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Based on document review and interview, it was determined that the facility failed to ensure that the nursing staff developed, and kept current, a nursing care plan for three (3) of four (4) patients (Patient # 1, # 2 and # 3) and, per the facility policy, developed an Interdisciplinary Plan of Care within seven (7) days of admission for two (2) of four (4) patients (Patients #1 and #3).

The findings include:

1. On May 6, 2019 at 1:22 p.m. a medical record review for Patient # 2 revealed the following:
Patient # 2 was admitted to the facility on March 7, 2019 with diagnoses of chronic respiratory failure, cerebral palsy, quadriplegia, scoliosis, seizure disorder and right lower abdominal wound.
The care plan, initiated on March 7, 2019, failed to include the right abdominal wound, present on admission. The care plan read in part "Alteration in skin integrity: Actual or Potential related to decrease mobility. [Patient # 2's name] will maintain intact skin, free of redness, blisters or discoloration."
On March 16, 2019 and March 30, 2019, there was a plan of care summary that read in part "Wound will improve in 30 days as evidenced by decrease wound size, wound bed beefy red and no signs and symptoms of infection."
On March 16, 2019, the care plan summary lists the attendees as Social Services, Dietitian, RN (Registered Nurse) Unit Manager and Respiratory.
On March 30, 2019, the care plan summary lists the attendees as Social Services, Recreational therapy, Dietitian and the RN Unit Manager. Wound care staff failed to attend care plan meetings.
There were no plan of care summaries after March 30, 2019. Staff failed to complete plan of care updates monthly per policy.

A review of wound care notes revealed the following:
The wound care note dated March 8, 2019 read in part "Patient noted to have post surgical would to right lower quadrant measuring 0.2 X 0.2 X 0.1 CM and G-tube to left upper quadrant. New order given to cleanse with puracyn plus cleanser skin prep peri wound and attach PICO system (negative pressure wound therapy system) changing on Tuesday and Friday."
On March 22, 2019: "right, lower abdomen, 0.5 X 0.5 X 0.1 CM, improved".
On March 29, 2019: "right, lower abdomen, 0.3 X 0.3 X 0.1 CM, improved".
On April 5, 2019: "right, lower abdomen, 0.4 X 0.3 X 0.1 CM, no change".
April 12, 2019: "right, lower abdomen, 0.4 X 0.4 X 0.1 CM, improved".
April 19, 2019: "right, lower abdomen, 0.4 X 0.3 X 0.1 CM, no change".
April 26, 2019 :"right, lower abdomen, 0.3 X 0.2 X 0.1 CM, improved".
May 3, 2019: "multiple wounds, stage 3 pressure wound neck for at least 1 day. Right, lower abdomen, 0.4 X 0.2 X 0.1 CM, no change".


On May 6, 2019 at 2:45 p.m., a medical record review for Patient # 3 revealed the following:
Patient # 3 was admitted to the facility on December 12, 2018 with diagnoses of chronic respiratory failure, subdural hematoma, subarachnoid hemorrhage, cranial injury, occipital and parietal fractures, and wounds.
The care plan, initiated on December 12, 2018, failed to include wounds present on admission, Occupational (OT) and Physical Therapy (PT). The care plan read in part "Alteration in skin integrity: Actual or Potential related to decrease mobility. [Patient # 3's name] skin integrity will be maintained or improved during hospitalization." The care plan did not include a problem, goal or interventions to include OT and PT.
On January 5, 2019, January 19, 2019, March 2, 2019 and March 30, 2019, there was a plan of summary that read in part "Patient's skin integrity will be maintained or improved during hospitalization."
On January 5, 2019, the care plan summary lists the attendees as Social Services, Dietitian, Recreational therapy, Respiratory and the RN Unit Manager.
On January 19, 2019, the care plan summary lists the attendees as Social Services, Dietitian, Recreational therapy, Respiratory and the RN Unit Manager.
On March 2, 2019, the care plan summary lists the attendees as Recreational therapy, Dietitian, Respiratory and the RN Unit Manager.
On March 30, 2019, the care plan summary lists the attendees as Social Services, Recreational therapy, Dietitian and the RN Unit Manager. Wound care staff, OT and PT failed to attend care plan meetings.
There were no plan of care summaries after March 30, 2019. Staff failed to complete plan of care updates monthly per policy.

