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Based on interview and record review, the facility failed to ensure the method/frequency of data collection was specified; data was collected for each physician who was on staff; and the data was analyzed for a contracted radiological service by a second read/interpretation of radiological examinations/tests. This had the potential to result in the facility being unaware of the quality of services being provided and if misinterpretation of radiological examinations was occurring.

Findings:

On August 5, 2015, at 9 a.m., an interview was conducted with the Director Radiology and Respiratory Services (DRRS). She stated the reading/interpretation of all radiological tests and ultrasounds was done by a contracted service. The DRRS stated the reading/interpretation of the tests was all done on line and the turn around time on "stats" was one hour and on "routines" was 24 hours. In addition, the DRRS stated a second read was done on some of the exams to determine if the interpretation was correct.

On August 5, 2015, at 10:10 a.m., an interview was conducted with the Director Quality/Risk Management (DQRM). She stated the reading/interpretation of radiological tests and ultrasounds was a contracted service and "peer" review was done for each radiologist, by doing a double/second read, and the statistics were presented at Quality Council and ultimately to the Governing Board.

The Radiology "second read" data for 2014, indicated the "second read" interpretation occurred for seven Radiologists, and the number of cases reviewed for each Radiologist ranged from two to nineteen cases.

On August 6, 2015, the Radiology "Exam Count Report(s)" were reviewed and indicated the following number of radiological examinations were performed each month and interpreted by the contract Radiological Service:

- January 2015: 302;
- February 2015: 298;
- March 2015: 334;
- April 2015: 288;
- May 2015: 293; and
- June 2015: 333.

On August 6, 2015, the "Speciality Roster" indicated there were 13 Radiologists who were associated with the facility's contracted Radiology Group, and three of the 13 had started within the last year.

On August 6, 2015, at 9:30 a.m., a follow-up interview was conducted with the DQRM. She stated six "Diagnostic Radiology Observer Form(s)" were completed for each Radiologists each year which was the second read and provided the facility with the quality data on the interpretation of radiological tests and ultrasounds. The DQRM stated the data/information was presented to the Governing Board every six months. The DQRM stated for the first six months of 2015, January through June, there had only been four second reads out of 1,848 radiological and ultrasound examinations performed.

When the DQRM was asked if the method/frequency of data collection was specified in regards to the number and type of cases that were reviewed by a "second read" each year for each physician, the DQRM stated there were no specifications, and she had nothing in writing outlining the method/frequency of data collection, types of cases reviewed, and number of cases reviewed per physician. The DQRM stated she had not followed up on the "second reads" for 2015, and was unaware not all of the physicians had at least six "second reads" in 2014.

Based on interview and record review, the facility failed to ensure a mechanism was in place for the Governing Body to evaluate the quality of the Radiology Service contracted clinical service to ensure it was provided in a safe and effective manner. This failed practice resulted in the potential for missed opportunities to identify problems and improve the care provided to patients through the contracted service.

Findings:

On August 5, 2015, at 9 a.m., an interview was conducted with the Director Radiology and Respiratory Services (DRRS). She stated the reading/interpretation of all radiological tests and ultrasounds was done by a contracted service. The DRRS stated the reading/interpretation of the tests was all done on line and the turn around time on "stats" was one hour and on "routines" was 24 hours. In addition, the DRRS stated a second read was done on some of the exams to determine if the interpretation was correct.

On August 5, 2015, at 10:10 a.m., an interview was conducted with the Director Quality/Risk Management (DQRM). She stated the reading/interpretation of radiological tests and ultrasounds was a contracted service and "peer" review was done for each radiologist, by doing a double/second read, and the statistics were presented at Quality Council and ultimately to the Governing Board.

The Radiology "second read" data for 2014, indicated the "second read" interpretation occurred for seven Radiologists, and the number of cases reviewed for each Radiologist ranged from two to nineteen cases.

On August 6, 2015, the Radiology "Exam Count Report(s)" were reviewed and indicated the following number of radiological examinations were performed each month and interpreted by the contract Radiological Service:

- January 2015: 302;
- February 2015: 298;
- March 2015: 334;
- April 2015: 288;
- May 2015: 293; and
- June 2015: 333.

On August 6, 2015, the "Speciality Roster" indicated there were 13 Radiologists who were associated with the facility's contracted Radiology Group, and three of the 13 had started within the last year.

