lacked evidence of coordination of care between the medical director and receiving facility (Rehab A).

During an interview on 9/23/20 between 10:50 AM and 11:28 AM, Director of Quality Management A reported:
- family made arrangements to admit to another acute rehabilitation hospital (Rehab A)
- coordination of care was done by release of medical record
- accommodated family's request of wanting Patient #3 to go to another acute rehabilitation hospital (Rehab A), so discharged patient home with family, so family could transport patient to Rehab A

Review of Patient #3's medical record revealed and interview with Director of Quality Management A on 9/23/20 at 11:20 AM, confirmed there was no documented evidence in the medical record that the necessary medical information was provided to the post discharge provider.