A wound care note dated December 12, 2018 list the wounds as follows:
1 - Left heel, pressure ulcer, present on admission.
2 - Left leg, pressure ulcer, present on admission.
3 - Left ischium, pressure ulcer, present on admission.
4 - Sacrum, pressure ulcer, present on admission.
5 - Buttocks # 1, pressure ulcer, present on admission.
6 - Back, pressure ulcer, present on admission.
7 - Right heel # 1, pressure ulcer, present on admission.
8 - Right heel # 2, pressure ulcer, present on admission.
9 - Buttock # 2, neuropathic ulcer, present on admission.

Wound care documentation showed the following:
1 - Left heel, pressure ulcer, resolved 12/24/2018.
2 - Left leg, pressure ulcer, resolved 4/19/29.
3 - Left ischium, pressure ulcer, resolved 12/18/2018.
4 - Sacrum, pressure ulcer, continued treatment as of 5/8/2019.
5 - Buttock # 1, pressure ulcer, resolved 2/16/19.
6 - Back, pressure area, resolved 1/2/19.
7 - Right heel # 1, pressure area, resolved 12/20/2018.
8 - Right heel # 2, pressure area, resolved 12/18/2019.
9 - Buttock # 2, neuropathic ulcer, resolved 12/18/18.
10 - Buttock # 3, device related injury, acquired 4/12/2019, continued treatment as of 5/8/2019.

A review of OT notes revealed the following:
On December 13, 2018, therapy was initiated. Goals included "bilateral UE (upper extremity) braces with increased ROM (range of motion).
OT discharged Patient # 3 from therapy on April, 5, 2019 after nursing staff was educated on donning and doffing of UE braces.

A review of PT notes revealed the following:
On December 13, 2018, therapy was initiated. Goals included "B (bilateral) LE (lower extremity) braces to assist with OOB (out of bed) activity tolerance."
PT discharged Patient # 3 from therapy on March 29, 2019 after nursing staff was educated on donning and doffing of LE braces.

The facility policy titled "Care Plan - Interdisciplinary" provided by Staff Member # 2 on May 7, 2019 at 1:00 p.m. reads in part "The facility will develop an Interdisciplinary Care Plan for each patient that includes measurable goals and objective to meet the patient's actual problem, mental and psychosocial needs, as identified by medical, nursing, respiratory (if applicable). All departments will assess the patient within 72 hours of admission.
An initial nursing care plan will be developed within 24 hours of admission by an RN. An initial respiratory care plan (if applicable) will be developed according to respiratory department guidelines of admission by an RT. The assessment of the patients care begins with the patient's chief complaint which is commonly generated from the discharging acute care hospital. An Interdisciplinary Care Plan will be developed by the interdisciplinary Care Planning team based on the physician's orders and reviewed after completion of the comprehensive assessment within 7 working days of admission for the Hospital levels of care.
The Interdisciplinary Care Planning team may consists of, and is contributed to by:
1 - The physician/practitioner, patient, patients family, and/or the patient's representative.
2 - Staff from the following departments: Nursing, Dietary, Recreation, Social Services, Rehabilitation, if indicated, and Respiratory, if indicated.
The Interdisciplinary Care Plan is revised when there is a change in condition.
The patients Interdisciplinary Care Plan is reviewed and updated to address progress towards goals and discharge plan, if applicable, at least monthly, by the interdisciplinary team with the patient and family representative, if able to attend.
Monthly each discipline develops the current care plan summary prior to conference and addresses progress on active problems from the previous care plan and/or noting any new problems, approaches and target dates as they are identified by the current medical condition, or discharge plan."