On August 6, 2015, at 9:30 a.m., a follow-up interview was conducted with the DQRM. She stated six "Diagnostic Radiology Observer Form(s)" were completed for each Radiologists each year which was the second read and provided the facility with the quality data on the interpretation of radiological tests and ultrasounds. The DQRM stated the data/information was presented to the Governing Board every six months. The DQRM stated for the first six months of 2015, January through June, there had only been four second reads out of 1,848 radiological and ultrasound examinations performed.

When the DQRM was asked if the method/frequency of data collection was specified in regards to the number and type of cases that were reviewed by a "second read" each year for each physician, the DQRM stated there were no specifications, and she had nothing in writing outlining the method/frequency of data collection, types of cases reviewed, and number of cases reviewed per physician. The DQRM stated she had not followed up on the "second reads" for 2015, and was unaware not all of the physicians had at least six "second reads" in 2014.

On August 6, 2015, the "Governing Board Report(s)" dated March 18, 2015, and June 18, 2015, were reviewed.

There was no indication in the meeting minutes the Governing Board was aware that:

- Not all of the Radiologists had been evaluated by a "second/double" read of the radiological examinations in 2014;
- The number of "second/double" reads per Radiologist was not clearly defined;
- The type of cases and variety of cases to be "second" read was not defined; and
- Only four out of 1,848 radiological and ultrasound examinations had been reviewed for 2015.

Based on observation, interview and record review, the facility failed to:

1. Ensure the sink in patient room 17 which housed 2 two patients in isolation, one of whom received dialysis, was functional;

2. Ensure Environmental Services Staff (EVS) 1 donned appropriate personal protective equipment (PPE) during trash removal in the intensive care unit (ICU);

3. Ensure all medical devices were kept off the floor in patient room 1, and in patient rooms 8 and 11 which housed isolation patients;

4. Ensure preventative maintenance was conducted on a weekly basis for six eye wash stations in the facility;

5. Ensure all hard surfaces in isolation room 10, which housed Patient 17, diagnosed with Methicillin Resistant Staph Aureus (MRSA), Vancomycin Resistant Enterococcus (VRE), Acinetobacter Baumannii (A. Baum) and Extended Spectrum Beta-lactamase (ESBL), (communicable bacterial infections) were disinfected during daily cleaning by the EVS Supervisor;

6. Ensure Registered Nurse (RN) 1, properly disinfected the glucometer prior to and after checking the blood sugar on Patient 8, who was diagnosed with Clostridium Difficile (C-Diff), (a highly contagious bacteria) and,

7. Ensure four RNs working in the ICU removed and changed their gloves after having direct patient contact prior to using the computer keyboard in patient rooms.

These failures could potentially spread communicable diseases throughout the facility, which may impact the health and welfare of all the patients, visitors and staff.


Findings:

1. On August 4, 2015, at 11:30 a.m., an observation of room 17 was conducted. Signage which indicated contact isolation precautions indicating PPE (personal protective equipment - gown, mask, gloves) was posted outside the door.

Inside the room, the patient in bed 17-A was receiving dialysis treatment. The patient in bed 17-B was asleep with the curtains drawn. Prior to exiting the room the surveyor went to the sink for the purpose of completing hand hygiene. The sink did not have running water.

An interview was conducted on August 4, 2015, at 11:45 a.m., with the dialysis nurse, who was actively conducting the dialysis treatment for the patient in bed 17 A. The dialysis nurse attempted to use the sink also, but it did not work.

The dialysis nurse stated we could have used the sink in the bathroom, but since the dialysis tubing was in the sink that was not possible. The dialysis nurses stated the patient received dialysis for 3-4 hours 3 times a week which required use of the sink.

A review of the "Infection Control Bedboard" dated August 4, 2015, was conducted. The bedboard indicated that both patients in beds 17 A and B, had MRSA (Methicillin Resistant Staph Aureus) and A. Baum (Acinetobacter Baumannii). The patient in bed 17 B also had VRE (Vancomycin Resistant Enterococcus).

An interview was conducted with RN 2 on August 4, 2015, at 12:15 p.m. RN 2 stated the sink in room 17 hadn't been working for "a while."

An interview was conducted with the Manager of Plant Operations on August 4, 2015, at 2:30 p.m., who stated he had not received notification or a work order indicating the sink in room 17 did not work.

