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Based on documentation review the LTAC Hospital failed to ensure that the care plan for 1 of 10 applicable patients (Patient #1) addressed refusal of care.

Findings included:

Review of medical record documentation indicated that Patient #1 was admitted to the LTAC Hospital on 12/14/10. Patient #1 had diagnoses of Chronic Obstructive Pulmonary Disease, Diabetes, Crohn's disease (on suppressive medications) with multiple stools daily, chronic psoriasis with plaques, chronic renal insufficiency (causes dry skin), and recently developed Shingles. On 1/9/11 Patient #1 was transferred to Hospital #2 with respiratory difficulties and mental status changes.

Review of medical record documentation from Hospital #2, dated 1/9/11, indicated that Patient #1 looked unkempt and there was dirt on Patient #1's feet and body.

Interviews were conducted with staff who cared for Patient #1 as follows: Nurse #1 was interviewed on 1/26/11 at 10:00 A.M.; Nurse #3 was interviewed on 1/26/11 at 10:25 A.M.; Nurse #4 was interviewed on 1/26/11 at 11:25 A.M.; Nurse #5 was interviewed on 1/26/11 at 1:10 P.M.; Certified Nurse Aide (CNA) #1 was interviewed on 1/25/11 at 1:00 P.M.; CNA #2 was interviewed on 1/25/11 at 1:15 P.M., and CNA #3 was interviewed on 1/25/11 at 1:25 P.M.

Interviews determined that Patient #1 had a history of poor self care when in the community, would at times refuse care, and had poor habits around eating meals and refused assistance. Staff provided care several times throughout the day due to Patient #1's appearance.

Review of medical record documentation indicated that Patient #1's refusal of care was not care planned.

Based on documentation review the LTAC Hospital failed to ensure that agency staff were adequately oriented to the LTAC Hospital's policies/procedures, and expectations.

Findings included:

On 1/26/11 the surveyor asked the LTAC Hospital to provide a personnel record for Agency CNA #1 and was unable to provide one.

The Risk Manager was interviewed on 1/25/11 and 1/26/11 intermittently throughout the survey. The Risk Manager said the LTAC Hospital had not used agency staff for a period of time and when reinstituted there was no formal orientation.

Review of documentation provided by the LTAC Hospital indicated that a general orientation manual had been developed that was to be used for both staff and agency orientation however; as of the time of the survey, the Hospital had not yet provided the orientation for agency staff currently in use.

Based on interviews and documentation review the LTAC Hospital failed to ensure that the recognized problem of lack of podiatry services was addressed through the quality assurance (QA) program.

Findings included:

Review of Patient #1's medical record documentation indicated that Patient #1 was admitted to the LTAC Hospital on 12/14/10. Documentation (photographs) indicated that Patient #1 had elongated toenails. Documentation indicated that Patient #1's diagnoses included Diabetes.

A tour of the LTAC Hospital Unit was conducted on 1/25/11 with the Nursing Supervisor and the Clinical Analyst present. During the tour patients were randomly selected for interviews and/or inspection of feet. The selected patients were first asked by the Nursing Supervisor for permission. Nine patients (Patients #2, #3, #4, #5, #6, #7, #8, #9, and #10) feet were observed. Patients #2 (admitted 10/27/10), #4 (admitted 1/6/11), #7 (admitted 11/24/10), and #9 (admitted 12/16/10) were observed to have elongated toenails.

The Risk Manager was interviewed in person intermittently throughput the survey on 1/25/11 and 1/26/11. The Risk Manager said that the LTAC Hospital currently did not have a credentialed consulting podiatrist on staff and was avidly pursuing podiatrists however; there were several issues causing podiatrists to refuse to provide services at the Hospital, 1) payment source, and 2) not enough patients who needed the service. The Risk Manager said the Hospital was in the process of negotiating with several podiatrists to cover several campuses.

Review of the LTAC Hospital's QA program (data and meeting minutes) for 2010 determined that although the lack of podiatry services was an identified problem, it was not addressed in the QA program. There was no evidence the Hospital documented steps taken to obtain a podiatrist or an interim plan to address patient needs until a podiatrist was hired.