An interview with Staff Member # 9 on May 8, 2019 at 9:50 a.m. revealed the following: When asked who attends the care plan meeting, Staff Member # 9 stated "Social Worker, RN, Recreation, Respiratory, Dietitian and Rehab if therapy is a part of their care." Staff Member # 9 stated "[he/she] is the wound care coordinator and meets with the wound care team weekly. [Staff Member #9] provides updates in the care plan meetings. Actual wounds are not listed on the care plan. Direct wound care staff do not attend the care plan meetings." Staff Member # 9 stated "Therapy has not attended any of the care plan meetings for Patient # 3."

2. A review of Patient #1's medical record occurred from May 6 to May 8, 2019 at various times. Patient #1 was admitted initially on 10/23/18 with the diagnoses of Acute Hypercapnic Respiratory Failure, Neuropathy with Paraparesis, Hyperlipidemia, History of Pulmonary Embolus, Diabetes Mellitus-type 2, Hypertension, Severe Malnutrition, Anasarca, Dysphagia, Chronic Hepatitis and Depression. Patient #1 was identified as a quadriplegic and chronic ventilator patient requiring a sip and puff call bell. Document review from the five (5) admissions for Patient #1 revealed the following:


Admission #1: 10/23/18 and discharged on 11/5/18 to acute care hospital:

10/24/18: Occupational Therapist (OT) Initial Evaluation noted Patient #1's short-term goal was to be able to use the sip and puff call bell 3 out of 5 attempts by 11/6/18.
(Sip-and-puff or sip 'n' puff (SNP) is assistive technology used to send signals to a device using air pressure by "sipping" (inhaling) or "puffing" (exhaling) on a straw, tube or "wand." This call bell is primarily used by people who do not have the use of their hands.)
There was no notation in Patient #1's medical record that the appropriate call bell was in place until 11/5/18 (thirteen (13) days after Patient #1's admission).

The Initial Evaluation on 10/24/18 indicated Patient #1 did not require any splinting devices.
The rehab note, dated 11/1/18 at 3:05 P.M., indicated that on 10/30/18 the therapist performed training with the CNAs (Certified Nursing Assistants) on PROM (Passive Range of Motion) and orthotic training for AFO (Ankle Foot Orthotic) included wearing schedule. The nursing staff demonstrated correct application for AFO independently, inspected skin with no irritation noted. Therapist notes also indicated training was offered on 10/31/18 for alternate nursing shift.
The assessment indicated Patient #1, while at rest, had pain "everywhere".

On 11/5/18 at:
10:47 A.M., OT made a note indicating the sip and puff call bell was in place, and Patient #1 was able to use the sip and puff call bell.

11:48 A.M., Registered Nurse note indicated at 7:30 A.M. Patient #1's respirations were even and unlabored. Patient #1 was able to communicate by mouthing words and facial gestures. No complaints of pain or discomfort but had signs and symptoms of anxiety. Patient #1 was administered Ativan which was not effective. Repositioning for comfort occurred several times for Patient #1 and the Physician saw Patient #1.

4:19 P.M., Registered Nurse (RN) note indicated at 3:20 P.M. the RN went to Patient #1's room. Upon arrival to the room, Respiratory Therapy (RT) was attempting to get Patient #1 to respond. Patient #1 was discolored and having agonal (gasping) breathing. Patient #1 was not responding to painful stimuli such as a sternal rub. Blood Pressure was WNL (within normal limits), O2 Sats. (Saturation) was at 56% and Blood Sugar was at 156. Staff called a Stat Response. RT used the ambu bag to maintain oxygenation. The staff called EMS (Emergency Medical Services/911) who transported Patient #1 to an acute care hospital at 3:50 P.M.

There was no indication in the Plan of Care for Patient #1 on 10/23/18 to 11/05/18 of the following:
Use of a sip and puff call bell system,
Use of an AFO,
Of Patient #1's pain.
There was no indication an Interdisciplinary Care Plan was developed for Patient #1 within the first seven (7) working days of admission or that any discipline other than Nursing, Dietary, Respiratory or Recreation were involved in the plan.
The care plan did indicate the staff should speak loudly but there was no indication that Patient #1 had a hearing deficit.