A review of the facility's competency demonstration record for isolation precautions (undated) reflected when leaving an isolation room staff "washes hands."

2. An observation of the Intensive Care Unit (ICU) was conducted on August 4, 2015, at 9:35 a.m. Signs were posted outside rooms 23, 22, 21, and 20 indicating the patients were in contact isolation.

Environmental Services Staff (EVS) 1 was observed emptying the trash for room 23. EVS 1 was wearing gloves, and had a protective mask around her neck.

EVS 1 exited room 23, entered room 22, and removed the trash. EVS 1 repeated the process for rooms 21, and 20 without removing or changing gloves. Upon entering room 20, EVS 1 donned a protective gown and placed the protective mask over her nose and mouth.

The document titled "Infection Control Bedboard" dated August 4, 2015, was reviewed. The document indicated the patients admitted to rooms 23, 22, 21, and 20, were on contact isolation precautions secondary to being diagnosed with multiple organisms to include MRSA, A.Baum, and VRE, present in both sputum and urine.

During an interview with EVS 1, on August 4, 2015, at 9:45 a.m., EVS 1 stated she did not change gloves while performing trash removal for rooms 23, 22, and 21, because the trash was located close to the doorway of the rooms. EVS 1 stated she donned a gown prior to the trash removal in room 20, because the trash was located away from the doorway of the room. EVS 1 stated she should have changed gloves prior to entering room 20.

An interview was conducted with the EVS Supervisor, on August 5, 2015, at 10:30 a.m. The EVS Supervisor stated gowns, gloves, and masks are worn during trash removal in rooms where patients were in isolation.

During an interview with the Infection Disease Specialist (IDS), on August 5, 2015, at 12:55 p.m., the IDS stated it was expected that all staff donned appropriate PPE when having contact with the patient or environment in rooms where patients were in isolation.

The facility's guide titled "Infection Prevention" undated, indicated "The prevention and appropriate management of infection is of the utmost importance in our facility. It is important that all staff take appropriate measures whenever possible...Categories of Precautions: Contact...Use gloves when you enter the room. Use a mask if your mouth, eyes or nose are likely to come in contact with body fluids. Use a gown if you will have direct contact with the patient or substantial contact with the patient's environment..."

3. During a tour of the facility conducted on August 4, 2015, at 9 a.m., an observation of room 1 was conducted with Licensed Vocational Nurse (LVN) 1. Observed on the floor included a packet of opened mouth moisturizer, three plastic caps used for medical equipment, and a gauze square. Located on a chair next to Patient 20 in bed 1 B was an intravenous container containing 250 cubic centimeters (cc) of .9 Sodium Chloride dated August 3, 2015, and an opened empty container labeled 1000 cc of .9 sodium chloride.

An interview was conducted with LVN 1, who stated none of those items should be on the floor or on the chair.

An observation of room 8 was conducted on August 4, 2015, at 10 a.m., with RN 3. Signage indicating room 8 was an isolation room was posted next to the door. Located on the floor near the left side of Patient 18's bed was a Yankauer suction tip (used to remove sputum) and a nasal cannula (used to supply oxygen).

A review of the document, "Infection Control Bedboard," dated August 4, 2015, indicated both patients in room 8 were in isolation for MRSA.

A concurrent interview was conducted with RN 3 who stated the nasal cannula and the suction tip should not be lying on the floor.

An observation of room 10 was conducted on August 4, 2015, at 10:30 a.m., with the EVS Supervisor. Signage indicating room 10 was an isolation room was posted next to the door.

A review of the document, "Infection Control Bedboard," dated August 4, 2015, indicated the patient in room 10 was under isolation for Methicillin Resistant Staph Aureus (MRSA), Vancomycin Resistant Enterococcus (VRE), Acinetobacter Baumannii (A. Baum) and Extended Spectrum Beta-lactamase (ESBL), (communicable bacterial infections) .

The EVS Supervisor, while mopping room 10 picked up 3 feet of disconnected wound vac tubing lying on the floor (wound vac-a suction device used to remove fluid from a wound in order to enhance healing). Also observed was wound vac tubing which was connected to the patient and draped onto the floor.

An interview was conducted with the Wound Care Coordinator on August 4, 2015, at 10:45 a.m., who stated both tubings were from the patient's wound vac and they should not be lying on the floor.

