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Based on record review, physician and staff interview, one of one Patient's medical records lacked sufficient information at the time of transfer to adequately care for the Patient's multiple medical problems including but not limited to respiratory failure with ventilator dependency, hemodialysis and nutritional needs and multiple pressure sores in March 2010.

The findings are as follow:

The Patient was transferred to an emergency department for an episode of hypoxia (low oxygen levels) at the request of family.

Review of the Integrated Progress Notes dated 03/19/10 indicated the Patient had completed hemodialysis with no ill effects. The Attending Physician indicated the Patient was ventilator dependent. The Attending Physician indicated the Patient became hypoxic (low oxygen levels) and tachypneic (rapid breathing). The Attending Physician indicated oxygen saturation levels were unable to be obtained. The Patient's vital signs were recorded as a blood pressure of 100/30 to 105/50, heart rate of 90 to 105 beats per minute with respirations ranging between 28 to 30 breaths per minute with minimal secretions. The Attending Physician indicated arterial blood gases were attempted multiple times by both the physician and a respiratory therapist.

The Attending Physician indicated the Patient was aware, non-verbal and responded to burn. The Patient was using accessory muscles to breathe and the Patient's abdomen was mottled.

The Attending Physician indicated the Patient had a coccyx wound covered by a VAC and a left leg wound covered by a VAC. There was no written description of the Patient's coccyx , right buttock and/or left leg wounds. There was no documentation by the Attending Physician for the Patient's right buttock deep tissue injury. The Attending Physician indicated the Patient was a full code.

The Attending Physician was interviewed by telephone on 03/25/10 at 1 PM. The Attending Physician said oxygen saturation levels were not able to be obtained on the Patient despite changing the probes and access areas. The Attending Physician indicated the Patient was mottled and arterial blood gases were not able to be obtained by either the physician or a respiratory therapist. The Attending Physician said a family member was called who elected to have the Patient transferred.

There was no documentation in the Patient's medical record for the interventions by the respiratory therapist.

Continued review of the Patient's medical record lacked a written progress note documentation by Registered Nurse #3 who cared for the Patient on 03/19/10. There was no written nursing progress note at the time of transfer to the emergency department at the acute care hospital.

Review of the two page referral sent to the acute care hospital lacked a written description for the nursing measures needed to care for the Patient including the condition and treatment for the Patient's multiple pressure sores.

Registered Nurse #3 was interviewed by telephone on 03/25/10 at 11 AM. Registered Nurse #3 said the Patient's coccyx was bleeding and excoriated. Registered Nurse #3 said the Nurse Manager requested the two wound VACS be removed from the Patient before sending the Patient out. There was no nursing documentation for protection and/or covering of the Patient's multiple open areas.

There was no documentation for the Patient's right buttock deep tissue injury by Registered Nurse #3 or the Attending Physician on the two page referral sent to the emergency department at the acute care hospital.

Review of the Wound Care Consultant's Assessment Note dated 03/18/10 indicated the Patient's coccyx was an unstageable deep tissue injury which measured 7.5 centimeters in length by 4 centimeters in width and 2.5 centimeters in depth. The Wound Care Consultant said in interview on 03/24/10 at 2 PM and documentation indicated the a negative pressure wound VAC appliance was placed to decrease drainage and to protect the area from fecal contamination. The Patient's right buttock had an unstageable deep wound injury measuring 4.5 centimeters in length by 6 centimeters in width and zero centimeters in depth.

Both the respiratory therapist and the Registered Nurse #3 failed to document the Patient's change in condition and the measures taken to stabilize the Patient prior to transfer to the acute care hospital.

Based on record review, physician and staff interview, one of one Patient's medical records lacked sufficient information at the time of transfer to adequately care for the Patient's multiple medical problems including but not limited to respiratory failure with ventilator dependency, hemodialysis and nutritional needs and multiple pressure sores in March 2010.

The findings are as follow:

The Patient was transferred to an emergency department for an episode of hypoxia (low oxygen levels) at the request of family.

Review of the Integrated Progress Notes dated 03/19/10 indicated the Patient had completed hemodialysis with no ill effects. The Attending Physician indicated the Patient was ventilator dependent. The Attending Physician indicated the Patient became hypoxic (low oxygen levels) and tachypneic (rapid breathing). The Attending Physician indicated oxygen saturation levels were unable to be obtained. The Patient's vital signs were recorded as a blood pressure of 100/30 to 105/50, heart rate of 90 to 105 beats per minute with respirations ranging between 28 to 30 breaths per minute with minimal secretions. The Attending Physician indicated arterial blood gases were attempted multiple times by both the physician and a respiratory therapist.

The Attending Physician indicated the Patient was aware, non-verbal and responded to burn. The Patient was using accessory muscles to breathe and the Patient's abdomen was mottled.

The Attending Physician indicated the Patient had a coccyx wound covered by a VAC and a left leg wound covered by a VAC. There was no written description of the Patient's coccyx , right buttock wound and/or left leg wounds. The Attending Physician indicated the Patient was a full code.

The Attending Physician was interviewed by telephone on 03/25/10 at 1 PM. The Attending Physician said oxygen saturation levels were not able to be obtained on the Patient despite changing the probes and access areas. The Attending Physician indicated the Patient was mottled and arterial blood gases were not able to be obtained by either the physician or a respiratory therapist. The Attending Physician said a family member was called who elected to have the Patient transferred.

There was no documentation in the Patient's medical record for the interventions by the respiratory therapist.

Continued review of the Patient's medical record lacked a written progress note documentation by Registered Nurse #3 who cared for the Patient on 03/19/10. There was no written nursing progress note at the time of transfer to the emergency department to the acute care hospital.

Review of the two page referral sent to the acute care hospital lacked a written description for the nursing measures needed to care for the Patient including the condition and treatment for the Patient'smultiple pressure sores.

Registered Nurse #3 was interviewed by telephone on 03/25/10 at 11 AM. Registered Nurse #3 said the Patient's coccyx was bleeding and excoriated. Registered Nurse #3 said the Nurse Manager requested the two wound VACS be removed from the Patient before sending the Patient out. There was no nursing documentation for the protection or covering of the Patient's multiple pressure sores/wounds.

Both the respiratory therapist and the Registered Nurse #3 failed to document the Patient's change in condition and the measures taken to stabilize the Patient prior to transfer to the acute care hospital.

Review of the Wound Care Consultant's Assessment Note dated 03/18/10 indicated the Patient's coccyx was an unstageable deep tissue injury which measured 7.5 centimeters in length by 4 centimeters in width and 2.5 centimeters in depth. The Wound Care Consultant said in interview on 03/24/10 at 2 PM and documentation indicated the a negative pressure wound VAC appliance was placed to decrease drainage and to protect the area from fecal contamination. The Patient's right buttock had an unstageable deep wound injury measuring 4.5 centimeters in length by 6 centimeters in width and zero centimeters in depth.

There was no nursing documentation by Registered Nurse #3 describing the right buttock pressure sore/deep wound injury included on the two page referral sent to the emergency department at the time of transfer.