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Based on staff interviews, clinical record review, and document review, it was determined the facility staff failed to ensure Patient #3's right to care in a safe setting was protected.

The facility failed to ensure Patient #3 received timely care when (he/she) reported an injury during a transfer. The patient experienced a significant decline in condition and an increased amount of pain. Twenty-two (22) days elapsed before the patient was diagnosed and received treatment. The facility staff also failed to ensure policy and procedures were followed for the reporting and investigation of the patient's allegation.

Please refer to A0144 for further information.

Based on staff interviews, clinical record review, and document review, it was determined the facility staff failed to ensure Patient #3 received timely care when (he/she) reported an injury during a transfer.

The findings included:

Patient #3 was admitted to the facility on 11/17/18 with diagnoses that included, but were not limited to: T-11 incomplete SCI (Thoracic vertebrae #11 spinal cord injury) with T9- T12 instrumented fusion ( a specialized surgery to stabilize the bones of the spinal column), diabetes mellitus, hypertension, obesity, history of pulmonary embolism, urinary retention, and acute pain. Patient #3 was discharged on 12/11/18 to a higher level of care and readmitted to the facility on 12/22/18 and discharged on 1/15/19.

According to the "History and Physical" dated 11/17/18, Patient #3 had a "ground level fall at home due to lower extremity weakness and was found to have a T-spine (thoracic/back) compression fracture...a Foley catheter (tube inserted into the bladder to drain urine) on 11/15/18 due to not fully emptying the bladder..." According to documentation Patient #3 had "skin: warm, dry, pink, no rashes or lesions". Further documentation revealed (in part): "Assessment/Plan: 1. L1 ASIA C incomplete paraplegia*- complete rehab. 2. Thoracic stenosis with myelopathy** s/p (status post) T9-11 fusion-TLSO*** when out of bed (OOB)..."

A "Physiatrist Progress Note" dated 11/23/18 at 11:02 a.m. documented: "S: INCREASE BACK PAIN SINCE ROUGH TRANSFER YESTERDAY"...Assessment/Plan: 1. INCREASED PAIN...CHECK XR (X-ray)."

There was no documentation of any concern/events that occurred on 11/22/18, however, a "Physical Therapy Note" from 11/21/18 documented: "...During transfer from bed > (to) wheelchair, completing a SPT (standing pivot transfer), patient experienced R (right) knee buckling and shooting pain in RLE (right lower extremity). Therefore, slide board transfer was performed for safety in which patient completed with minimal vc (verbal cues) for correct technique and required supervision..."

There was no other documentation in the clinical record regarding any incidents of Patient #3 having any transfer concerns/events or the use of a sit to stand lift. There was however, a "Correspondence Message" (Phone Message) from the RN (Registered Nurse) to the physician on 11/22/18 at 04:43 (4:43 a.m.) which documented "Pt (patient) c/o (complaint of) constant pain not being relieved with medication nor ice. (He/She) stated that the bed is uncomfortable."

On 11/26/18 the "Physiatrist Progress Note" documented"...SL (slightly) weaker LES (lower extremity strength)...adding steroid burst...increased pain...no change in XR...consider further imaging if worse..."

The PTA (Physical Therapy Assistant) documented on 11/26/18 at 8:22 a.m., "...Subjective Statement PT: Says (he/she) has had a quick semi fall that made (his/her) R (right) leg weaker..." A "Clinical Assessment Summary" documented at 12:17 p.m. evidenced, "Pt (patient) participated well during short 30 minute session this afternoon. Demonstrating significant difficulty performing seated exercises against gravity especially in RLE (right lower extremity), requiring therapist assistance for "place and hold"....."

On 11/27/18 at 18:06 (6:06 p.m.) the Physical Therapist sent a "Correspondence Message" (phone message) to the physician which documented: "I wanted to follow up in regards to the therapy session with (Patient #3) this afternoon. I saw a significant decline in just the past 24 hours in mobility and LE (lower extremity) strength. (He/She) was unable to perform a STS (sit to stand) with 2-3 people and was not even able to perform a slide board transfer due to decreased strength and fatigue. (He/she) reported that (he/she) has been sleeping sitting on the side of the bed the past few nights with (his/her) feet in the dependent position and with pillows used for back support. I told (him/her) this could be a reason for the decline in (his/her) mobility with all the stress on the lumbar/low thoracic region. I have recommended nursing to use the hoyer lift and for (him/her) to sleep in the recliner instead on the side of the bed. Just wanted you to be aware of this change as I have been working the last five days and each day have seen a decline in strength and mobility." The response from the physician was documented on 11/27/18 at 18:38 (6:38 p.m.) which evidenced: "Thanks. MRI (magnetic resonance imaging) ordered for Wednesday to assess".

