HospitalInspections.org

Based on a review of documentation and interview, the facility failed to ensure each patient had the right to receive care in a safe setting as evidenced by failing to implement orders to protect skin integrity and failing to document routine oral care.

Findings included:

Facility based policy entitled, "Pressure Injury Prevention/Basic Treatment" stated in part,
"2. Patient positioning ...
B. Establish a regular repositioning schedule for patients who are unable to manage pressure relief independently or need assistance with cueing. Individualized schedules will be determined by the interdisciplinary team, considering contraindications and need for more frequent repositioning."

Review of current inpatient medical records revealed Patient #1 from the complaint had orders to turn every 2 hours that were not documented consistently.
Patient #1 had an order to turn the patient every 2 hours in place from 09/02/20 through the date of their discharge on 09/09/20.
Turning of the patient was not consistently documented for this patient.
Turning was documented on the following dates and times:
* 09/09/20: 0727, 1003
* 09/08/20: 0000, 0708, 1111, 1355, 1715
* 09/07/20: 0100, 0300, 0800, 2100-2300
* 09/06/20: 0030, 0200, 0300, 2100, 2300
* 09/05/20: 0600
* 09/04/20: 0400
* 09/03/20: No turning documented
* 09/02/20: 1309, 1512

Review of current inpatient medical records at the time of this investigation (09/23/20) revealed 2 of 2 patients (#11 and 12) with orders to turn every 2 hours that also were not documented consistently.
Patient #11 had an order to turn the patient every 2 hours when in bed from 09/06/20 through the date of the survey on 09/23/20.
Turning of the patient was not consistently documented while the patient was in bed.
Turning was documented on the following dates and times:
* 09/23/20: 0532, 0918
* 09/22/20: 0300, 1900
* 09/21/20:1600, 2100, 220
* 09/20/20: 0000, 0100, 0300, 0700-1100, 1300-1600,1800, 1900, 2337
* 09/19/20: 0100, 0300, 0500, 1100-1300, 1500-1800, 2100
* 09/18/20: 0100, 0300-0400, 0800, 1000, 1200, 1400-1600, 1800-1900, 2200, 2300
* 09/17/20: 0300, 0500-0600, 0800, 1000, 1200-1400, 1600, 1800, 2100-2300
* 09/16/20: 0000, 0400, 0800, 1000, 1300-1400, 1600, 1800
* 09/15/20: 2000, 2200
* 09/14/20: 2300
* 09/13/20: 0100, 0300, 0500, 1900, 2100, 2300
* 09/12/20: 0100, 0300, 0500
* 09/11/20: 0000-0600, 1900, 2100, 2300,
* 09/10/20: 0100, 0300, 0400, 0600, 2100-2300
* 09/09/20: 0800, 1900, 2100
* 09/08/20: 0200, 0800, 1000, 2200
* 09/07/20: 1000, 1200, 1400, 1600, 2000, 2200
* 09/07/20: 0400

Patient #12 had an order to turn the patient every 2 hours when in bed from 09/16/20 through the date of the survey on 09/23/20.
Turning of this patient was not consistently documented while the patient was in bed.
Turning was documented on the following dates and times:
* 09/22/20: 0000-0600
* 09/21/20: 0100, 0300, 2000-2300
* 09/20/20: 0046, 0200, 0400, 0600, 1900, 2100
* 09/19/20: 1900, 2100
* 09/18/20: 0100, 0300, 0403, 2000, 2200
* 09/17/20: 0000, 0300, 1900, 2100, 2300
* 09/16/20: 2000, 2300

All three of these patients had compromised skin integrity including breakdown in the sacral/coccyx area documented; therefore, following the orders to turn these patients regularly was important to prevent further skin breakdown. By failing to document turning of these patients per orders, these patients' skin potentially could be at risk of continued or worsening breakdown.

