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Based on review of the medical records for 6 of 6 sampled patients (4 open and 2 closed records) the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for patient #1 and reviewed and updated a care plan for patients #2-#6.
Findings:

Review of the closed medical record revealed patient #1 was admitted to Hospital A on 7/02/10 for IV antibiotic therapy for treatment of cellulitis and diabetic foot ulcer care. Review of the admission nursing assessment revealed patient #1 was dependent for all ADLs (activities of daily living). Further review of the medical record failed to revealed documented evidence of a nursing care plan.

Interview with S4 RN on 9/23/10 at 11:10 AM revealed the nursing staff used the Patient Staffing form as a care plan which was developed soon after admission and updated 1 time a week by all disciplines involved the patient's care. After reviewing patient #1's medical record, S4 confirmed the section on the Patient Staffing record for Nursing Services was not complete for patient #1 and that there were no interventions developed to address individual nutritional assistance needs from a nursing prospective or other ADL needs. S4 also indicated information regarding each patient's care plan was reported by the nurses to the oncoming shift. S4 stated there was no other documented plan of care.

Review of the Patient Staffing Record dated 7/08/10 (1st week) and 7/20/10 (3rd week) revealed Nursing Services, Pharmacy, Wound Care, Nutrition services, PT, OT, and Discharge Planning were disciplines involved in patient #1's care. Review of each discipline section revealed the Nursing section was incomplete. Further review revealed the 2nd week was not in the record.

Interview with S2 RN DON on 9/23/10 at 1:00 PM revealed he had identified that using the Weekly Patient Staffing form as a nursing care plan was a problem. S2 stated the nurses did not have time to complete and update the information because every patient was assessed 1 time a week during Patient Staffing meetings when all the disciplines met. S2 indicated this decision to use this form was made by the hospital's corporate office.

Review of the medical records for patients #2-#6 revealed a one page preprinted check-off form that the nurses addressed at time of admission. The form listed variables such as cognition, fluid balance, cardiopulmonary status, etc. and the nurse checked planned interventions to achieve the patients' discharge goals. There failed to be other documented evidence that anyone reviewed the form after admission. Additionally, the nursing section was incomplete or not addressed on each patients' Weekly Patient Staffing Form.

Interview with S9 RN, Quality Officer on 9/23/10 at 1:20 pm revealed the use of the Weekly Patient Staffing form as a patient care plan was implemented about 2 months ago. S9 confirmed problems had been identified with the nurses' failure to complete the nursing section of the form and she also validated that nursing interventions were not evident for patient #1 and not reviewed and updated for patients #2-#6.

Based on review of 1 of 2 closed medical records in a total sample of 6, review of Weekly Patient Staffing forms and interview, the Registered Dietitian failed to ensure patient #1's nutritional needs were met by not reporting to the attending physician that patient #1 had a 10 pound weight loss and by not recommending a nutritional supplement for the patient. Findings:

Review of the closed medical record revealed patient #1 was admitted to Cornerstone Hospital on July 2, 2010 for wound care of left foot ulcers with cellulitis and necrotic tissue. Further review revealed patient #1 was a 71 year-old that resided in a nursing home due to severe general debility.

Review of the Pre-Admission Screening record dated 6/25/10, which was completed at Entity A, revealed patient #1 was dependent for all ADLs (activities of daily living) and exhibited severe weakness in all extremities. The assessment identified that the patient had swallowing difficulties. Further review revealed the "Reason for Admission/Plan for Treatment" was 1) "aggressive wound care with debridement, 2) IV antibiotics for cellulitis, and 3) to monitor nutritional status; promote healing".

Review of the July 2010 physician orders revealed a No Concentrated Sweets, Mechanical Soft, Pureed Meat diet with Nectar Thickened liquids was ordered for the patient. The physician also ordered that the intake and output should be monitored every shift and to weight patient #1 weekly.