11/29/18 at 18:47 (6:47 p.m.) the physiatrist documented "Unable to fit in MRI and declines CT (computerized tomography) scan. Unable to image (his/her) spine but strength seems stable today...Assessment/Plan: ...MRI not accessible, Pt (patient) declines CT without full sedation which is high risk..."

11/30/18 physiatrist note at 18:12 (6:12 p.m.) documented, "...Unable to tolerate CT or MRI but LE motor strength improving..."

12/1/18 at 20:27 the physiatrist note evidenced: "...Sleeping sitting reclined all night-declines sleeping in bed flat due to pain..." On 12/2/18 at 21:09 (9:09 p.m.) was documented: "...Pain about the same. Sleeping sitting in reclined position..." 12/4/18 at 20:50 (8:50 p.m.) "...Poor motivation addressed with patient today...Assessment/Plan:...pushing patient to participate in all therapies..." The Occupational Therapist (OT) documented "Pt perceverative on "breaking my back" and poor sensation in BLE (bilateral lower extremities)..."

Physical Therapy "Correspondence Message" (phone message) to physician on 12/5/18 at 17:36 (5:36 p.m.) documented: "...I am not sure if it is behavioral or not, however, I again saw a decrease in BLE strength today. Patient continues to have poor initiation to complete slide board transfers, requiring assist of two today to complete (Total A X2). Pt unable to scoot. OT (Occupational therapy) also noted today decreased LE strength when donning/doffing clothes. Patient continues to ask about MRI as (he/she) is worried something is going on as (he/she) is not getting better."

12/6/18 21:20 Physiatrist Note at (9:20 p.m.) "...wants to be reimaged at (initials of university hospital). Call in to (name of physician)...." 12/7/18 16:36 (4:36 p.m.) "...wants to be reimaged at (initials of university hospital. Call in to (name of physician but no word yet on transfer..." unable to lie flat for CT or MRI even with sedation...Poor progress- consider transfer back to (initials of university hospital) for large MRI machine and full anesthesia before imaging at pt (patient) request..." 12/8/18 17:54 (5:54 p.m.) "...pain and LE MVT (lower extremity movement) better- unable to tol (tolerate) MRI or CT here..." 12/11/18 18:27 (6:27 p.m.)"...pain better controlled but feeling weaker in trunk and les (lower extremities) (he/she) wants transfer to (initials of university hospital) for open MRI with full sedation..."

On 12/11/18, Patient #3 was transferred to the acute care hospital for imaging studies the "Discharge Summary" dated 12/21/18 evidenced the following: "HOSPITAL COURSE:...The patient was at Sheltering Arms Rehab and was doing well until approximately 2 weeks prior to readmission when (he/she) had a near fall. (He/She) reports that after the near fall event, (he/she) had significant lower extremity weakness...a CT of the thoracic and lumbar spine was performed on 12/12 which showed a suspected fracture of T12....arrangements were made for the patient to undergo MRI with sedation...This MRI revealed new marked good disk space widening and grade 1 retrolisthesis (a backward slippage of the vertebrae) at the levels of T11 -12 suggesting instability, had resulted in severe spinal cord stenosis and constriction of the thecal sac. On the morning of December 13th, the patient was noted to have no motor exam in (his/her) lower extremities. Given the radiographic and physical exam findings, the patient was taken to the operating room emergently for stabilization and in the evening of December 13th the patient underwent a T9-L5 posterior instrumental fusion (Instrumented spinal fusion is a procedure in which a surgeon uses instruments such as rods, plates, and screws to help bones in the spine fuse, or grow together. An instrumented spinal fusion is performed in adult or pediatric patients when the spine has been weakened by degenerative conditions, deformity, trauma, tumor, or surgery.) with T11-T12 laminectomies ( a surgical operation to remove the back of one or more vertebrae, usually to give access to the spinal cord or to relieve pressure on nerves.), removal of old hardware and ORIF (open reduction internal fixation) of the T12 fracture.

