HospitalInspections.org

Based on record review and interview, the hospital failed to ensure that nursing services were furnished to patients based on their needs, in 11 of 12 patients (Patient #'s 1, 2, 3, 4, 7, 10, 11, 12, 13, 14, 15 and 16). This has the potential to affect the total hospital census of 28 patients.

Findings include:

1) Nursing staff failed provide a comprehensive assessment of patient's condition every shift, and failed to assess and document patient's wound conditions upon admission and throughout their hospital stay. (A0392)

2) The nursing staff failed to ensure that patients with potential for or actual impairment of skin integrity were provided with care that met their needs, and failed to provide accurate documentation of patient's oral and intravenous intake and urine output. (A0395)

3) Nursing staff failed to develop skin integrity care plans that met patient's needs, and failed to update care plans when patient needs changed. (A0396)

4) Nursing services failed to ensure that all nursing staff were properly oriented to their duties. (A0397)

The cumulative effect of these nursing deficiencies created a high potential for harm to the hospital's patient population.

Based on record review and interview, the governing body failed to ensure that contracted services were performed in a safe and effective manner, in 4 of 12 contracted services (dialysis, linen, agency staff and Wisconsin Caregiver Background Checks). This has the potential to affect the total hospital census of 28 patients.

Findings include:

During interview on 6/13/17 at 11 a.m. with Director of Quality B, B stated there is "no documentation" of the PI (Performance Improvement) committee's review of contracted services for dialysis, linen or contracted agency staff.

The 6/13/17 at 12 p.m. review of the hospital's "QAPI (Quality Assessment Performance Improvement) Plan, reviewed/revised 1/2015" revealed under "III.1. Data routinely collected and analyzed include: ... i. Quality indicators for services provided under contractual arrangement (Physical therapy, Laboratory, Radiology, Dialysis, Wound Care). This policy does not address linen services, agency staffing, or mandated state requirements for Wisconsin hospitals.

1) Record review of the dialysis contract ("In-Hospital Dialysis and Aphersis Services Agreement, effective 9/25/13") on 6/13/17 at 12 p.m. revealed under "section 1.07" that the dialysis contractor agreed to maintain an ongoing quality management program. Services subject to monitoring by the hospital were the following safety and quality issues: direct observation of dialysis staff for proper infection control techniques, water and dialysate culture samples, equipment maintenance logs, documentation audits of dialysis care, performance improvement information on the efficacy of services, patient satisfaction surveys, input from hospital staff and patients about dialysis services and the dialysis service's quarterly QAPI (Quality Assessment Performance Improvement) reports/ indicators.

2) Record review on 6/13/17 at 12 p.m. of the "Service Agreement" contract for staff clothing and patient linen services, "effective 2/19/16" revealed no documentation of how the contracted service or the hospital would ensure appropriate use of off-site chemical cleaning/ disinfecting agents, appropriate linen handling and storage or appropriate linen transport.

3) During interview with Chief Nursing Officer A on 6/13/17 at 4 p.m., A stated "We do not do any formal evaluation of (contracted) agency staff that work here, other than to ask our nurses "How did they do". "We do not document anything".

During interview on 6/13/17 at 4 p.m. with Chief Executive Officer D, D could not provide any documented evidence that the governing body or the PI committee was ensuring that the hospital reviewed the care and services provided by the above contracted services.

4) During interview on 6/14/17 at 12 p.m. with Director of Human Resources K, K stated that we use an outside contractor to conduct our hospital's Wisconsin caregiver background checks. K told of being "unaware" that the DHS (Wisconsin Department of Health Services) letter was part of a complete Wisconsin Caregiver background check process used in all Wisconsin hospitals. K stated that contact with the contracted agency would be made to determine if the agency was reviewing the DHS letter as part of the caregiver review process for the hospital. As of exit on 6/20/17 at 10:30 a.m., no information/documentation was provided.

Based on record review and interview, the hospital failed to ensure that grievances were thoroughly investigated to ensure appropriate resolution, in 3 of 5 grievances reviewed (Patient #'s 17, 18 and 19). This has the potential to affect the total census of 28 patients.

Findings include:

Record reviews of the hospital's complaint/grievance files and policy were conducted on 6/12/17 from 3:20 p.m. through 4 p.m.

1) Record review of the 1/17/17 grievance filed by Patient #17's parent revealed concerns with missing bed equipment and "disrespectful" physical therapy staff. Documentation of the facility's "File ID: 40368" revealed the facility met with the parent, observed a video taken of the incident and made an apology to the parent. There was no documented evidence of any investigative details done by the facility to determine resolution of this complaint. There was no dates /times of interviews/meetings. There was no documented details of what the video showed. There were no documented evidence of any investigation to determine what happened to the missing bed equipment. There were no documented evidence of any investigation to determine who the "disrespectful" staff was nor any documentation of an investigation to rule our patient abuse.

2) Record review of the 3/23/17 grievance by Patient #18's spouse revealed concerns about medication administration, rude staff behavior and patient hygiene provided by the nursing staff. There was no documented evidence of any investigative details done by the hospital to determine resolution of this complaint.

3) Record review of the 4/19/17 grievance by Patient #19's spouse revealed concerns about missing glasses after transfer to another room. There was no documented evidence of any investigative details done by the facility to determine resolution of this complaint.

Interview with Director of Quality B on 6/12/17 at 4 p.m. revealed "I didn't document details of what was done for these grievance investigations".

The record review of hospital policy "Grievance Resolution, reviewed/revised 10/28/2014" revealed no information regarding what investigative information must be documented in order for the grievance committee to determine if investigation and actions taken thereafter were handled appropriately.

Based on record review and interview, the hospital failed to ensure that patients or patient representatives filing a grievance received a written response to that grievance with the required resolution information, in 4 of 5 grievances reviewed (Patient #'s 17, 18, 19 and 20). This has the potential to affect the total census of 28 patients.

Findings include:

Records review of the hospital's complaint/grievance files and policy were conducted on 6/12/17 from 3:20 p.m. through 4 p.m.

The record review of hospital policy "Grievance Resolution, reviewed/revised 10/28/2014" revealed no information that if a complaint requires an investigation and/or requires further actions for resolution that the complaint becomes a grievance. Under 30.3.8, it states "The grievance committee performs the following functions: ...3) Provides in writing to the patient who files the grievance: a. Name of the hospital contact person, b. The steps taken on behalf of the patient to investigate the grievance, c. The results of the grievance process, and d. The date of completion of the grievance process."

1) Record review of the 1/17/17 grievance filed by Patient #17's parent revealed a letter sent to complainant by the facility dated 1/17/16 (date should have been 1/17/17 as verified by Director of Quality B on 6/16/17 at 10 a.m.). Review of this letter revealed that it did not include date of completion.