Admission #2: 11/8/18 Patient #1 admitted with a diagnoses that included Chronic Pain and discharged on 11/26/18 to an acute care hospital:
On 11/08/18:
5:19 P.M., Nursing Shift Assessment: Section- Neurological History: Nursing did not identify any issues, did not check paralysis (Patient #1 previously admitted as a quadriplegic) and did not document assessment for pain.
6:49 P.M., Nursing Shift Assessment: Section-
Equipment Needs: Did not identify the need for a specialized call bell.
Neurological: Nursing staff identified Speech was "Clear" (Patient #1 is non-verbal). Integumentary - Hosp.: Nursing staff indicated Patient #1 had a surgical wound, but did not indicate where the wound was.
Musculoskeletal: Orthopedic/Prosthesis: Nursing staff identified "None" (Patient #1 used an AFO splint).
Pain Assessment for Verbal/Non-Verbal Patients: Nursing staff identified "None".

On 11/9/18 -
11:49 A.M. Nursing Shift Assessment:
Integumentary - Hosp.: Nursing staff indicated Patient #1 did not have a surgical wound. (A Would was identified on the previous assessment.)
Musculoskeletal: Orthopedic/Prosthesis: Nursing staff identified "None". (Patient #1 used an AFO splint.)
Pain Assessment for Verbal/Non-Verbal Patients: Nursing staff identified "Intermittent Pain".

There is no indication in the Plan of Care for Patient #1 of 11/8/18 to 11/26/18 of the following:
Use of a sip and puff call bell system,
Use of an AFO.
There was no indication an Interdisciplinary Care Plan was developed for Patient #1 within the first seven (7) working days. The last staff signature for completion was on 11/23/18. There was no indication any discipline other than Nursing, Dietary, Respiratory or Recreation was involved in the plan.
The care plan did indicate the staff should speak loudly but there was no indication Patient #1 had a hearing deficit.


Admission #3: 12/1/18 and discharged on 1/30/19 to an acute care hospital:

The OT Initial Evaluation for this admission, performed on 12/3/18, indicated Patient #1 did not require any splinting devices. (On previous admission, Patient #1 was using an AFO splint.) There was no indication that pain was assessed during this evaluation.

Nursing Shift Assessments on the identified dates and times noted the following:
12/1/18 at 12:03 A.M.,
Cardiovascular - Hosp.; Indicated Patient #1 had localized edema but did not indicate where. Integumentary - Hosp.; Indicated Patient #1 had no wounds.
Musculoskeletal: Orthopedic/Prosthesis: Nursing staff identified "None".
Pain Assessment for Verbal/Non-Verbal Patients; Indicated Chronic Pain.
12/1/18 at 2:10 A.M.,
Cardiovascular - Hosp.; Indicated Patient #1 had no edema.
Musculoskeletal: Orthopedic/Prosthesis: Nursing staff identified "None".
Pain Assessment for Verbal/Non-Verbal Patients; Indicated "None".
1/23/19 at 7:55 P.M.,
Neurological: Nursing staff identified that Speech was "Soft Speaking" (Patient #1 was non-verbal).
Musculoskeletal: Orthopedic/Prosthesis: Nursing staff identified "None". (Patient #1 used an AFO splint.)
Pain Assessment for Verbal/Non-Verbal Patients; Indicated "Generalized".

The medical record contained the following physician's orders:
An order for a L (left) shoulder x-ray was written on 12/4/18. On 12/4/18, the x-ray impression was moderate A.C. joint arthritis.
On 12/6/18 for "PT - Eval (evaluate) and Tx (treat), Dx (diagnosis) L shoulder arthritis for ROM (Range of Motion Lidoderm patch 5% apply to L shoulder on 12° (hours) and off 12° X 10 days." There was documentation that this evaluation occurred.

There was no indication in the Plan of Care for Patient #1 for 12/1/18 to 1/30/19 of the following:
Use of a sip and puff call bell system,
Use of an AFO,
There was no indication an Interdisciplinary Care Plan was developed for Patient #1 within the first seven (7) working days of admission. The last staff signature for completion was on 1/16/19. There was no indication any discipline other than Nursing, Dietary, Social Work, Respiratory or Recreation was involved in the plan.
The care plan indicated the staff should speak loudly but there was no indication Patient #1 had a hearing deficit.

