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Based on observation, interview, and record review, the facility failed to ensure nursing developed and maintained a current care plan for 6 (Patient ID ' s: 3, 6, 7, 8, 9, 11) of 11 sampled patients.

Findings include:

TX # 00164759

Observation on 09-11-12 at 10:20 a.m. during initial tour of the facility revealed Patient ID # 7 lying in bed. Interview at this same time with the patient ' s spouse, she stated Patient ID # 7 received dialysis treatments at the bedside , three (3) times per week, usually early in the morning. Patient # 7 ' s spouse went on to say the staff had not educated her or her husband about dialysis but she stated " I have not really asked questions yet. "

Further observation during initial tour of the facility on 09-11-12 revealed four (4) additional patients who received dialysis treatments at the bedside (Patient ID #s 6, 8, 9, 11) according to interview with Chief Clinical Officer (staff ID # 3).

Record review on 09-11-12 of the sampled patients ' clinical records revealed the following:

Current in-house patients:

Patient ID # 6: admitted on 08-28-12 with diagnoses of Acute Renal Failure, Nausea, Vomiting and Abdominal Pain. Initial physician order for dialysis three times weekly was dated 08-29-12. Further review of the physician orders revealed Patient # 6 also received Total Parenteral Nutrition (TPN). Review of Patient # 6 ' s care plan failed to reveal that either dialysis or TPN was addressed as a problem or concern.

Patient ID # 7: admitted on 08-28-12 with a diagnosis of End Stage Renal Disease and history of Coronary Artery Disease and Decubitus Ulcers. Initial physician order for dialysis three times weekly was dated 08-27-12. Review of Patient # 7 ' s care plan failed to reveal that dialysis was addressed as a problem or concern.

Patient ID # 8: admitted on 08-28-12 with a diagnosis of Metastatic Breast Cancer and history of Vancomycin Resistant Enterococcus (VRE) infection. Initial physician order for dialysis three times weekly was dated 09-03-12. Review of Patient # 8 ' s care plan failed to reveal that dialysis was addressed as a problem or concern.

Patient ID # 9: admitted on 09-07-12 with a diagnosis of Respiratory Failure. Initial physician order for dialysis three times weekly was dated 09-10-12. Review of Patient # 9 ' s care plan failed to reveal that dialysis was addressed as a problem or concern.

Patient ID # 11: admitted on 08-23-12 with a diagnosis of Respiratory Failure. Initial physician order for dialysis three times weekly was dated 08-24-12. Review of Patient # 11 ' s care plan failed to reveal that dialysis was addressed as a problem or concern.

Discharged patient:

Patient ID # 3: admitted on 05-11-12 with a diagnosis of Respiratory Failure; Patient # 3 was discharged from the facility on 06-22-12. Initial physician order for dialysis three times weekly was dated 05-14-12. Review of Patient # 3 ' s care plan failed to reveal that dialysis was addressed as a problem or concern.

Interview on 09-11-12 at 2:20 p.m. with Director of Quality Management (Staff ID # 4) she stated the care plans for patient ID ' s #: 3, 6, 7, 8, 9, 11 should have addressed dialysis.

Record review on 09-11-12 of facility policy titled " Care Delivery, " dated 08/2012, read: " ....Nursing Department: 1. An assessment is performed by a Registered Nurse and is recorded in the medical record within 12 hours of admission. ...the initial assessment of the patient ' s nursing care needs will include ...biophysical, psychosocial, cognitive environment, self-care needs .... A Patient Care Treatment Plan is then prepared in accordance with the patient ' s needs and identified problems .... An RN reassesses the patient every 24 hours. The assessment(s) are recorded in the medical record, using the reassessment the RN responsible for the patient, updates the patient ' s needs/problems and plan of care .... Patients are reassessed ...to evaluate his or her response to care, treatment, and services ... "

Based on interview and record review, the facility failed to ensure that 2 of 11 (Patient ID # 1, # 5) sampled patients were provided sufficient preparation to ensure a safe discharge.

Patient # 1 was discharged without a prescription or documented education regarding Warfarin, a " blood thinner " (anticoagulant) medication.

Patient # 5 was discharged without written instructions for date-specific laboratory work (coagulation studies) and follow-up with physician per specific discharge order.