4. A tour of the facility was conducted on August 4, 2015, at 11 a.m. An emergency eye wash station was observed in the nurses station in the medical/surgical unit.

A review of the "Emergency Eye Wash Station Weekly PM (preventive maintenance)2015" was conducted. The document indicated the engineering staff will perform weekly tests on the eyewash stations by opening the water valve and running the water for approximately 180 seconds (to remove stagnant water which may contain bacterial debris). The document failed to indicate the weekly PM was conducted the first three weeks of July, 2015.

An interview was conducted with the Manager of Plant Operations on August 4, 2015, at 3:30 p.m., who stated he did not know why the weekly cleaning/maintenance of the eye wash stations in the facility was not done the first three weeks of July.

5. An observation of the EVS Supervisor disinfecting room 10 was conducted on August 4, 2015, at 10:15 a.m. Signage indicating Patient 17 was under isolation precautions was posted at the entrance to the room.

A review of the document, "Infection Control Bedboard," dated August 4, 2015, indicated the patient in room 10 was under isolation for MRSA, VRE, A. Baum, and ESBL.

The EVS Supervisor was observed pouring disinfectant onto clean towels and then proceeded to wipe the hard surfaces in the room. When the EVS Supervisor finished wiping a surface she placed each dirty towel on top of the lid of the trash container that was for used personal protective equipment, such as gowns, gloves and masks. When the EVS Supervisor was done cleaning the room, she placed all the dirty towels from the lid of the trash container into a bag and exited the room.

The EVS Supervisor was not observed disinfecting the top of the trash container where she had placed multiple dirty towels prior to exiting room 10.

6. The facility's policy and procedure titled "Cleaning of Shared Patient Medical Equipment" dated May 2015, indicated" All equipment will be disinfected with a bleach disinfectant after use on a patient with clostridium difficile (C-Diff.)... Rationale: to assure that shared patient medical equipment has been cleaned and disinfected prior to use on other patients so that transmission of infections is minimized...Blood Glucose Monitor (frequency of disinfection) after patient use..."

An observation of Registered Nurse (RN) 1 checking Patient 8's blood sugar using a blood glucose monitor, was conducted on August 6, 2015, at 11:18 a.m. After donning personal protective equipment (PPE), RN 1 removed the monitor from the holder located at the nurse's station. RN 1 placed the monitor in a plastic bag and then entered Patient 8's room.

Two signs posted outside of Patient 8's room indicated the patient was on isolation precautions for the organisms C-Diff. and MRSA.

RN 1 completed the procedure, removed her PPE, and exited the room. RN 1 removed the blood glucose monitor from the plastic bag and placed the blood glucose monitor in the holder located at the nurses station.

RN 1 did not clean and/or disinfect the blood glucose monitor prior to or after patient use.

During an interview with RN 1, on August 6, 2015, at 11:25 a.m., RN 1 stated the blood glucose monitor was used to check the blood sugar for multiple patients in the ICU. RN 1 stated the facility's practice was to clean the monitor prior to and following checking the patient's blood sugar. RN 1 further stated if a patient had the organism C-Diff., the practice was to first clean the blood glucose monitor, then use bleach as a disinfectant following the procedure.

RN 1 stated "I should have cleaned the monitor."

7. Observations of the Intensive Care Unit (ICU) were conducted on survey days August 4, 5, and 6, 2015. Seven of the seven patient rooms had signs posted outside the rooms to indicate the patients were in isolation for various infectious organisms to include C-Diff., MRSA, and VRE.

On August 4, 2015, at 8:45 a.m., Registered Nurse (RN) 7 was observed in room 23 wearing gloves, and repositioning the patient's intravenous tubing located on the patient's gown.

After performing patient care, RN 7 began using the computer located in the patient's room. RN 7 did not remove and or change gloves prior to touching the computer keyboard.

During a concurrent interview, RN 7 stated gloves should be removed and or changed prior to using the computer keyboard.

On August 4, 2015, at 9:05 a.m., RN 8 was observed administering both intravenous and feeding tube medications for the patient in room 22.

After performing care, RN 8 began using the computer located in the patient's room. RN 8 did not remove and or change gloves prior to touching the computer keyboard.