Further documentation in the acute care record revealed the following: PT (Physical Therapy) Evaluation dated 12/13/18 at 1509 (3:09 p.m.)...readmission from SARH (Sheltering Arms Rehabilitation Hospital) after a fall and increased LE (lower extremity) weakness...pt reports fear of trying to stand due to (his/her) fall with nursing staff getting him back to bed at SARH..."

Nursing Documentation on 12/15/19 at 19:10 (7:10 p.m.) documented: "...ORIF of fx after fall 1(one) month ago..." 12/18/19 at 9:40 a.m. evidenced: "...Pt is 6 (six) days post-op from re-fusion after (he/she) reportedly fell in Rehab facility..."

The surveyor requested on 9/23/19 at 1:30 p.m., the facility incident/accident reports related to reported falls/incidents for November 2018. After review of the incident logs, there was no documentation of a reported fall or "near fall" for Patient #3 in November of 2018. On 9/25/19 at 2:30 p.m., staff member #1 (Clinical Manager) stated, "It should have been reported and it would have been investigated."

On 9/24/19 at 10:45 a.m., Staff Member #1 and #2 were interviewed regarding the concern that Patient #3 had stated (he/she) had an incident during a transfer, which documented by staff and the physician and had not been investigated. Staff Member #1 and 2 stated, "We had no idea anything happened. Nothing was reported to us. (He/She- Patient #3) had an x-ray which was fine and then was sent out and maybe the staff thought it was the same issue (he/she) came in with." The surveyor inquired as to why the facility did not complete a follow-up investigation after the patient's readmission to the facility when it was evidenced in the transfer documents and clinical record that the patient had alleged there had been a rough transfer/fall? Staff Member #1 stated, "We didn't see that. The staff thought it was the same issue."

The Physical Therapy (T) Director, Staff Member # 10 was interviewed on 9/25/19 at 11:10 a.m. and stated, "If (Patient #3) had stated during therapy that (he/she) had pain or that anything felt like it had "popped" we would have immediately contacted the MD. If there are any falls or incidents during therapy they are documented and reported. If a patient stated they have pain during a transfer but then after resting state that the pain has subsided and there is not change then it would be documented, but not necessarily would be something that is formally reported...I do know the PT who was working with (Patient #3) was concerned about (his/her- Patient #3) sleeping position and that (he/she) didn't remember back precautions. We talked about it with the patient multiple times. The PT was concerned about the mount of pressure the patient was placing on (his/her) back from prolonged sitting and not lying down..."

On 9/26/19 at 9:30 a.m., the surveyor interviewed Staff Member #12, the physician who cared for Patient #3 during the November/December 2018 admission. Staff Member #12 stated, "(Patient #3) came from (acute care hospital) with an incomplete SCI (spinal cord injury) and paraplegia after surgery. The patient was not compliant and was sometimes difficulty, wanting to sit up most of the time. (He/She) was motivated and was making progress. We started an intensive program. (He/She) had lots of pain when (he/she) got here and we had to manage that pain. We tried a lot of different things but (he/she) was never really comfortable. (He/She) experienced a lot of post-op pain. (He/she) had lots of other complications with diabetes, previous surgery, obesity, and liver problems...The pain was uncontrolled and got worse and (he/she) said to me that (he/she) did something, that a transfer was hard and it "hurt my back". There was no MRI that would fit (him/her) and we did an x-ray which showed no change. We sent "him/her) back for an MRI but (he/she) couldn't tolerate it. I consulted (name of physician) at (name of hospital) to see (Patient #3) and (Patient #3) was sent for a MRI at (name of hospital). The MRI showed a fracture...the actual conversation I had with (Patient #3) was that "they're (staff) were just rough" but no specific incident, but I know that's an issue...(He/She- Patient #3) wanted IV (intravenous) sedation for the MRI but we can't do that here. I told (him/her) I would give (him/her) some mild sedation...(He/She) was high risk for sedation but told (him/her) we'll do it if "you're willing". (He/She) declined the oral sedation. I was worried about the sedation and it needed to be done in the hospital...with (him/her) being so large, transfers were difficult." When interviewed as to the facility protocol and expectation regarding Patient #3's complaint of the "rough transfer" and increased pain, Staff Member #12 stated, "The expectation would have been to clarify that. To investigate what (he/she) said..."