2) Record review of the 3/23/17 grievance by Patient #18's spouse revealed concerns about medication administration, rude staff behavior and patient hygiene provided by the nursing staff. There was no documented evidence that the complainant received a written decision notice containing name of hospital contact person, investigative steps taken, grievance results or date of grievance completion.

3) Record review of the 4/19/17 grievance by Patient #19's spouse revealed concerns about missing glasses after transfer to another room. There was no documented evidence that the complainant received a written decision notice containing name of hospital contact person, investigative steps taken, grievance results or date of grievance completion.

4) Record review of the 4/19/17 grievance by Patient # 20's health care plan's quality improvement department director revealed that Patient #20 had complaints about not having linens changed, room temperatures, lack of access to hospital clothing the patient's size, not being seen by a therapist, social worker or case management about substance abuse and suicide ideation, not receiving a cast/brace, medication concerns and late meal arrival. Review of the 5/10/17 letter sent to the health plan director revealed that it did not include date of completion for this grievance.

Interview with Director of Quality B on 6/16/17 at 10 a.m. revealed "I didn't believe that a letter was needed". B verified that completion dates for the investigation were missing.

Based on record review and interview, the hospital failed to implement immediate actions to ensure appropriate documentation of care and services to it's patients and failed to have a system to measure improvement activities, in 1 of 3 Quality Assessment Performance Improvement areas reviewed (Nursing Services). This has the potential to affect the total census of 28 patients.

Findings include:

During interview with CNO (Chief Nursing Officer) A on 6/7/17 at 4 p.m., A stated that the hospital had recognized problems with nursing documentation of assessments, patient care and care planning "approximately 3 weeks ago". A stated that a meeting was held for an action plan.

Record review of "Nursing Meeting Action plan meeting minutes, May 22, 2017" revealed the agenda topics of poor nursing communication, incomplete patient admission assessments and problems with patient information binders. After the record review of the meeting agenda minutes, A was asked to provide nursing documentation audit data, and to provide information on how the hospital was implementing and monitoring actions to ensure corrections were sustained. As of exit on 6/20/17, there was no written information provided.

Based on record review and interview, the governing body failed to ensure that the hospital's Quality Assessment Performance Improvement program maintained documented evidence of it's review of services provided by contract, in 4 of 12 contracted services (dialysis, linen, agency staff and Wisconsin Caregiver Background Checks). This has the potential to affect the total hospital census of 28 patients.

Findings include:

During interview on 6/13/17 at 11 a.m. with Director of Quality B, B stated there is "no documentation" of the PI (Performance Improvement) committee's review of contracted services for dialysis, linen or agency staff.

The 6/13/17 at 12 noon review of the hospital's "QAPI (Quality Assessment Performance Improvement) Plan, reviewed/revised 1/2015" revealed under "III.1. Data routinely collected and analyzed include: ... i. Quality indicators for services provided under contractual arrangement (Physical therapy, Laboratory, Radiology, Dialysis, Wound Care). This policy does not address linen services, agency staffing, or mandated state requirements for Wisconsin hospitals.

1) Record review of the dialysis contract ("In-Hospital Dialysis and Aphersis Services Agreement, effective 9/25/13") on 6/13/17 at 12 noon revealed under "section 1.07" that the dialysis contractor agreed to maintain an ongoing quality management program. Services subject to monitoring by the hospital were the following safety and quality issues: direct observation of dialysis staff for proper infection control techniques, water and dialysate culture samples, equipment maintenance logs, documentation audits of dialysis care, performance improvement information on the efficacy of services, patient satisfaction surveys, input from hospital staff and patients about dialysis services and the dialysis service's quarterly QAPI (Quality Assessment Performance Improvement) reports/ indicators.

2) Record review on 6/13/17 at 12 noon of the "Service Agreement" contract for staff clothing and patient linen services, "effective 2/19/16" revealed no documentation of how the contracted service or the hospital would ensure appropriate use of off-site chemical cleaning/ disinfecting agents, appropriate linen handling and storage or appropriate linen transport.

3) During interview with Chief Nursing Officer A on 6/13/17 at 4 p.m., A stated "We do not do any formal evaluation of agency staff that work here, other than to ask our nurses "How did they do" and stated "We do not document anything in PI unless there is a problem".

During interview on 6/13/17 at 4 p.m. with Chief Executive Officer D, D could not provide any documented evidence that the PI committee was ensuring that the hospital reviewed the care and services provided by the above contracted services.

4) During interview on 6/14/17 at 12 noon with Director of Human Resources K, K stated that "we use an outside contractor" to conduct our hospital's Wisconsin caregiver background checks. K told of being "unaware" that the DHS (Wisconsin Department of Health Services) letter was part of a complete Wisconsin Caregiver background check" process. K stated "we do not report" any information to the PI committee.

Based on record reviews and interviews, the hospital failed to ensure that registered nurses provided a comprehensive nursing assessments to meet their patient's needs, in 5 of 12 patients reviewed (1, 2, 7, 10 and 11). This has the potential to affect the total census of 28 patients.

Findings include:

Per record review conducted on 6/15/17 at 3 p.m., Wisconsin Chapter N6 -Standards of Practice for Registered Nurses and Licensed Practical Nurses (LPN) states under N6.03(3)- "Supervision and Direction of Delegated Nursing Acts that the RN (Registered Nurse) "shall" (a) delegate tasks commensurate with educational preparation and demonstrated abilities of the person supervised (b) provide direction and assistance to those supervised, and (c) observe and monitor the activities of those supervised, and (d) evaluate the effectiveness of acts performed under supervision." A Board of Nursing Position statement published in the Wisconsin Regulatory Digest Vol. 8, No.1, Page 3-4 in May of 1995 states the following: "While nursing acts may be delegated, the function of assessment and evaluation may not. The LPN and less skilled assistant may assist the RN in these functions, but may not perform them in their entirety."

Record review conducted on 6/15/17 at 3 p.m. of hospital policy "Assessment-Reassessment Nursing, effective September 2013" revealed "1. A nursing assessment is completed on all patients admitted to the hospital. The nursing process, assessment planning intervention evaluation is used to help determine the patient's needs and plan of care. The admission process must be supervised by a registered nurse who will identify patient care needs and initiate the plan of care...". Reassessment, 1. Reassessments will be performed by the RN or the LPN within their scope of practice when assuming responsibility for patients care. Reassessments will occur at least every shift and more frequently as the patient's condition/circumstances warrant...". Documentation, a. All assessments/reassessments will be documented and the medical record...".