Review of the Nutritional Screening Assessment Form dated 7/05/10 completed by S13 RD (Registered Dietitian) revealed patient #1 had a fair appetite, dysphagia was noted, and the patient was on a mechanical soft diet with pureed meats. Review of documentation in the medical record revealed patient #1's average oral intake was 50 % and that she weighed 120#. Review of the documented lab values revealed the albumin level was 2.8. Patient #1's caloric and fluid/day needs were assessed and documented by the RD. Further review revealed the dietitian's plan was to "monitor nutritional status, continue diet as ordered, and assist in menu selection/food preferences". Review of the Classification of Malnutrition Assessment dated 7/05/10 by S13 revealed patient #1 met the nutrition parameter that was consistent for moderate degree of malnutrition and the reason for that determination according to the form was an albumin level of 2.8g/dL but less than 3g/dL.

Review of the weekly RD monitoring record revealed documentation on 7/12/10 that patient #1's oral intake of diet was 50-75 %, her weight was 110#, and the albumin level was 2.5. S13 RD noted "will follow up". Review of the 7/19/10 documentation revealed the oral diet intake was 10-50%, weight was 115# and the albumin level was 2.7.

Interview with S13 RD on 9/23/10 at 11:05 AM revealed she made her assessment of patient #1 as soon as possible after admit. S13 noted patient #1 was admitted Friday, 7/02/10 and her assessment was dated 7/05/10. S13 indicated she determined caloric and fluid needs and noted the plan for the patient was to provide nutritional monitoring. S13 stated the daily intake recorded on the graphic record and the weekly weight were reviewed for Weekly Patient Staffing that she attended. After further review of the closed medical record for patient #1, S13 confirmed the patient's admit weight was 120#, the second week her weight was 110# and the third week her weight was 115#. S13 confirmed there was a 10 pound weight loss that was not addressed, by either requesting patient #1 be weighed again or by not recommending extra calorie intake by means of a health shake or Ensure. S13 reviewed the Weekly Patient Staffing records and confirmed she failed to bring the weight loss to the attention of the attending physician.

Based on observation, review of 1 of 6 medical records and interviews, the infection control officer (S9) failed to perform surveillance of patients in contact isolation to identify potential problems and implement corrective action when patient #4, who was placed in contact isolation, was left in a ward-type room with two other patients who were not in contact isolation. The infection control officer also failed to ensure the same nurse assigned to care for patient #4 was not assigned to a patient who was ventilator dependent and had a central line (triple lumen) and was not in isolation. Findings:

In an interview on 9/212010 S18 RN stated when a patient is placed in contact isolation the staff places an appropriate sign on the entrance to the room to alert anyone entering the room that the patient was in isolation. S18 added that the sineage should also indicate what personal protective equipment should be worn before entering the room. S18 further stated when a patient is in contact isolation, gloves should be worn and if there is contact with the patient, a gown should also be worn by staff and visitors.

On 9/22/2010 at 11:00 AM observation of room 731 revealed there were three patients in the room and that the beds were designated as A, B and C. The head of the beds for patients A and B were against the same wall and bed C (sampled patient #4) was against a far wall to the left. This was a ward-type room with curtains for privacy. Further observation of the room revealed a typed note on an 8 inch x11 inch sheet of paper was taped to the wall near Bed C which read, "Contact Isolation". Patient #4 who was in Bed C, was completely visible to anyone who walked into room 731.

Review of the open medical record on 9/23/2010 at 11:20 AM revealed patient #4, who was in bed C in room 731, was a 71 year-old admitted on 9/10/2010 after a splenectomy, pleural effusion and fractured tibia from a motor vehicle accident. Further review revealed on 9/20/2010 the patient was diagnosed with shingles on her left shoulder and placed in contact isolation.

Review of the Patient Assignments Sheets for 9/21/2010 for the 6:00 AM-6:00 PM shift revealed the same nurse was assigned to 731B and to patient #4. Continued review revealed on the 6:00 AM-6:00 PM on 9/22/2010 and on 9/23/2010 the same nurse was assigned to patient #4 and the two patients in room 732. It was noted that one of the patients in room 732 was on a ventilator and had a central line.