Findings include:

TX # 00164759

Patient ID # 1

On 09-11-12 record review of Patient ID # 1 ' s clinical record revealed he was 76 years old and admitted to the facility on 06-08-12 with diagnoses of Acute Renal Failure, Deep Vein Thrombosis, Urinary Tract Infection and Sepsis. In addition, Patient #1 had a history of Congestive Heart failure, Hypertension, Diabetes, and Pneumonia. He was discharged home form the facility on 0Patient

Continued record review of Patient # 1s Medication Administration Record (MAR) revealed he had been administered Warfarin 2 milligrams by mouth daily with the first dose being administered on 06-18-12. The physician ' s order read to: hold (medication) if INR (International Normalized Ratio) greater than 3.0. "

Review of Patient ID# 1 ' s Discharge Instructions revealed a list of " Discharge Medications, " that included dosages, times, and rationale for medication, as well as any special instructions regarding the medication. The medication Warfarin was not listed. The discharge instructions were signed by Patient # 1 ' s daughter.

Further review of Patient # 1 ' s clinical record revealed copies of all prescription written by the physician for Patient # 1 prior to discharge. The medication Warfarin was not among the copied prescriptions in the record.

Review of the physician ' s " Discharge Summary, " dated 08-07-12 for Patient # 1, read: " During his hospital stay ...his Coumadin (Warfarin) was managed daily according to his PT/INR. At the time of discharge he was started back on his Coumadin at 5 mg ... "

Interview on 09-11-12 at 11 a.m. with Director of Quality Management (Staff ID # 4) she stated Patient # 1 ' s daughter had written a letter to the hospital with several concerns, one of which was the absence of the Warfarin prescription upon hospital discharge. Staff # 4 reported the hospital investigated the issue with Patient # 1 ' s physician and determined the Warfarin should have been prescribed at discharge; " the physician missed it. "

Interview on 09-11-12 at 1:50 p.m. with RN Nurse Manager (ID # 5) he stated there were several steps in the actual discharge process. The medication process involved the nurse reviewing the " medication reconciliation form " (based upon medications administered /ordered in the hospital (MAR) and at discharge (RX) and checking either ' yes " or " no. " The yes/no check marks on the computer based form determined the medications that would be listed on the actual discharged medications list. The discharged medication list became part of the written discharge instructions that were signed and given to the patient/family at discharge. RN (ID # 5) went on to say that copies of the written prescription by the physician were placed in the medical record.

RN # 5 reviewed the " medication reconciliation ' form for Patient # 1 dated 06-23-12 and stated the Warfarin had not been checked either " yes or no " by the nurse at time of discharge. He went on to say " it was possible the nurse intended to check with the physician and got distracted with another task. " RN # 5 acknowledged that any nurse who discharged a patient, who had been receiving Coumadin while in the hospital, should clarify with the physician if he/she wanted it prescribed upon discharge. RN # 5 further acknowledged it was a nursing responsibility to ensure all discharge medications were correctly listed and explained, and to clarify any possible medication concerns with the physician prior to the patient ' s discharge.

Patient ID # 5

On 09-11-12 record review of Patient ID # 5 ' s clinical record revealed he was 77 years old and admitted to the facility on 06-05-12 with diagnoses of Chronic Obstructive Pulmonary Disease, Pneumonia, Amiodarone-induced Pulmonary Fibrosis and history of Mitral Valve Replacement on anticoagulation.

Review of physician " Discharge Summary, " dated 06-22-12 for Patient # 5 read: " ...he was discharged home on 06-22-12. He will continue with prednisone 10mg, 2 tablets daily for 14 days, then taper to 1 tablet daily, Coumadin 5 mg daily ....Patient will need to follow-up for PT/INR draw ( coagulation studies) in 5 to 7 days and he will call dr. ( pulmonologist) for follow-up appointment as directed. "

Review of physician order dated 06-22-12, read " D/C (discharge) home. please instruct patient to get PT/INR in 5 to 7 days with PCP ( primary care provider). Pt. needs to call his pulmonologist ( Dr ) for follow-up appointment ... "

Review of written discharge instructions for Patient # 5 dated 06-22-12 revealed " pt d/c home today accompanied by wife, instructions on how to take meds and to follow up with all drs apt ... " Further review failed to reveal documentation of instructions to obtain the PT/INR laboratory studies in 5 to 7 days or specific instructions to make an appointment with the pulmonologist.


Interview on 09-11-12 at 2: 15 p.m. with Director of Quality Management (Staff ID # 4) she stated Patient # 5 ' s written discharge instructions should have included the PT/INR studies and the follow-up with the pulmonologist.

Record review on 09-11-12 of facility policy titled " Discharge Planning, " dated 08/2012, read: ...Roles in Discharge Planning: ....Nurses: Confirm that a follow-up appointment has been made ...Provide patient and family/caregiver with the discharge instruction sheet on prescribed treatment, medications, nutrition plan, activity levels, and scheduled follow-up appointments ( all written instructions and prescriptions should be in layman ' s terms) ... "