1) Patient #1- Record reviews were conducted on 6/7/17 from 2:30 p.m. through 4 p.m., and 6/8/17 at 9:30 a.m. through 10:30 a.m.
Review of the "nursing daily flow sheets" revealed that that Patient #1 nursing care failed to be supervised and evaluated by a registered nurse on the following dates:
On 4/8/17, the "7 a.m. through 7 p.m. assessment" was documented by LPN (Licensed Practical Nurse) S. There is no documented evidence that a RN verified the data collection and comprehensively assessed this patient in the following areas: neurosensory, pulmonary, nutritional, cardiovascular, skin, gastrointestinal, intravenous site and genitourinary.
On 4/9/17, the "7 a.m. through 7 p.m. assessment" data was blank for the following areas: neurosensory, pulmonary, nutritional, cardiovascular, skin, gastrointestinal, intravenous site and genitourinary). There was no evidence of data collection by a LPN or assessment by an RN during this 12 hour period.
On 4/16/17, the "7 p.m. through 7 a.m. assessment" was documented by LPN (Licensed Practical Nurse) T. There is no documented evidence that a RN verified the data collection and comprehensively assessed this patient in the following areas: neurosensory, pulmonary, nutritional, cardiovascular, skin, gastrointestinal, intravenous site and genitourinary.
On 4/26/17, the "7 p.m. through 7 a.m. assessment" data was blank for the following areas: neurosensory, pulmonary, nutritional, cardiovascular, skin, gastrointestinal, intravenous site and genitourinary). There was no evidence of data collection by a LPN or assessment by an RN during this 12 hour period.

2) Patient #2- Record review was conducted on 6/7/17 at 1 p.m.
a) Patient #2, a paraplegic, was admitted on 6/2/17 for debridement of infected right hip/buttock pressure ulcers. The 6/2/17 at 5:45 p.m. initial nursing assessment failed to document the condition of ulcers/wounds on admission. There was no documented evidence of an initial nursing assessment of ulcer/wound size, location, appearance, drainage/discharge or presence of an ulcer/wound covering.

b) Patient # 2 was admitted on 6/2/17 for debridement of infected right hip/buttock pressure ulcers. Observations of wound care in the patient's room on 6/7/17 at 9:30 a.m. revealed an approximate 2 inch long and ¼ inch wide, dark-colored open wound on the patient's left anterior calf. When questioned about this wound, Nurse Practitioner P stated "we didn't notice it when patient came in". Patient #2 stated "it's been there several days". There was no documented evidence that the nursing staff or the wound care team assessed this open wound area before 6/7/17 at 9:30 a.m. observation.

3) Patient #7- Record review was conducted on 6/12/17 at 1 p.m.
Review of the "nursing daily flow sheets" revealed that Patient #7's nursing care failed to be supervised and evaluated by a registered nurse on the following dates:
On 5/7/17, the "7 a.m. through 7 p.m. assessment" was documented by LPN (Licensed Practical Nurse) S. There is no documented evidence that a RN verified the data collection and comprehensively assessed this patient in the following areas: neurosensory, pulmonary, nutritional, cardiovascular, skin, gastrointestinal, intravenous site and genitourinary.
On 5/8/17, the "7 a.m. through 7 p.m. assessment" data revealed no LPN data collection or RN assessment of the following areas: neurosensory, pulmonary, cardiovascular or skin.
On 5/9/17, the "7 a.m. through 7 p.m. assessment" was documented by LPN (Licensed Practical Nurse) U. There is no documented evidence that a RN verified the data collection and comprehensively assessed this patient in the following areas: neurosensory, pulmonary, nutritional, cardiovascular, skin, gastrointestinal, intravenous site and genitourinary.

During interview on 6/15/17 at 4 p.m. with Chief Nursing Officer A, Director of Quality B and Chief Executive Officer D, the above information was shared. When shown this information, A stated "it's not there".


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4) Review of Patient 10's medical record on 6/20/17 beginning at 8:05 AM reveals Patient 10 was admitted for Respiratory Failure on 3/27/17 and expired in the hospital on 3/31/17 at 4:30 PM. Per "Admission Order Set" signed by physician on 3/28/17, Patient 10 was to receive 8 to 15 liters of oxygen, and staff was to titrate to maintain oxygen saturation "greater than or equal to 90%". Per admission orders, staff should check oxygen saturation "every shift".

Review of daily vital sign assessment sheets (Graphic Record) on 3/27/17, 3/28/17, 3/29/17, and 3/30/17 shows no evidence of nursing staff assessing patient 10's oxygen saturation. Graphic record on 3/30/17 showed no evidence of staff assessing day shift vital signs including blood pressure, heart rate, temperature, respiratory rate, and oxygen saturation.

Per interview with "A" at the time of review, "A" revealed staff should be documenting vital signs every shift, Per "A" nursing shifts are 12 hour days and 12 hour nights. "A" agreed nursing staff should be assessing and documenting oxygen saturation.

Review of Patient 10's "Rapid Response Team Record" form dated 3/31/17 at 4:00 PM, shows no evidence of nursing staff assessing and monitoring Patient 10's vital signs during the "Rapid Response". "Vital signs on arrival" section is blank, no repeat vital signs are documented on the record. Rapid response record shows sections for "Heart sounds, Pain, Capillary refill, Pupillary Reaction" were blank.

5) Review of Patient 11's medical record on 6/20/17 beginning at 9:15 AM reveals Patient 11 was admitted for sepsis on 3/23/17 and expired due to aspiration and cardiopulmonary arrest on 4/6/17 at 2:30 am. Review of Patient 11's daily vital sign assessment sheets (Graphic Record) dated 4/3/17, 4/4/17, 4/5/17, shows no evidence of nursing staff assessing and monitoring Oxygen Saturation with vital signs.

Per interview with "A" at the time of review, "A" revealed staff should be documenting vital signs every shift, Per "A" nursing shifts are 12 hour days and 12 hour nights. "A" agreed nursing staff should be assessing and documenting oxygen saturation.

Based on observations, record reviews and interviews, the hospital failed to ensure that a registered nurse supervised and evaluated the provision of nursing services given to patient's based on their needs, in 5 of 12 patients reviewed (1, 2, 4, 7 and 11). This has the potential to affect the total census of 28 patients.

Findings include:

Record review conducted on 6/15/17 at 3 p.m. of hospital policy "Assessment-Reassessment Nursing, effective September 2013" revealed "1. A nursing assessment is completed on all patients admitted to the hospital. The nursing process, assessment planning intervention evaluation is used to help determine the patient's needs and plan of care. The admission process must be supervised by a registered nurse who will identify patient care needs and initiate the plan of care...". Reassessment, 1. Reassessments will be performed by the RN or the LPN within their scope of practice when assuming responsibility for patients care. Reassessments will occur at least every shift and more frequently as the patient's condition/circumstances warrant...". Documentation, a. All assessments/reassessments will be documented and the medical record...".