In an interview on 9/22/2010 at 3:00 PM S9 Infection Control Officer provided data on quality indicators that she tracked through the infection control program. Review of the infection control data presented to the survey team failed to reflect periodic surveillance of patients in contact isolation to determine compliance to isolation precautions.

Based on review of 1 of 6 medical records and interviews, the Case Manager failed to follow through with the discharge plan for patient #1 after the initial plan was documented and then changed before the patient left the hospital. The Case Manager did not have accurate information in the medical record as to where patient #1 went after discharge.
Findings:

Review of the closed medical record revealed patient #1 was admitted to Cornerstone Hospital on July 2, 2010 for wound care of left foot ulcers with cellulitis and necrotic tissue. Further review revealed patient #1 was a 71 year-old that resided in a nursing home due to her severe general debility.

Review of the Psycho-Social Assessment dated 7/02/10 revealed patient #1 was admitted to Cornerstone Hospital from Entity A where she was receiving skilled nursing care since admit to that facility on 6/04/10. Further review revealed the discharge plan was for patient #1 to return to Entity A after the estimated length of stay of 3 weeks at Cornerstone Hospital.

Review of the Weekly Patient Staffing Record dated 7/08/10 revealed Nursing Services, Pharmacy, Wound Care, Nutrition Services, PT, OT, and Discharge Planning were the disciplines involved in patient #1's care. Review of the Weekly Patient Staffing dated 7/20/10 revealed Discharge Planning noted patient #1's optimal discharge date was 7/23/10 and that she would return to the nursing home (Entity A).

Interview with S11 RN on 9/23/10 at 8:35 AM revealed she was the Case Manager for Cornerstone Hospital and she reviewed the Nurse Liaison's initial assessment done prior to admission to get an overview of patient #1's information. Next, she reviewed the Psycho-Social Assessment which was done within 72 hrs of admission. S11 stated she was responsible for completing the Continued Stay Criteria document every 7 days which the physician signs. S11 reviewed the closed medical record for patient #1 and recalled that patient #1 was admitted from Entity A (nursing home). S11 stated patient #1's husband told her his wife would be returning to Entity A at discharge. S11 also indicated the husband was happy with the care at Entity A but that later he must have changed his mind because patient #1 was discharged to home.

Interview with S12 GSW on 9/23/10 at 9:00 AM revealed she was responsible for the initial assessment on patient #1 and on admit, it was determined that the patient would return to the nursing home. S12 stated she attended the Weekly Patient Staffing where all patient concerns were discussed. S12 also stated that unless there was a problem brought to her attention with the initial discharge plan, she only provided follow-up at discharge. If there was a problem, staff informed her and she would contact the family at that time.

S12 recalled patient #1 was supposed to return to Entity A nursing home at discharge and she had not heard of any concerns with the plan. On the day of patient #1's discharge, she contacted Entity A and was told the husband had "taken her out". S12 indicated Entity A had not contacted Cornerstone about any change of discharge destination. S12 stated she called the patient #1's husband to inform him the physician had discharged his wife and he told her "well, I guess we will have to call (Entity A)". S12 further recalled she called Entity A and was told they did not have a bed for patient #1. S12 stated when she talked with the husband about this he did not tell her he could not take the patient home and further indicated if he had told her he could not, then she would have found her another nursing home for the patient. When questioned, S12 stated she talked with the husband that day and he was aware that if he could not take patient #1 home, she would find a nursing home for her. S12 stated the Case Manager would also have recommended not discharging patient #1 at that time in order contact the Medicare Administration for an extension of the patient's stay and to find placement. S12 repeated the statement that the husband never told her he could not take his wife home at discharge. S12 confirmed there was no documented evidence to verify the decision for patient #1 to be discharged home rather than the nursing home. Review of nurse notes dated 7/23/10 revealed patient #1 was "discharged home with her husband per private vehicle-instructions given to husband and prescriptions for home use".