The surveyor discussed with Staff Members #1 (Clinical Manager), #2 (Quality Director), #3 (CEO-President), and #4 COO (Chief Operating Officer) on 9/25/19 at 2:30 p.m. the concern that Patient #3 reported to staff and the physician that (he/she) had an incident during a transfer that caused (him/her) significant pain and, based on the documentation in the clinical record, a decline in the patient's progress and increased pain was evidenced. The patient had asked on multiple occasions for re-imaging and there was a period of 22 (twenty-two) days before this was completed; the imaging demonstrating that Patient #3 had a new "back fracture and stenosis of the spinal column with worsening paraplegia (acute care physician's discharge notes 12/22/18)".

Based on staff interviews, clinical record review and document review, it was determined facility staff failed to document and report one (1) adverse event to the facility's Quality Assurance and Performance Improvement (QAPI) program (Patient #3's complaint of "rough transfer" that resulted in an injury).

The findings include:

Patient #3 was admitted to the facility on 11/17/18 with diagnoses that included, but were not limited to: T-11 incomplete SCI (Thoracic vertebrae #11 spinal cord injury) with T9- T12 instrumented fusion ( a specialized surgery to stabilize the bones of the spinal column), diabetes mellitus, hypertension, obesity, history of pulmonary embolism, urinary retention, and acute pain. Patient #3 was discharged on 12/11/18 to a higher level of care and readmitted to the facility on 12/22/18 and discharged on 1/15/19.

A "Physiatrist Progress Note" dated 11/23/18 at 11:02 a.m. documented: "S: INCREASE BACK PAIN SINCE ROUGH TRANSFER YESTERDAY"...Assessment/Plan: 1. INCREASED PAIN...CHECK XR (X-ray)."

There was no documentation of any concern/events that occurred on 11/22/18, however, a "Physical Therapy Note" from 11/21/18 documented: "...During transfer from bed > (to) wheelchair, completing a SPT (standing pivot transfer), patient experienced R (right) knee buckling and shooting pain in RLE (right lower extremity). Therefore, slide board transfer was performed for safety in which patient completed with minimal vc (verbal cues) for correct technique and required supervision..."

The surveyor requested on 9/23/19 at 1:30 p.m., the facility incident/accident reports related to reported falls/incidents for November 2018. After review of the incident logs, there was no documentation of a reported fall or "near fall" for Patient #3 in November of 2018. On 9/25/19 at 2:30 p.m., staff member #1 (Clinical Manager) stated, "It should have been reported and it would have been investigated."

On 9/24/19 at 10:45 a.m., Staff Member #1 and #2 were interviewed regarding the concern that Patient #3 had stated (he/she) had an incident during a transfer, which documented by staff and the physician and had not been investigated. Staff Member #1 and 2 stated, "We had no idea anything happened. Nothing was reported to us. (He/She- Patient #3) had an x-ray which was fine and then was sent out and maybe the staff thought it was the same issue (he/she) came in with." The surveyor inquired as to why the facility did not complete a follow-up investigation after the patient's readmission to the facility when it was evidenced in the transfer documents and clinical record that the patient had alleged there had been a rough transfer/fall? Staff Member #1 stated, "We didn't see that. The staff thought it was the same issue."

On 9/26/19 at 9:30 a.m., the surveyor interviewed Staff Member #12, the physician who cared for Patient #3 during the November/December 2018 admission. When interviewed as to the facility protocol and expectation regarding Patient #3's complaint of the "rough transfer" and increased pain, Staff Member #12 stated, "The expectation would have been to clarify that. To investigate what (he/she) said..."

Based on clinical record review, staff interview and facility document review, it was determined the facility staff failed to ensure a nursing care plan was developed to include the risk for skin breakdown for three (3) of three (3) patients (Patient #3, #5, and #7).

Patient #3's risk score (Braden) dropped below "18" on 12/2/18 and on 12/6/18 the patient had developed skin breakdown.

Patient #5 had a risk score (Braden) of "14" on admission (2/4/19) and developed an "area of purple non-blanching tissue on the right buttock".

Patient #7 had a sacral decubitus present on admission (9/13/19) and a Braden Risk score of "15".

The findings included:

Patient #3 was admitted to the facility on 11/17/18 with diagnoses that included, but were not liited to: T-11 incomplete Spinal Cord Injury, obesity and diabetes. A review of the clinical record for Patient #3 revealed on 11/19/18 (two days after admission to the facility), the patient was assessed by the wound care nurse. This assessment evidenced the patient had the following: " 9:31 a.m.- Pressure areas assessed: sacral area/buttocks- intact; no redness. Bilateral Heels- dried callused tissue of left lateral heel; skin otherwise intact without redness. Lumbar incision (surgical site)- honeycomb dressing dry and intact; did not disturb. Chin- tender firm lesion within [beard]; patient reports ongoing prior to admission..."