Record review conducted on 6/15/17 at 3 p.m. of hospital policy "Intake and Output, effective September 2013, revealed " it is imperative to keep an accurate intake and output record on those patients requiring it the following patients will be placed one intake and output: patients receiving ID fluids, patients with nasogastric tubes, patients receiving tube feedings, patients with Foley catheters."

1) Patient #1- Record reviews were conducted on 6/7/17 from 2:30 p.m. through 4 p.m., and 6/8/17 at 9:30 a.m. through 10:30 a.m.
a) The "initial nursing assessment dated 4/7/17 at 5:20 p.m." revealed the patient is at "risk for skin breakdown" with Braden scale score of 11 (less than 16, skin precautions implemented/ wound care team notified). Under "wound description", the "buttocks" were described as" pink, red, inflamed". The "wound care orders" dated 4/7/17 at 4:55 p.m., revealed use of specialty mattress, turn (reposition) every 2 hours, offload (protect) heels with pillows, incontinence care with barrier cream. The wound care consultation notes dictated by Nurse Practitioner P on 4/16/17 revealed the skin is "warm, dry and intact". The 4/18/17 wound care "progress note" dictated on 4/20/17 at 9:34 a.m. revealed that Patient #1 was "found to have what appears to be a circumscribed unstageable pressure ulcer to the right flank of unknown origin (hospital acquired pressure ulcer)". The wound bed was filled with black-colored dead tissue (eschar) and measured approximately 2.6 cm. by 2.2 cm with serosanguinous (blood and blood serum) drainage. This wound required debridement (surgical removal of dead tissue) for the benefit of wound healing on 4/20/17.

Review of the "Interdisciplinary plan of care" revealed a care plan for "high risk for impaired skin integrity, initiated on 4/9/17, with interventions of "assess skin every shift with attention to reddened areas over bony prominences, reposition every 1-2 hours ...". When the patient was found to have impaired skin integrity on 4/18/17, the care plan was not revised or updated to reflect this change.

Review of the "nursing daily flow sheets" revealed staff failed to turn /reposition Patient #1 on the following dates and time frames:
On 4/8/17 from 1 a.m. through 6 a.m.,
4/9/17 from 1 a.m. through 5 a.m.,
4/12/17 from 7 p.m. through 7 a.m.,
4/13/17 from 2 p.m. through 6 a.m.,
4/14/17 from 9 a.m. through 7 p.m.,
4/15/17 from 5 p.m. through 12 midnight,
4/16/17 from 4 p.m. through 7 p.m. and from 9 p.m. through 6 a.m., and on
4/26/17, this patient was only repositioned once in a 24 hour period.

b) Patient #1, a comatose ventilator-dependent acute hemorrhagic cerebrovascular accident (Stroke) patient, was admitted on 4/7/16. Review of the "History and Physical" dictated at 4/7/17 at 5:13 p.m. by Physician R revealed a plan to "continue IV (intravenous) fluids at 50 ml. an hours...resume tube feeding...monitor input and output daily."

Review of the "graphic" records for Patient #1 revealed the nursing staff failed to record the total amount of IV fluids administered on:
Day shift (7 a.m. through 7 p.m.) for the following dates: April 7, 11, 14, 23, 24, and 25 of 2017. It could not be determined that Patient #1 was receiving medically-ordered IV fluids at the rate prescribed.

Review of the dietitian's "initial nursing assessment, dated 4/8/17 at 10:01 a.m.", revealed Patient #1 is dependent on tube feedings. The 4/8/17 nutrition assessment revealed tube feeding solution at 43 cc per hour with 100 ml. water flushes every 6 hours (4 times per day) to maintain nutritional status, and documented the weight as 166.76 pounds. The dietitian's monitoring included "intake and output, labs and (body) weight".

Per review of the nursing service's "graphic record", the nursing staff failed to record the amount of tube feeding given on the following 12 hours shifts:
Day shift (7 a.m. through 7 p.m.) for the following dates: April 7, 11, 14 and 23 of 2017; and
Night shift (7 p.m. through 7 a.m.) for the following dates: April 8, 10, 11, 12, 13, 16, 17 and 22 of 2017. It could not be determined that Patient #1 was receiving medically-ordered tube feeding in the amount prescribed.

Per review of the nursing service's "graphic record", the nursing staff failed to document urine output per Foley catheter on the following 12 hours shifts:
Day shift (7 a.m. through 7 p.m.) for the following dates: April 4, 14 and 17; and
Night shift (7 p.m. through 7 a.m.) for the following dates: April 13 and 22. It could not be determined if fluid balance was maintained on these days.

The nursing staff failed to obtain and document daily weights as per dietitian's order on April 7, 8, 12, 13, 14, 15, and 22 of 2017.

Review of the 4/24/17 at 3:40 p.m." follow-up dietary assessment" revealed that Patient #1's weight was 142.34 pounds (24.42 pound decrease over 17 days).

2) Patient #2- The record review was conducted on 6/7/17 at 1 p.m.
Review of the dietitian's "initial nursing assessment dated 6/3/17 at 3:34 p.m.", revealed a monitoring plan for meals consumption due to "altered nutrition related to ... glycemic control", and "not eating well at home before hospitalization". The 6/3/17 "altered nutrition care plan revealed a goal of "will consume greater than 75% of prescribed diet".
Review of the nursing service's "graphic record" revealed the following:
On 6/4/17, there was no meal consumption recorded for breakfast, lunch or dinner;
On 6/7/17, there was no dinner meal consumption recorded.

On 6/3/17 and 6/5/17, there was no urine output recorded for the 12 hour day shift from the patient's urinary catheter.

On 6/4/17, there was no vital signs (blood pressure, pulse, respiratory rate, temperature) recorded for the 12 hour day shift. On 6/7/17, there were no vital signs, oral intake or urinary catheter output recorded for the 12 hour night shift.

3) Patient #4- record review was conducted on 6/12/17 at 10:30 a.m.
Observation on 6/8/17 at 11 a.m. of the nursing activity board on the 3rd floor adjacent to the nurses station revealed that Patient #4 is a "feeder".

Review of the dietitian's "initial nursing assessment dated 5/24/17 at 5 p.m." revealed intervention of "feed patient" with a goal of "greater than 75% meal intake" and a "monitoring" plan including "...weights, intake and output...".

Per review of the nursing service's "graphic record", the nursing staff failed to record meal consumption on the following 12 hours day shifts:
On 6/3/17, there was no meal consumption recorded for lunch or dinner;
On 6/4/17, there was no dinner meal consumption recorded. It could not be determined whether Patient #4 was meeting the dietitian's consumption goals.