Facility based policy entitled, "Wound Assessment and Documentation" stated in part,
"VI. Policy Adherence and Reporting
1. The hospital has identified certain circumstances that must be reported through the hospital Electronic Reporting System (RL Systems).
A. If a patient is admitted without a documented pressure injury/ulcer, but develops a pressure injury Stage 2 or greater, then an event report must be completed. The risk manager/designated file manager will initiate an investigation as needed."

Patient #1 developed an unstagable pressure injury (which would be considered > stage 2) while inpatient (08/24/20 through 09/09/20), however no event report was completed at that time per policy. In an interview on 09/23/20, staff member #1 verified the event report was not completed by nursing until 09/23/20, well after the patient's discharge.

Review of oral hygiene for Patient #1 revealed it was not documented routinely. The following dates had no oral hygiene noted: 08/29/20, 08/30/20, 09/02/20, 09/05/20, 09/06/20, and 09/07/20. In an interview on 09/23/20 at 10:30 AM, Staff member #1 verified that the standard of care at the facility would be to document oral care/hygiene on the patient daily, at minimum.

The above findings were verified on 09/23/20 with staff members #1 and 2.

Based on review of documentation and interviews, the facility failed to ensure the discharge planning process included the regular re-evaluation of the patient's condition to identify changes that require modification of the discharge plan. The discharge was not updated, as needed, to reflect these changes.

Findings included:

Facility based policy entitled, "Discharge Planning" stated in part,
"The discharge planning process begins during the preadmission screening and continues throughout the inpatient rehabilitation stay. It is re-evaluated and adjusted as the patient's condition, functional status, and clinical needs change throughout the stay ....
* Throughout the patient's stay, the case manager works with the patient/patient representative to develop a discharge plan based on the patient's clinical care requirements, goals of care and treatment preferences, and available support system ...
Discharge Planning and Process and Documentation ...
* The Case manager, in collaboration with the physician and interdisciplinary care team, helps determine the most appropriate post-discharge care setting and durable medical equipment to meet the patient's needs ...
* Physician orders are obtained and post-discharge referrals are made as indicated ..."

Review of the medical record for Patient #1 revealed the following:
* A Physical Therapy note on 09/08/20 at 1500 stated in part, "Pt was a max A for transfers from WC <> bed and to the car. Pt uses leg lifter during transfers but is still unable to lift LE's without assistance. Once pt was transferred to WC pt was unable to hold L leg in neutral position and continued to fall into adduction and internal rotation ....PT advised case manager that returning home is unsafe for pt due to level of assist. Case manager notified PT that pt will be going home and will have caregivers to assist wife in care."
* Case Management note on 09/09/20 at 0837 stated, "cm spoke w/ pt wife and completed dc plans/process. Pt to return home today via tac med stretcher with pickup at 1300 pm from EH. EHH will f/u w/ nursing/therapy/HHA services. Aerocare dme to deliver wc and bsc. Pt has not met rehab goals at pt is u/u to bear wt to LE d/t pain. Pt has televisit w/ Dr. [name] on 09/14 and f/u with Dr. [name] on 10/06/20. IMM and HH choice letter signatures obtained. Cm spoke w/ [name], assigned nurse and informed of dc time/transport via tac med."
* In an interview on 09/23/20, staff member #4 was asked how the patient was safely discharged on 09/09/20 after the Physical Therapist noted that the patient was unsafe to return home on 09/08/20. Staff member #4 replied, "We offered other arrangements such as a skilled nursing facility. She (patient representative/wife) didn't want a nursing home because of quarantine, she'd already gone so long without him home. She said she had the son and daughter in law listened in on the conversation. She said they were going to be with her for at least 2 more weeks that could help him. I told her he could go home but if it didn't work out to contact me."
* This discussion with the patient representative/wife was not reflected in the medical record, though it appeared the patient representative/wife agreed to the discharge home via facility ambulance. This information should have been documented to reflect why the facility continued with plans to discharge home despite the physical therapist's documented concerns regarding patient safety.
* There also was no physician order for discharge of the patient on 09/09/20 per policy.

The above findings were verified on 09/23/20 in interviews with staff members #1, 3, and 4.