During a concurrent interview, RN 8 stated gloves should be removed and or changed prior to using the computer keyboard.

On August 4, 2015, at 9:15 a.m., RN 9 was observed repositioning the patient in room 20.

After performing patient care, RN 9 began using the computer located in the patient's room. RN 9 did not remove and or change gloves prior to touching the computer keyboard.

During a concurrent interview, RN 9 stated gloves should be removed and or changed prior to using the computer keyboard.

On August 6, 2015, at 9 a.m., RN 1 was observed administering medication through a feeding tube for the patient in room 18.

After performing patient care, RN 1 began using the computer located in the patient's room. RN 1 did not remove and or change gloves prior to touching the computer keyboard.

The facility's guide titled "Infection Prevention" undated, indicated "The prevention and appropriate management of infection is of the utmost importance in our facility. It is important that all staff take appropriate measures to reduce the risk of possible whenever possible...Gloves: When changing tasks particularly going from a dirty task to a clean task at the patients bedside, you should remove your gloves, perform hand hygiene and reapply clean gloves. Some examples are...you have completed patient care and are preparing to document on the computer at the bedside..."

Based on interview and record review, the facility failed to ensure discharge planning was initiated at the time of admission per facility policy and procedure for five of six sampled patients (Patients 1, 2, 4, 5, and 6). This had the potential to result in a delay in meeting the discharge needs of the patients.

Findings:

a. On August 4, 2015, the record for Patient 1 was reviewed. Patient 1 was admitted to the facility on July 2, 2015, with diagnoses including pneumonia and kidney failure requiring dialysis.

The initial nursing assessment dated July 2, 2015, did not include the "Discharge planning" which included the following questions:

- "Patient is alert, is oriented, is confused, is unconscious, lives alone, lives with spouse. lives with others."
- "Assistance needed at home:"
- "Community services utilized:"
- "Patient is concerned about the care of someone while in hospital:" and
- "Patient anticipates financial difficulties during or after hospitalization."

b. On August 4, 2015, the record for Patient 2 was reviewed. Patient 2 was admitted to the facility on May 22, 2015, with diagnoses including acute respiratory failure and acute alcohol withdrawal.

The initial nursing assessment dated May 22, 2015, did not include the "Discharge planning" which included the following questions:

- "Patient is alert, is oriented, is confused, is unconscious, lives alone, lives with spouse, lives with others."
- "Assistance needed at home:"
- "Community services utilized:"
- "Patient is concerned about the care of someone while in hospital:" and
- "Patient anticipates financial difficulties during or after hospitalization."

c. On August 4, 2015, the record for Patient 4 was reviewed. Patient 4 was admitted to the facility on May 13, 2015, with diagnoses including osteomyelitis of the sacral area (infection of the bone), malnutrition and kidney failure requiring dialysis.

The initial nursing assessment dated May 13, 2015, did not include the "Discharge planning" which included the following questions:

- "Patient is alert, is oriented, is confused, is unconscious, lives alone, lives with spouse, lives with others."
- "Assistance needed at home:"
- "Community services utilized:"
- "Patient is concerned about the care of someone while in hospital:" and
- "Patient anticipates financial difficulties during or after hospitalization."

d. On August 4, 2015, the record for Patient 5 was reviewed. Patient 5 was admitted to the facility on June 29, 2015, with diagnoses including acute respiratory failure, diabetes, and a urinary tract infection.

The initial nursing assessment dated June 29, 2015, did not include the "Discharge planning" which included the following questions:

- "Patient is alert, is oriented, is confused, is unconscious, lives alone, lives with spouse, lives with others."
- "Assistance needed at home:"
- "Community services utilized:"
- "Patient is concerned about the care of someone while in hospital:" and
- "Patient anticipates financial difficulties during or after hospitalization."

e. On August 4, 2015, the record for Patient 6 was reviewed. Patient 6 was admitted to the facility on April 29, 2015, with diagnoses including hidradenitis suppurativa (chronic skin disease characterized by clusters of abscesses) and acute kidney injury.

The initial nursing assessment dated April 29, 2015, did not include the "Discharge planning" which included the following questions:

- "Patient is alert, is oriented, is confused, is unconscious, lives alone, lives with spouse, lives with others."
- "Assistance needed at home:"
- "Community services utilized:"
- "Patient is concerned about the care of someone while in hospital:" and
- "Patient anticipates financial difficulties during or after hospitalization."