Per review of the nursing service's "graphic record", the nursing staff failed to record the amount of urine from Patient #4's suprapubic Foley catheter on the following 12 hour nursing shifts:
Day shift (7 a.m. through 7 p.m.) for the following dates: June 1, 2, 3, 5 and 7 of 2017; and
Night shift (7 p.m. through 7 a.m.) on June 7, 2017.

4) Patient #7- The record review was conducted on 6/12/17 at 1 p.m.
a) Record review of the 4/18/17 care plan for "impaired skin integrity related to pressure ulcer" revealed interventions of "Reposition every 1-2 hours and PRN (as needed)".

Review of the "nursing daily flow sheets" revealed staff failed to turn/reposition Patient #7 on the following dates and time frames:
5/10/17 from 2 p.m. through 7 p.m.,
5/11/17 from 2 p.m. through 7 p.m., and
5/12/17 from 3 a.m. through 6 a.m.

b) Review of the "4/19/17 initial dietary assessment at 1:30 p.m." and the "follow-up nutritional assessments" conducted on 4/26/17 at 11 a.m. and 5/4/17 at 2:45 p.m., revealed that Patient #7 was medically-ordered to have tube feeding at 50 cc/hours to meet calorie needs.

Review of the "graphic" record which documented intake and output revealed that the actual amount of tube feeding delivered to this patient was not recorded on:
Day shift (7 a.m. through 7 p.m.) for May 9, 10, and 11 of 2017

Per review of the nursing service's "graphic record", the nursing staff failed to record the amount of urine obtained from Patient #7's Foley catheter on the following 12 hour nursing shifts:
Day shift (7 a.m. through 7 p.m.) and Night shift (7 p.m. through 7 a.m.) of May 12th, 2017.

During interview on 6/15/17 at 4 p.m. with Chief Nursing Officer A, Director of Quality B and Chief Executive Officer D, the above information was shared. When shown this information, A stated "it's not there".



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5) Review of Patient 11's medical record on 6/20/17 beginning at 9:15 AM revealed Patient 11 was admitted for sepsis on 3/23/17 and expired due to aspiration and cardiopulmonary arrest on 4/6/17 at 2:30 am.

a) Review of the "Medication Administration Record" shows Water Flush 100 milliters should be given via feeding tube every 6 hours, medication record showed no evidence of nursing staff giving water flush on 4/1/17 at 12:00 AM, 4/2/17 at 6:00 AM and 12:00 PM, and 4/3/17 at 6:00 PM. Per interview with Chief Nursing Officer "A" and Director of Quality "B" at the time of review, "A" and "B" confirmed staff should initial by the time when medication is given; no initials are noted during these times.

b) Review of Patient 11's "Nursing Daily Flowsheet" dated 4/5/17 showed no evidence of staff performing a nursing assessment during night shift.

"Nursing Daily Flowsheets" on 4/3/17, 4/4/17, and 4/5/17 showed no evidence of nursing staff checking gastric residuals via feeding tube during first and/or second shift. Per Patient 11's "Admission Order Set" dated 3/23/17, gastric residuals should be checked for every 6 hours.

Based on observation, record review and interview, the hospital failed to ensure that patient care plans were developed or revised based on the patient's needs, in 3 of 12 patients reviewed (1, 2 and 4). This has the potential to affect the total census of 28 patients.

Findings include:

1) Record review of Patient #2 on 6/7/17 at 1 p.m. revealed admission on 6/2/17 for debridement of infected right hip/buttock pressure ulcers. The 6/4/17 care plan for "impaired skin integrity related to pressure ulcers(s)" revealed no documented evidence of nursing goals for wound healing.

2) The record review on 6/12/17 at 10:30 a.m. revealed that Patient #4's "initial nursing assessment" dated 5/16/17 at 5:17 p.m. documented a Braden scale score of "13" indicating this patient was at risk for skin integrity breakdown due to being bedfast and completely immobile.

Review of the wound care "tissue analytics" on 6/12/17 at 10:30 a.m., revealed the 5/17/17 development of 2 pressure ulcers areas and 1 surgical wound.

Review of the care plan on 6/12/17 at 10:30 a.m., revealed no documented evidence of a current care plan to reflect actual impairment of skin integrity, and had no goals nor interventions to improve/promote wound healing.

3) Patient #4's record review was conducted on 6/12/17 at 10:30 a.m.
Observation on 6/8/17 at 11 a.m. of the nursing activity board on the 3rd floor adjacent to the nurses station revealed Patient #4 was a "feeder".

Review of the dietitian's "initial nursing assessment" dated 5/24/17 at 5 p.m. revealed interventions of "feed patient", a goal of "greater than 75% meal intake and a "monitoring" plan including "...weights, intake and output...".

Review of the care plan for "Altered Nutrition" revealed a care plan stating "assist with meals". This care plan was not updated to reflect the patient's current status.

4) Patient #1- Record reviews were conducted on 6/7/17 from 2:30 p.m. through 4 p.m., and 6/8/17 at 9:30 a.m. through 10:30 a.m.

Review of the "Interdisciplinary plan of care" revealed a care plan for "high risk for impaired skin integrity, initiated on 4/9/17, with interventions of "assess skin every shift with attention to reddened areas over bony prominences, reposition every 1-2 hours ...". When the patient was found to have impaired skin integrity on 4/18/17, the care plan was not revised or updated to reflect this change.

During interview on 6/15/17 at 4 p.m. with Chief Nursing Officer A, Director of Quality B and Chief Executive Officer D, the above information was shared. When shown this information, A stated "it's not there".

Based on record review and interview, the hospital failed to ensure that all direct care staff had written evidence of orientation to their nursing duties, in 1 of 9 employee files reviewed (Registered Nurse E). This has the potential to affect the total hospital census of 28 patients.

Findings include:

All interviews and record reviews were conducted on 6/14/17 at 11:30 a.m.

The record review of the employee file for Registered Nurse E (agency nurse), revealed no documented evidence of E's hospital orientation folder.

During interview with Chief Nursing Officer A, A verified that the information was not in the employee folder, and verified that it was missing. A verified that this RN is currently working in the hospital as a staff RN.

As of exit interview, on 6/20/17 at 10:30 a.m., no information was brought forward for review.

Based on record review and interview, staff failed to ensure all entries into the medical record are complete, timed, dated and authenticated, in 7 of 12 records reviewed (10, 11, 12, 13, 14, 15 and 16). This could potentially impact all 28 patients receiving treatment at this facility.

