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Based on record review and interview, the hospital failed to recognize opportunities for improvement and initiate changes to ensure compliance. This deficient practice was evidenced by failure of the hospital to implement a performance improvement plan after a patient was discharged to another facility without documented communication regarding the patient's medical issues (Patient #1).
Findings:


Review of the medical record for Patient #1 revealed an admit date of 10/22/2024.

Review of the nurses notes dated 11/03/2024 at 2:20PM revealed that as the nurse was positioning the patient, a "pop" was heard and a deformity to the patient's right upper arm was observed. An xray was obtained which showed a severely displaced spiral fracture of the right humerus and a splint was placed on the right arm.

Review of the physician's discharge summary dated 12/02/2024 revealed no mention of the fractured humerus. Review of the Patient Discharge/Teaching Instructions form dated 12/02/2024 and signed off by the physician and case manager revealed no mention of the fractured humerus. Review of the nurses notes dated 12/02/2024 at 12:45PM revealed report was called to the nursing home where the patient was discharged to, but no documented evidence that the patient's humerus fracture and treatment was communicated in the verbal report.

On 01/14/2025 at 2:55PM, interview with S3Director of Quality confirmed that there was no documented evidence that the patient's right humerus fracture was reported to the nursing home upon discharge. She further confirmed that there was no documentation on the physician's discharge summary, Patient Discharge/Teaching Instructions form or in the discharge nurses notes that indicated the humerus fracture was reported to the nursing home. S3Director of Quality stated that the nursing home called her a few days after the patient was discharged from this hospital, stating that they had sent the patient to the ER where he was diagnosed with a right humerus fracture. The nursing home informed S3Director of Quality that it was not reported that the patient was returning to the nursing home with a fractured humerus and splint in place. When asked if there had been any performance improvement plans put into place regarding communication at discharge, S3Director of Quality stated no and stated that this was something the hospital needed to improve upon.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. This was evidenced by 1) failing to provide a complete discharge report to a facility that a patient was discharged to (Patient #1); 2) failing to perform central line dressing changes per policy (Patient #1); 3) failing to obtain an order to utilize a patient's central line (Patient #1); and 4) failing to follow discharge orders for 2 patients (Patient #1, #3).
Findings:

Patient #1
Review of the medical record for Patient #1 revealed an admit date of 10/22/2024. The admission nursing assessment dated 10/22/2024 revealed the patient was admitted with a central line catheter to the right subclavian. Review of admission physician orders revealed an order to administer Protonix 40mg intravenous daily. There was no order to use the central line catheter that the patient was admitted with.

Further review of the record revealed there was no documented evidence that the central line dressing was changed until 11/02/2024 (11 days after admission).
Review of the hospital policy titled, Central Venous Catheter Maintenance (01/2024), revealed in part that central venous catheter dressings should be changed every 7 days and as needed.

Review of the nurses notes dated 11/03/2024 at 2:20PM revealed that as the nurse was positioning the patient, a "pop" was heard and a deformity to the patient's right upper arm was observed. An xray was obtained which showed a severely displaced spiral fracture of the right humerus.

Review of the discharge orders dated 12/02/2024 at 7:00AM revealed orders to discontinue IV/PICC lines.
Review of the nurse notes dated 12/02/2024 at 10:30AM revealed right subclavian Hickman catheter sutures removed in attempt to discontinue line. Strong resistance felt. Charge nurse made aware.
Nurses notes dated 12/02/2024 at 10:45AM revealed S1DON here to evaluate.
Nurses notes dated 12/02/2024 at 10:58AM revealed Hickman catheter to remain in place per case management.
There were no further nurses notes, physician notes or case management notes regarding the reason the central line catheter was to remain. There was no order obtained to keep the central line catheter in place upon discharge or the plan for catheter care since the catheter sutures were removed by the nurse.

Review of the physician's discharge summary dated 12/02/2024 revealed no mention of the fractured humerus or the central line catheter. Review of the Patient Discharge/Teaching Instructions form dated 12/02/2024 and signed off by the physician and case manager revealed no mention of the fractured humerus or central line catheter. Review of the nurses notes dated 12/02/2024 at 12:45PM revealed report was called to the nursing home where the patient was discharged to, but no documented evidence that the patient's humerus fracture and treatment was communicated in the verbal report.