During an interview with the Chief Clinical Officer (CCO), on August 4, 2015, at 9:55 a.m., she reviewed the records for Patients 1, 2, 4, 5, and 6, and was unable to find documentation of the discharge planning process, by the Registered Nurse (RN), beginning at the time of admission. The CCO stated the RN should have started the discharge planning process at the time of admission, and should have followed and completed the pathway in the facility's computer documentation system.

The facility policy and procedure tilted "Assessment/Re-Assessment - Interdisciplinary Patient" dated May 2015, revealed "... The RN admission of the Patient will include: ... Discharge Planning. ... Discharge planning begins upon the patient's admission to the hospital. ..."

Based on interview and record review, the facility failed:

1. To ensure there was a clear indication of changes from the patent's pre-admission medications to the patient's discharge medications and literature/information was provided for new medications prescribed at the time for discharge from the facility for two sampled patients (Patients 2 and 6). This had the potential to result in the patient/patient's responsible party not being aware of the possible side effects of new medications prescribed.

2. To ensure there was documentation of what information/instructions the patient/patient's responsible party received at the time of discharge from the facility for two sampled patients (Patients 2 and 6). This resulted in not being able to determine what instructions the patient/patient's responsible party received and also resulted in an incomplete medical record.

3. To ensure a discharge summary/discharge instructions were provided to the patient/patient's responsible party when the patient was discharged to a Skilled Nursing Facility (SNF) for three sampled patients (Patients 3, 4, and 5). This had the potential to result in the patient/patient's family being unaware of the discharge plan to include medications, treatments and follow-up appointments.

4. To ensure there was documentation that post discharge providers were given the necessary medical information prior to the patient's first post-discharge appointment or within seven days of discharge, whichever comes first, for one sampled patient (Patient 6). This had the potential to result in the providers being unaware of the patient's medical information.

Findings:

1a. On August 4, 2015, the record for Patient 2 was reviewed. Patient 2 was admitted to the facility on May 22, 2015, with diagnoses including acute respiratory failure and acute alcohol withdrawal.

The "Discharge Report" dated June 10, 2015, indicated Patient 2 was discharged from the facility with ten medications which were listed in alphabetical order. The second medication listed was Amiodarone HCL (antiarrhythmic medication used to treat ventricular tachycardia) 200 milligrams once a day, and was a new medication being prescribed to Patient 2 with a start date of June 10, 2015.

There was no clear indication of the changes from the patient's pre-admission medications to the patient's discharge medications.

Patient 2 signed the "Discharge Report" on June 10, 2015.

There was no indication in the record Patient 2 was given literature/information for the new medication prescribed.

Patient 2 was discharged to home from the facility on June 10, 2015.

b. On August 4, 2015, the record for Patient 6 was reviewed. Patient 6 was admitted to the facility on April 29, 2015, with diagnoses including hidradenitis suppurativa (chronic skin disease characterized by clusters of abscesses) and acute kidney injury.

The "Discharge Report" dated June 3, 2015, indicated Patient 6 was discharged from the facility with five medications which were listed in alphabetical order. The first medication listed was Chlorhexidine gluconate 2% topical solution every 24 hours with a first dose date of May 1, 2015, and the last medication listed was Hydrocodone (medication for pain) 5 milligrams (mg)/acetaminophen 325 mg three times a day as needed with a prescription provided at discharge.

There was no clear indication of the changes from the patient's pre-admission medications to the patient's discharge medications.

Patient 6 signed the "Discharge Report" on June 3, 2015.

There was no indication in the record Patient 6 was given literature/information for the new medications prescribed.

Patient 6 was discharged to home from the facility on June 3,2015.

During an interview with the Chief Clinical Officer (CCO), on August 4, 2015, at 4 p.m., she reviewed the records for Patients 2 and 6, and was unable to find documentation of medication instructions being given to the patients. The CCO stated the list of the patient's discharge medications was in alphabetical order and there was no clear delineation of pre-admission medications versus new medications prescribed since admission.

The CCO further stated the staff can print medication instructions/information through the facility's computer system but there was no indication in the patients' records that this had been done. The CCO stated the patients should have been given information on at least the new medications prescribed since admission.