Findings Include:

Review of policy titled, "Medical Record Documentation" effective date 9/2013 states the following:
-All entries into the medical record must be legible, signed, dated, and timed.
-Records of assessment and intervention, including graphic charts and medication records and appropriate interdisciplinary notes

1) Review of Patient 12's medical record on 6/16/17 beginning at 9:10 AM reveals the following medical record issues:
-"History and Physical Examination" form dated 5/13/17 shows time is not documented,
-"Home Discharge Instructions" form dated 5/24/17 shows time is not documented, and is not signed by patient and staff,
-"Case Management Home Discharge Instruction" form dated 5/24/17 at 11:05 AM is blank, and is not signed by patient/representative.
-"Interdisciplinary Treatment Team Meeting" "Discharge Barriers" forms dated 5/17/17 and 5/24/17 shows issues related to Patient 12's care are not checked off as being addressed (Intravenous antibiotics, Anticipated stop dates, Patient non-compliant, Durable Medical Equipment, Rehabilitation, Patient/family aware of discharge plan, Respiratory). Times are not documented on forms.
-Case Management weekly treatment plan update dated 5/17/17 shows "Current Treatment Plan of Care" section is blank, "The Discharge Plan is as Follows" section is blank, and "Discharge Back Up Plan/Pending Referrals" is blank.

2) Review of Patient 13's medical record on 6/16/17 beginning at 12:55 PM reveals the following medical record issues:
-"Freedom of Choice Form" dated 4/6/17 is blank,
-Case Management weekly treatment plan update forms dated 4/19/17 and 4/26/17 shows "Current Treatment Plan of Care" section is blank, "The Discharge Plan is as Follows" section is blank, and "Discharge Back Up Plan/Pending Referrals" is blank. One form with no time and date; One form with no time, date, and staff did not sign.
-"Interdisciplinary Treatment Team Meeting" "Discharge Barriers" forms dated 4/5/17, 4/12/17, 4/19/17, 4/26/17, 5/3/17, 5/10/17 show times are not documented.

3) Review of Patient 14's medical record on 6/16/17 beginning at 1:55 PM reveals the following medical record issues:
-"Patient Transfer Form" dated 6/1/17 shows sections for vital signs, allergies, mental status, safety alerts, isolation, and restraints are blank. Sensory, Dental condition/care, Personal items/Assistive devices sections are blank. Transport section shows Sending Facility contact and Receiving Facility Contact section is blank. Time of transfer section is blank.
-"Case Management Initial Discharge Planning Assessment" form shows Advance Directives/Living Will section is blank.
-"Freedom of Choice Form" signed on 4/26/17 at 3:33 PM is blank,
-Case Management weekly treatment plan update forms dated 5/2/17, 5/10/17, 5/17/17, and 5/31/17 shows times are not documented.
-"Interdisciplinary Treatment Team Meeting" "Discharge Barriers" forms dated 5/3/17, 5/10/17, 5/17/17, and 5/24/17 shows times are not documented.

4) Review of Patient 15's medical record on 6/16/17 beginning at 3:30 PM reveals the following medical record issues:
-"Home Discharge Instructions" form dated 6/7/17 is blank, time is not documented, and form is not signed by patient/patient representative and staff.
-"Family Conference Summary" form dated 6/5/17 shows time is not documented.
-"Interdisciplinary Treatment Team Meeting" "Discharge Barriers" forms dated 5/23/17, 5/30/17, and 6/6/17 shows issues related to Patient 15's care are not checked off as being addressed (intravenous antibiotics, anticipated stop dates, Durable Medical Equipment, Rehabilitation, Respiratory, Dietary). Times are not documented on forms.
-Case Management weekly treatment plan update dated 5/23/17 shows "Current Treatment Plan of Care" section is blank, "The Discharge Plan is as Follows" section is blank, and "Discharge Back Up Plan/Pending Referrals" is blank.

5) Review of Patient 16's medical record on 6/16/17 beginning at 3:55 PM reveals the following medical record issues:
-"Memorandum of Transfer" dated 5/12/17 shows "Attachments" section which includes check off for x-rays, lab reports, History and Physical, MD progress notes, nurses progress notes, and medication record is blank.

Per interview with Chief Nursing Officer "A" at the time of review, "A" revealed this section should be filled out as documentation of what medical records were sent to receiving hospital.

-"Patient Transfer Form" shows vital signs, allergies, mental status, safety alerts, isolation, and restraints sections are blank. Sensory, Dental condition/care, Personal items/Assistive devices sections are blank. Transport section is blank, Sending Facility Contact, and Receiving Facility Contact section is blank. Time of transfer section is blank.

6) Review of Patient 10's medical record on 6/20/17 beginning at 8:05 AM reveals the following medical record issues:
-"Rapid Response Team Record" dated 3/31/17 shows "Vital signs on arrival" section is blank, no Repeat vital signs are documented on the record, and the arrival time is blank. Heart sounds, Pain, Capillary refill, Pupillary Reaction sections are blank.
-"Code Blue Flowsheet" dated 3/31/17 shows staff arrival times to code blue are blank.
-"Admission Order Set" dated 3/28/17 shows Vital sign orders are blank, Activity orders are blank, Input and Output orders are blank. Per interview with Chief Nursing Officer "A" at the time of review, "A" confirmed Admission orders should address vitals sign frequency, activity, and input and output.
-Daily vital sign assessment sheets (Graphic Record) on 3/27/17, 3/28/17, 3/29/17, and 3/30/17 shows O2 saturation is not documented with vital signs, Intake and Outputs are not documented every shift, and meal consumption is not documented every shift. Graphic record on 3/30/17 showed day shift vital signs, intake and output, and meal consumption were not documented.

Per interview with "A" at the time of review, "A" revealed staff should be documenting vital signs, intake and output, and meal consumption on the Graphic Record every shift. Patient 10 was admitted to hospital for Respiratory failure, "A" agreed nursing staff should be assessing and documenting O2 saturation.

7) Review of Patient 11's medical record on 6/20/17 beginning at 9:15 AM reveals the following medical record issues:
-Daily vital sign assessment sheets (Graphic Record) on 4/3/17, 4/4/17, 4/5/17, shows O2 saturation is not documented with vital signs and Intake and Outputs are not documented every shift.
-"Admission Order Set" dated 3/23/17 shows Admitting Diagnosis is blank, Activity orders are blank, Input and Output orders are blank.
-"Medication Administration Record" shows order for "Water flush 100 ml. by feeding tube every 6 hours" is not signed off as given on 4/1/17 at 12:00 AM, 4/2/17 at 6:00 AM and 12:00 PM, 4/3/17 at 6:00 PM.

Per interview with Chief Nursing Officer "A" and Director of Quality "B" at the time of review, "A" and "B" confirmed staff should initial by the time when medication is given.