On 12/6/18 at 18:20 (6:20 p.m.) "Wound Care Documentation" evidenced: "Sacrum- left, Incision/Wound activity: Assess, Wound Status: Acute, Skin Abnormality Type (T110)- Blister, Erythema, Maceration, Other, Skin Abnormality pattern: Scattered, Skin Abnormality Color: Red, Wound bed tissue type: Red, Wound exudate type: Bloody, Wound exudate amount: small Periwound Tissue condition (T112) Blister, intact, blister, ruptured, other: one ruptured and one intact."

A further review of the clinical record for Patient #3 revealed a "Braden Score" (The scale consists of six subscales and the total scores range from 6-23. A lower Braden score indicates higher levels of risk for pressure ulcer development. Generally, a score of 18 or less indicates at-risk status.) on 11/17/18 (date of admission) as "18". On 12/2/18 the score was "17" and on 12/5/18 the scores were "13", "14", and "16" (each shift assessment). On 12/6/18 the score was "14", "14", and "16" (the day the "sacral left" area was identified.

According to the facility policy and procedure in place at the time: "Pressure Injury Prevention Protocol and Assessment: 1) All licensed nurses are responsible for completion and documentation of skin assessment on admission and every shift (8 hour or 12 hour shifts)...2) A licensed nurse must perform a Braden risk assessment upon admission and once every 24 hours, with any change of condition, and with transfer to or from another facility...7) Once the Braden assessment is completed, implement interventions based on each of the six subscale scores in collaboration with the multidisciplinary team (sensory perception, moisture, activity, mobility, nutrition, friction/shear)...14) report any hospital acquired pressure ulcer to Attending Physician, patient and or family and consult wound care nurse..." An Addendum to the policy evidenced: "Braden Score of 18 or less will launch Altered Skin Status Prevention/Management IPOC (Interdisciplinary plan of care)".

Staff Member #1 stated on 9/30/19 at 12:35 p.m., "If a patient has a Braden less than "18" this should have triggered the care plan and the nurse to add the goals for skin and pressure ulcer prevention."


Patient #5 was admitted to the facility on 2/4/19 with diagnoses that included, but were not limited to: stroke, diabetes and hypertension. On 2/5/19 the wound care nurse documented an assessment of the patient which evidenced: "...no redness noted to sacrum/buttocks. No redness to heels. Eczema areas on arms..."

On 2/11/19 the wound care nurse assessment documented, :...developed area of purple non-blanching tissue on right medical buttock..."

On 2/4/19 the licensed nurse had documented the Braden risk scale as "14". On 2/5/19 the risk score was "17", 2/6/19 - "16", 2/7/19 -"14", 2/8/19- "15", 2/9/19 -"15", 2/10/19 - "14", 2/11/19, the date the skin injury/breakdown was noted, "12".

Patient #5 did not have a nursing care plan that addressed the potential for skin breakdown based on the facility policy for Braden risk score. Staff Member #1 stated on 9/30/19 at 12:35 p.m., "If a patient has a Braden less than "18" this should have triggered the care plan and the nurse to add the goals for skin and pressure ulcer prevention." Staff Member # 11 stated, "Currently it doesn't trigger anything and we have to add it. We are working on it."


Patient #7 was admitted to the facility on 9/13/19 with diagnoses that included but were not limited to: weakness secondary to metatastatic adenocarcinoma, status post colectomy and loop ileostomy on 9/5/19. The admission assessment for Patient #7 revealed a sacral decubitus ulcer present on admission. The patient was assessed with a Braden risk score of "15", however the patient did not have a nursing care plan developed for the skin breakdown until 9/15/19.

Staff Member #1 stated on 9/30/19 at 12:35 p.m., "If a patient has a Braden less than "18" this should have triggered the care plan and the nurse to add the goals for skin and pressure ulcer prevention." Staff Member # 11 stated, "Currently it doesn't trigger anything and we have to add it. We are working on it."

On 10/1/19 at 4:00 p.m. the surveyor discussed the concerns with Staff Member #1 (Clinical Manager), #2 (Quality Director), #3 CEO/President, #4 (COO), and #17 (CNO).