The facility policy and procedure titled "Discharge Planning" dated May 2015, revealed "... Provide patient and family/caregiver with the discharge instruction sheet on prescribed treatment, medications (including food/drug interactions), the nutrition plan, activity level, and scheduled follow-up appointments. (All written instructions and prescriptions should be in layman's terms). ..."

2a. On August 4, 2015, the record for Patient 2 was reviewed. Patient 2 was admitted to the facility on May 22, 2015, with diagnoses including acute respiratory failure and acute alcohol withdrawal.

The "Discharge Report" dated June 10, 2015, indicated Patient 2 was discharged from the facility with education "on a low fat, low cholesterol diet, safety in the home environment."

The was no indication what the education "on a low fat, low cholesterol diet, safety in the home environment" included.

There was no indication information/discharge instruction sheets were provided to the patient "on a low fat, low cholesterol diet, safety in the home environment."

Patient 2 signed the "Discharge Report" on June 10, 2015, and was discharged from the facility to home.

b. On August 4, 2015, the record for Patient 6 was reviewed. Patient 6 was admitted to the facility on April 29, 2015, with diagnoses including hidradenitis suppurativa (chronic skin disease characterized by clusters of abscesses) and acute kidney injury.

The "Discharge Report" dated June 3, 2015, indicated Patient 6 was discharged from the facility with "discharge instructions on chlorhexidine washes and personal care."

There was no indication what the "instructions on chlorhexidine washes and personal care" included.

There was no indication information/discharge instruction sheets were provided to the patient on "chlorhexidine washes and personal care."

Patient 6 signed the "Discharge Report" on June 3, 2015, and was discharged from the facility to home.

During an interview with the Chief Clinical Officer (CCO), on August 5, 2015, at 3:30 p.m., she reviewed the records for Patients 2 and 6, and was unable to find documentation of discharge instruction sheets being provided to the patients as appropriate based on their current medical conditions. The CCO stated the facility's computer system had the capability of providing information sheets based on medical conditions/treatments and these should be provided to the patient as well as a copy maintained in the record for documentation of what was given to the patient at the time of discharge as part of the patient's discharge instructions.

The facility policy and procedure titled "Discharge Planning" dated May 2015, revealed "... Provide patient and family/caregiver with the discharge instruction sheet on prescribed treatment, medications (including food/drug interactions), the nutrition plan, activity level, and scheduled follow-up appointments. (All written instructions and prescriptions should be in layman's terms). ..."

3a. On August 4, 2015, the record for Patient 3 was reviewed. Patient 3 was admitted to the facility on June 3, 2015, with diagnoses including acute respiratory failure, urinary tract infection, and anemia.

Patient 3 was discharged from the facility on June 25, 2015, to an acute rehabilitation facility.

There was no indication in the record the patient/patient's responsible party was provided with a discharge summary/discharge instructions to include discharge medications.

b. On August 4, 2015, the record for Patient 4 was reviewed. Patient 4 was admitted to the facility on May 13, 2015, with diagnoses including osteomyelitis of the sacral area (infection of the bone), malnutrition and kidney failure requiring dialysis.

Patient 4 was discharged from the facility on July 7, 2015, to a Skilled Nursing Facility (SNF).

There was no indication in the record the patient/patient's responsible party was provided with a discharge summary/discharge instructions to include discharge medications.

c. On August 4, 2015, the record for Patient 5 was reviewed. Patient 5 was admitted to the facility on June 29, 2015, with diagnoses including acute respiratory failure, diabetes, and a urinary tract infection.

Patient 5 was discharged from the facility on July 17, 2015, to a SNF.

There was no indication in the record the patient/patient's responsible party was provided with a discharge summary/discharge instructions to include discharge medications,

During an interview with the Chief Clinical Officer (CCO), on August 5, 2015, at 3:30 p.m., she reviewed the records for Patients 3, 4, and 5, and was unable to find documentation of the patient/patient's responsible party being provided with a discharge summary/discharge instructions, to include discharge medications, at the time of discharge from the facility to a SNF. The CCO stated it was not the facility's practice to provide the patient/patient's responsible party with a discharge summary/discharge instructions to include discharge medications.

The facility policy and procedure titled "Discharge Planning" dated May 2015, revealed "... Provide patient and family/caregiver with the discharge instruction sheet on prescribed treatment, medications (including food/drug interactions), the nutrition plan, activity level, and scheduled follow-up appointments. ..."