-"Nursing Daily Flowsheet" dated 4/5/17 shows "7P-7A Assessment" sheet is blank, "7A-7P Assessment" shows no time, date, and signature, "Pain Assessment and Intervention" section is blank, first and second shift "Enteral Feedings" section documenting tube feeding residuals is blank. "Nursing Daily Flowsheet" dated 4/4/17 shows "Hygiene" section is blank, first shift "Enteral Feedings" section documenting tube feeding residuals is blank. "Nursing Daily Flowsheet" dated 4/3/17 shows first and second shift "Enteral Feedings" section documenting tube feeding residuals is blank. First shift nursing flowsheet shows no time and date documented.
-"Code Blue Flowsheet" dated 4/6/17 shows line for Physician Signature, Date/Time is blank.

Based on observations, record reviews and interviews, the hospital failed to ensure that dietary staff were competent in their duties, in 2 of 5 dietary department areas (Equipment storage and Food preparation). This has the potential to affect the total census of 28 patients.

Findings include:

1) Record review on 6/20/17 at 1 p.m. on the ServeSafe, 6th edition, cleaning and sanitization guidelines, under section 12-11 states "once utensils, tableware, and equipment have been cleaned and sanitized, they must be stored in a way that will protect them from contamination."

During observation on 6/20/17 at 1 p.m. of kitchen Food preparation/serving and storage areas. Clean uncovered cookware and cook utensils were stored on the bottom shelf of racks that were in kitchen staff's corridors. This cookware was not protected from dust and debris from clothing or floors.

2) During observations of the kitchen (food preparation) on 06/13/17 at 2 p.m., it was observed that 1 of 3 dietary staff (N) did not have effective hair restraint. Dietary Manager N had loose hair that was not contained inside hairnet. N's beard was not covered.

During an interview with Lab Manager M (infection control officer) at 1:30 p.m. on 6//20/17, M verified that hair should be covered, and that cookware should be maintained as clean equipment.

Based on interview and record review, the hospital failed to demonstrate that infection control officers were qualified by training or experience to develop and maintain a hospital-wide program for infection control, in 1 of 2 infection control interviews conducted (Chief Nursing Officer A). This has the potential to affect the total census of 28 patients.

Findings include:

During interview with Chief Nursing Officer A on 6/14/17 at 12:30 p.m., A stated that while working as a Director of Nursing (DON) at a Sub-Acute facility and another skilled nursing facility, A had some experience working with their infection control designees. A stated that A did not have any formal education, training or certification, and had no documented evidence of infection control experience from previous employment. A stated that the infection control officer duties were shared with Laboratory Manager M.

Record review of Laboratory Manager M's employee files on 6/14/17 at 12:30 p.m. revealed only CEU's (education credits) for a pathology course for emerging pathogens. There was no evidence of any formal education nor prior experience in the management of a hospital-wide infection control program.

During interview on 6/14/17 at 12:30 p.m., A stated there was no other evidence of education, training or certification for M.

Based on observations, record reviews and interviews, the hospital failed to ensure it had a system for controlling infections and communicable diseases, in 4 of 18 areas (hand hygiene, aseptic medication administration, care of venous catheter care, patient isolation practices) reviewed. This has the potential to affect the total census of 28 patients.

Findings include:

Review of policy titled, "Hand Hygiene" effective date 7/2013 states, hand hygiene is to be performed at a minimum before applying gloves and after removing gloves, before performing clean/aseptic procedure, after touching patient surroundings.

Review of policy titled, "Standard Precautions" last revised 9/2014 states, "Remove gloves promptly after use and wash or disinfect hands immediately before touching non-contaminated items and environmental surfaces...", "Change gloves and wash or disinfect hands between tasks and procedures on the same patient after contact with materials that may contain blood or other body fluids.

1) On 6/16/17 at 9:40 AM observed Registered Nurse "F" drawing up an intravenous medication for Patient 9. "F" removed the cap from the vial, and proceeded to insert needle and draw up medication into the syringe. "F" did not clean the rubber septum of the medication vial prior to inserting needle.

Per interview with Chief Nursing Officer "A" on 6/16/17 beginning at 4:00 PM, "A" revealed staff should be cleaning the rubber septum of medication vial with alcohol wipe before inserting needle. "A" confirmed there is no facility policy and procedure that includes this cleaning process.

2) On 6/16/17 at 10:00 AM observed Registered Nurse "F" performing Patient 6's peripherally inserted central catheter (PICC) dressing change. "F" placed PICC line supplies onto tray table without cleaning and disinfecting tray table first. "F" then donned 2 pairs of gloves, removed Patient 6's old dressing, then removed 2nd pair of gloves, and proceeded to don sterile gloves over 1st pair of gloves. "F" did not first remove potentially contaminated gloves and perform hand hygiene before donning sterile gloves. "F" then applied antiseptic to skin surrounding exit site for 33 seconds and not 2 minutes as per manufacturer's guidelines. "F" waited 10 seconds before applying dressing, not allowing antiseptic to air dry for 1 and 1/2 minutes as per manufacturer's guidelines. "F" then removed sterile gloves and proceeded to reattach intravenous medication lines to PICC line without removing 1st pair of gloves, performing hand hygiene, and donning clean gloves. "F" removed face mask touching ears and hair with same gloves used throughout the procedure allowing for potential cross contamination; Patient 6 was in contact isolation.

Review on 6/20/17 at 9:00 AM of the manufacturer's package insert for the PICC line dressing change kit, showed Chlorascrub stick (Prevantics) should be used to scrub back and forth for 1 minute then turn the swabstick over and repeat scrub for 1 minute. Antiseptic should be allowed to air dry for 1 and 1/2 minutes. Per interview on 6/20/17 at 9:15 AM, "A" revealed staff should be following manufacturer's guidelines for antiseptic use.

3) On 6/16/17 at 10:25 AM observed Certified Nursing Assistant "G" performing Patient 9's Foley catheter and perineal care. "G" donned gloves and proceeded to clean Patient 9's perineal area, "G" then removed gloves and obtained additional clean washcloths from linen closet. "G" did not perform hand hygiene after removing gloves and before obtaining clean supplies.

4) On 6/16/17 at 2:25 PM observed Environmental Services staff "H" and Environmental Services staff "I" terminally cleaning Room 309. "H" changed gloves 6 times while cleaning the bathroom, "H" did not perform hand hygiene between glove changes. Observed "I" change gloves 1 time while cleaning the room, "I" did not perform hand hygiene between glove change.

5) Review on 6/16/2017 at 4:45 PM of N-95 respirator fit testing, showed no evidence of Registered Nurse "E" having a respirator fit test done to prevent potential exposure to Tuberculosis (TB).

Per interview with Chief Nursing Officer "A" at the time of review, "A" revealed "E" is a traveling nurse that works at the facility and is employed through a contracted staffing agency, Per "A" staffing agency did not have evidence of "E" having respirator fit testing done. "A" revealed all staff should have respirator fit testing completed upon hire and annually. Per "A" staff should have fit testing done prior to working on the unit.