On 01/13/2025 at 2:30PM, interview with S1DON revealed that the nurse who attempted to remove the patient's central line did not realize that it was a tunneled catheter that could not be removed. S1DON further confirmed that there was no documentation regarding the reason the cental line remained. S1DON further confirmed there were no physician orders addressing the use of the central line and the central line dressing was not changed per policy.
S1DON further confirmed that there was no documented evidence that the patient's right humerus fracture was communicated with the facility that the patient was discharged to on 12/02/2024.

Patient #3
Review of the medical record revealed an admission date of 12/23/2024. There were discharge orders written on 01/10/2025 to discontinue all lines and discharge the patient to the nursing home.

Review of nurse notes dated 01/13/2025 at 10:50AM revealed all lines were discontinued and the patient was discharged to the nursing home. There was no documentation regarding the reason for the patient not being discharged as ordered on 01/10/2025.

There were no documentation in the record from 01/10/2025 until 01/13/2025 regarding the reason that the patient remained in the hospital for three more days. There was no new physician order obtained to keep the patient in the hospital for three more days.

On 01/14/2025 at 10:20AM, interview with S3Director of Quality confirmed that there was no documented evidence in the record the reason for the patient staying in the hospital for three more days after the physician wrote discharge orders.

Based on record review and interview, the hospital failed to ensure that all patient medical record entries were complete as evidenced by incomplete physician progress notes (Patient #1), History and Physical (Patient #1) and discharge summary (Patient #1, #4) for 2 of 2 patient records reviewed for completeness.
Findings:

Patient #1
Review of the medical record revealed the patient was admitted on 10/22/2024 in a chronic bedridden state with multiple contractures. Review of the admission nursing assessment dated 10/22/2024 revealed the patient was admitted with a central line catheter to the right subclavian. There were no physician orders regading the use of the central line catheter that the patient was admitted with.

Review of the History and Physical dated 10/22/2024 revealed no mention of the central venous catheter that the patient was admitted with.

The patient sustained a right humerus fracture on 11/03/2024. Review of a typed and signed physician progress note dated 11/04/2024 revealed in part "Plan: to monitor the right arm for healing now. Now, I think he is a candidate for any type of surgery or internal splinting. The patient is so inactivity_____ hard cast."

On 01/13/2025 at 2:30PM, S1DON reviewed the above progress note dated 11/04/2024 and confirmed that the progress note was inaccurate, and that the patient was not a candidate for surgery. S1DON further confirmed that the progress note was not clearly written. S1DON further confirmed that the History and Physical did not indicate that the patient was admitted with a central line catheter in place.

On 01/14/2025 at 2:15PM, S2Medical Records reviewed the above progress note and confirmed that there should be no blanks/holes in the physician progress notes. S2Medical Records confirmed that this progress note was incomplete and unable to be understood.

Patient #4
Review of the History and Physical, dated 12/16/2024 and signed off by the physician on 12/17/2024, revealed it included the following blanks/holes in the document: "his urine culture showed _______."; "Lungs decreased at base _______."; "Extremities: no significant edema, cyanosis, clubbing ____."; "Plan: previous hospital showing multiple previous CVAs and ______."

On 01/14/2025 at 2:20PM, S2Medical Records reviewed the above History and Physical and confirmed it was incomplete. S2Medical Records confirmed that the physician should have filled in the blanks before he signed off on it.

Based on record review and interview, the hospital failed to ensure the discharge summary discussed the outcome of hospitalization, the disposition of the patient, and provisions for follow-up care for 1 (Patient #1) of 3 sampled patient records (Patient #1, 2, 3) reviewed for a discharge summary.
Findings:

Review of the medical record for Patient #1 revealed an admission date of 10/22/2024 and a discharge date of 12/02/2024. Further review of the record revealed the patient sustained a right humerus fracture during his hospitalization and a splint was applied to the area.

Review of nurses notes dated 12/02/2024 at 10:30AM revealed right subclavian Hickman catheter sutures removed in attempt to discontinue line. Strong resistance felt. Charge nurse made aware.
Nurses notes dated 12/02/2024 at 10:45AM revealed S1DON here to evaluate.
Nurses notes dated 12/02/2024 at 10:58AM revealed Hickman catheter to remain in place at discharge per case management.

Review of the patient's discharge summary dated 12/02/2024 revealed no mention of the patient's humerus fracture or any follow-up care or any mention of the patient's central venous catheter that remained in place upon discharge.

On 01/13/2025 at 2:30PM, S1DON confirmed the patient sustained a right humerus fracture during his hospital stay and a splint was applied to the area. S1DON also confirmed that the patient's central venous catheter remained in place upon discharge. S1DON further confirmed that the discharge summary had no mention of the humerus fracture or the central venous catheter that remained in the patient.