The facility policy and procedure titled "Transfer to Non-Acute Facilities" dated December 2013, did not indicate the patient/patient's responsible party was to receive a discharge summary/discharge instructions to include discharge medications.

4. On August 4, 2015, the record for Patient 6 was reviewed. Patient 6 was admitted to the facility on April 29, 2015, with diagnoses including hidradenitis suppurativa (chronic skin disease characterized by clusters of abscesses) and acute kidney injury.

The "Discharge Report" dated June 3, 2015, indicated Patient 6 was to follow-up with a surgeon on June 11, 2015, and an internal medicine physician on June 24, 2015.

There was no indication in the record the providers were given the necessary medical information, to include a list of current medications, for Patient 6, in order to provide continued care.

During an interview with Director Case Management (DCM), on August 5, 2015, at 3 p.m., she reviewed the record and was unable to find documentation of the post discharge providers being given the necessary medical information prior to the patient's first post-discharge appointment or within seven days of discharge.

The DCM further stated there was no facility policy and procedure for providing post discharge providers with the patient's medical information. The DCM stated generally when the post discharge provider was called to schedule an appointment for the patient, the provider was asked at that time what medical information was wanted and the information was faxed to the provider, and sometimes this was documented in the record.

Based on interview and record review, the facility failed to ensure a process was in place, to include documentation in the record, of providing the results of tests, pending at the time of discharge, to the patient and/or post hospital providers of care. This had the potential to result in the patient/provider being unaware of test results which were obtained after the patient had been discharged from the facility.

Findings:

On August 5, 2015, at 2:15 p.m., an interview was conducted with the Chief Clinical Officer (CCO). The CCO was asked the question "What is the facility process of notifying the patient, physician, and/or Skilled Nursing Facility (SNF) of test results which were not available at the time of discharge from the facility?" The CCO stated she did not know what the facility's process was but she would check.

During a subsequent interview with the CCO, on August 6, 2015, at 11:45 a.m., she stated the process of notifying the SNF of positive culture results involved the Laboratory notifying the "station (nurses station/charge nurse)" or the Infection Control Manager (ICBM), and then that individual would contact the SNF and facsimile the results to the SNF.

The CCO stated there was no documentation in the patient's record of the SNF being notified of positive culture results obtained after the patient had been discharged from the facility. The CCO stated if negative culture results were obtained after the patient had been discharged from the facility, the SNF was not notified. The CCO stated there was no process in place to notify a SNF of other test results obtained after the patient had been discharged from the facility. In addition, the CCO stated there was no process in place to notify a patient/patient's responsible party or a physician who was caring for the patient post discharge of test results (positive or negative) obtained after the patient had been discharged from the facility.

The CCO further stated if a patient was discharged home, and was being seen by an outside provider for post discharge care, and if there were test results obtained after the patient had been discharged from the facility, neither the patient/patient's responsible party nor the post discharge provider would be notified of those test results.

The facility was unable to provide a policy and procedure which outlined the process of notifying the patient/patient's responsible party, post discharge provider, home health care provider, and/or the SNF of test results obtained after the patient had been discharged from the facility.

Based on interview and record review, the facility failed to ensure the discharge planning process was reviewed by the assessment/evaluation of readmissions to the facility and by considering feedback from post-acute providers in the community in regards to the effectiveness of the facility's discharge planning process. This had the potential to result in the facility being unaware of the effectiveness of their discharge planning process.

Findings:

On August 4, 2015, at 3:30 p.m., an interview was conducted with the Director Case Management (DCM). When the DCM was asked if the discharge planning process was reviewed by the assessment/evaluation of readmissions to the facility, she stated the facility had "very few readmits" and the facility did not track readmissions.

In addition, when the DCM was asked if the facility obtained feedback from post-acute providers in the community in regards to the effectiveness of the facility's discharge planning process, she stated the facility did not contact Skilled Nursing Facilities (SNFs) for feedback on the effectiveness of the facility's discharge planning process.

On August 5, 2015, at 11 a.m., an interview was conducted with the Director Quality/Risk Management (DQRM). When the DQRM was asked if the facility tracked readmissions, she stated the facility had tracked readmission in the past but had not done so for several years. The DQRM stated the facility did not track/monitor readmissions to the facility.