Review of policy titled, "Tuberculosis Control Plan" last revised 4/2017 reveals personal respiratory protective equipment will be used in situations in which the risk of infection with TB may be high. Specific measures to reduce the risk for transmission include Respiratory fit testing program. Per policy, all personnel should don respirator (N-95/NIOSH mask) and conduct fit checks for potential air leakage prior to entering room.





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6) Observations on the 3rd floor nursing care unit on 6/6/17 at 1:40 p.m. revealed two male visitors in room 313. The sign outside the room states the patient in this room is in "contact isolation". Neither of the two male visitors were wearing protective gowns or gloves (personal protective equipment) required for contact isolation patients.

During interview with CEO D at 1:45 p.m., D was asked if the two visitors were suppose to use contact isolation personal protective equipment, CEO D was observed to walk into the room without benefit of personal protective equipment, talked to the two males who were escorted out of the room, and observed to put on gowns and gloves.

7) Patient Room observations of Wound Care Coordinator C on 6/8/17 at 10:30 a.m. revealed that C hand washed with soap and water and put on clean gloves. On the way to the patient's bed, C touched the mid portion of the patient privacy drape contaminating the right glove before caring for Patient #5's wound.

8) High Observation Unit observations of Wound Care Nurse Practitioner P on 6/8/17 at 10:40 a.m. revealed that P hand washed with soap and water and put on clean gloves. P used the clean glove of the right hand to put back the bed covers of Patient #6, contaminating this glove, so the wound site could be visualized.

Based on record review and interview, staff failed to educate patient and/or patients representative on the discharge plan in 2 of 6 discharged records reviewed (12 and 15). This could potentially impact all 28 patients receiving treatment at this facility.

Findings Include:

Review of policy titled, "Discharge/Transition Planning" last revised 11/2016 states the following:

-If discharge plan is home, provide patient and/or family/responsible caregiver with discharge instructions (prescribed treatment, medications, nutritional plan, activity level, and follow-up appointments).
-Perform teach back with patient, and/or family/responsible caregiver and provide return demonstration on any care procedures. Have the patient, and/or family/responsible care giver sign the discharge instructions attesting to the receipt of the information.
-The nurse and the patient and/or family/responsible caregiver should date, time, and sign the form.
-Document discharge activities in the medical record.

1) Review of Patient 12's medical record on 6/16/17 beginning at 9:10 AM reveals Patient 12 was admitted to the hospital on 5/11/17 and discharged on 5/24/17 with the diagnosis of Non-healing wounds, UTI (Urinary Tract Infection), Sepsis, and history of paralysis. Per Patient 12's History and Physical signed by physician on 5/13/17, Patient 12 has a right ischial wound, bilateral ischial decubitus ulcers, and a left groin wound. Patient 12 is paraplegic (paralysis of legs and lower body). Registered Nurse case management progress notes dated 5/12/17 at 3:30 PM states, "Pt (patient) has been a paraplegic for 34 years. States (Patient 12's) family prefers to care for (Patient 12) at home whenever possible has a spouse and 23 year old child in the home that can be taught to do (Patient 12) cares."

Patient 12's "Home Discharge Instructions" form dated 5/24/17, has no documentation in the categories for diet, activity level, discharge medication list, treatment instructions, and follow up. The "Home Discharge Instructions" are not signed by patient or staff. Patient 12's "Case Management Home Discharge Instruction" form dated 5/24/17 at 11:05 AM, is blank and not signed by patient/representative.

Review of Patient 12's medical record shows no evidence of staff having a discussion with Patient 12 or family/caregivers in regards to Patient 12's discharge orders, medication orders, or arranged home support services. Patient 12's medical record shows no evidence of staff assessing and evaluating family/caregiver support needs to ensure a safe discharge home.

2) Review of Patient 15's medical record on 6/16/17 beginning at 3:30 PM reveals Patient 15 was admitted to the hospital on 5/19/17 and discharged on 6/7/17 with a diagnosis of respiratory failure. Per Patient 15's history and physical signed by physician 5/22/17, Patient 15 has a history of cerebral palsy and spastic quadriplegia and normally lives at home with family. Patient 15 has independent care workers and family to providing care at home.

Review of Patient 15's medical record shows no evidence of staff having a discussion with family or independent care workers in regards to Patient 15's discharge orders, medication orders, or arranged home support services. Patient 12's "Home Discharge Instructions" form dated 6/7/17, has no documentation in the categories for diet, activity level, discharge medication list, treatment instructions, and follow up. The "Home Discharge Instructions" are not signed by patient guardian and staff.

Per interview with Director of Case Management "C" on 6/16/17 beginning at 9:10 AM, "C" revealed staff should be contacting family support and/or caregivers to discuss and evaluate discharge needs. Per "C" staff should be completing the "Home discharge instructions" form and the "Case Management Home Discharge instruction" form with the patient.

Based on record review and interview, staff failed to ensure that all patients and/or patient representative are provided a list of Home Health Agencies or Skilled Nursing Facilities to meet post hospital needs in 3 of 6 records reviewed (12, 13, 14). This could potentially impact all 28 patients receiving treatment at this facility.

Findings Include:

Review of policy titled, "Discharge/Transition Planning" last revised 11/2016 states Case Managers will "offer patient freedom of choice in their geographic area on any post acute services required/needed. Explain bed availability and any admission criteria required for a chosen facility or if third party payer has specific choices."

1) Review of Patient 12's medical record on 6/16/17 beginning at 9:10 AM shows Patient 12 was discharged on 5/24/17 to home with a Home Health agency to provide post discharge needs. Patient 12's medical records shows no evidence of staff offering Patient 12 a list of Home Health Agencies to choose from to allow for freedom of choice.

2) Review of Patient 13's medical record on 6/16/17 beginning at 12:55 PM shows Patient 13 was discharged on 5/30/17 to a skilled nursing facility. Patient 13's medical records show no evidence of staff providing Patient 13's guardian with a list of skilled nursing facilities to choose from to allow freedom of choice. Patient 13's "Freedom Of Choice Form" dated 4/6/17 is blank.

3) Review of Patient 14's medical record on 6/16/17 beginning at 1:55 PM shows Patient 14 was discharged on 6/2/17 to a skilled nursing facility. Patient 14's medical records show no evidence of staff providing Patient 14's guardian with a list of skilled nursing facilities to choose from to allow freedom of choice. Patient 14's "Freedom of Choice Form" dated 4/26/17 is blank.

Per interview with Director of Case Management "C" on 6/16/17 at 9:15 AM, "C" revealed staff should be providing patients a list of eligible providers for post discharge needs. Per "C" patients or patient's representative should list top 3 choices on "Freedom of Choice Form", Case Management staff will then attempt to get placement for patients based on preference and availability.