Admission #4: On 2/5/19 and discharged on 4/4/19 to acute care hospital for IVIg (Intravenous Immunoglobulin Therapy) infusion for five (5) days:
The physician added the diagnosis of Guillain-Barre Syndrome to Patient #1's list of diagnoses. (Guillain-Barre syndrome is a rare disorder in which your body's immune system attacks your nerves. Weakness and tingling in your extremities are usually the first symptoms.)

The OT Initial Evaluation for this admission, performed on 2/11/19, indicated Patient #1 did not require any splinting devices and there was no mention of the AFO splint in this evaluation.
The section of the Evaluation titled Client Factor -Musculoskeletal - Strength documents, "Right/Left Lower Extremity Strength = Impaired (no AROM B LE (active range of motion, bilateral, lower extremities), able to move LE through PROM (passive range of motion) with pt (Patient) c/o (complaining of) pain.
Client Factor - Integumentary/Pain = Pain absent.

The Physician's H&P (History and Physical) dated 2/6/19 states, "The patient is still complaining of left shoulder pain. On physical examination, there is a postsurgical scar, which is indicative of a rotator cuff repair, but the patient does not recall ever having any surgery ...
For now, we will discontinue the CT and pursue an MRI of the left shoulder, as I believe in retrospect, that this will provide better information ...
I am just so concerned because this limits [his/her] ability to interact and [he/she] is so depressed because of persistent pain and his current diagnosis...
Review of Systems: ...Some weight gain, in that [his/her] has upper extremities are swollen, but he is not very much concerned about that.
Extremities: ... [He/She] has significant edema in the upper extremities and as well as in the lower extremities, possibly from fluid resuscitation. "

There was no indication in the Plan of Care for Patient #1 for 2/5/19 to 4/4/19 of the following:
Use of a sip and puff call bell system,
Use of an AFO,
Edema in upper extremities.
There was no indication an Interdisciplinary Care Plan was developed for Patient #1 within the first seven (7) working days of admission. The last staff signature for completion was on 3/14/19 except for nursing which was on 5/7/19. There was no indication any discipline other than Nursing, Dietary, Social Work, Respiratory or Recreation was involved in the plan.
The care plan indicated the staff should speak loudly but there was no indication Patient #1 had a hearing deficit.


Admission #5: On 4/9/19 and was still a patient in the Long Term Care Hospital at the time of the survey.

There was no indication in the Plan of Care for Patient #1 for 4/9/19 to the date of survey, 5/8/19, of the following:
Use of a sip and puff call bell system, which was in use until 4/23/19 and then OT evaluated as unable to use, no care plan involving any type of call system.
Use of an AFO.
Edema in upper extremities.
On 4/23/19, OT received an order for hemi sling for left shoulder subluxation. There was no care plan available for review that included the use of a sling.
The care plan indicated the staff should speak loudly but there was no indication Patient #1 had a hearing deficit.

Wound identified in OT evaluation performed on 4/11/19 but Impaired Skin Integrity was not care planned until 4/18/19 and did not identify wound(s) location.
There was no indication an Interdisciplinary Care Plan was developed for Patient #1 within the first seven (7) working days of admission. The care plan had the previous admission date and the last staff signature for completion on 3/14/19 except for nursing which was signed on 5/7/19. There was no indication that any discipline other than Nursing, Dietary, Social Work, Respiratory or Recreation was involved in the plan.

During an interview on 5/7/19 at approximately 10:45 A.M., Staff Member #4 (Director of Rehab Services) stated, "We complete our evaluations and develop a plan of care for the patient based on those evaluations. The evaluations are placed in Document Storage in the EMR, where anyone can access them." During the interview, Staff Member #4 confirmed that Patient #1 used an AFO (a plastic lined support from the back of the leg to under the foot) during each of his/her admissions outlined above.




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