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Based on record reviews and interviews, the facility failed to follow the Documentation Standards policy and perform a skin assessment on 1(P[patient] 1) out of 6 (P1 through P6) patients reviewed, after a change in condition. This deficient practice could lead to all patients being admitted to the facility and patients with a significant change, not having a skin assessment. This could lead to skin breakdown, bruises not being identified and infections to open wounds not being cared for in a timely manner.

The findings are:

A. Review of Policy titled "Documentation Standards" dated 12/2023 Section 3 titled, "Skin Assessment" stated, "Skin assessment will be completed on admission, at a minimum, and after any significant change".

B. Review of the incident log for 08/23/25 revealed an incident where P1 had fallen to the floor while attempting to stand. Review of P1's medical record revealed there was no skin assessment completed after this incident.

C. Review of P1's medical chart at the facility there is only 1 skin assessment that was completed on admission dated 08/16/25 at 2:00am. Reviewing P1's medical record it was documented on 08/17/25 at 10:45am, 08/18/2025 at 1:11pm, 08/20/25 at 10:40am, 08/21/2025 at 7:23pm and 08/24/2025 at 10:45am that P1 became agitated with aggression and self harming behaviors and received Zyprexa (Antipsychotic) 15 milligrams intramuscular (administered in a large muscle) shots. On 08/18/25 at 11:12am P1 complained of pelvic (area of the body below the abdomen) pain and Diflucan (antifungal medication) for yeast infection was ordered on 08/18/25. There were no skin assessment after any of these significant changes.

D. During an interview with S(Staff)3 (clinical) it was confirmed that a skin assessment was not completed after P1 fell on 08/23/25 and a skin assessment should have been completed. S3 also stated a skin assessment should have been completed after the need for the Zyprexa shots and Diflucan because there were considered changes in condition.

E. During an interview S4 (clinical) confirmed that a skin assessment was completed on P1 at admission and there was no further skin assessment during the patient's admission.

F. During an interview with S10 (clinical) it was confirmed that a skin assessment is completed on admission and with any changes. S10 also confirmed that after an incident such as a fall a skin assessment should be completed.

Based on interviews and record reviews, the facility failed to ensure medical staff ordered a diabetic diet for 1 (P[patient]4) out of 6 (P1 through P6) patient files reviewed for compliance with therapeutic diets. This deficient practice could lead to delays in care (such as high or low blood sugar levels requiring medical intervention) and potential patient harm because staff did not meet the dietary needs of the patient.

A. During an interview on 09/10/25 at 9:20 am with S(staff)8, clinical, it was confirmed that both medical providers and nursing staff can place requests for patient nutritional consults to the facility dietician.

B. During an interview on 09/10/25 at 10:15 am with S(staff)9, clinical, it was reported that if nursing staff realized that a patient's current diet order did not meet their therapeutic needs then nursing staff must communicate this information to the medical provider to request a dietary order change.

C. Record review of P4's medical chart demonstrates that the Nursing Admission Assessment denoted that the admitting nurse reviewed the referring facility's information about the patient (page 182) and reviewed all the patient's home medications (page 183). Both items flagged the patient as a person with diabetes (a chronic disease caused by the body not being able to produce or to use insulin hormone effectively).

D. Record review of P4's medical chart demonstrates that the Nursing Admission Assessment denoted that the admitting nurse included diabetes in the "Consult" portion of the patient's medical history (page 190).

E. Record review of P4's medical chart demonstrates that the, "Narrative Note", in the "Nursing Admission Assessment," states, "Patient reports history of diabetes mellitus ... BS [blood sugar] 105. This has been reported to [provider name], awaiting orders" (page 191).

F. Record review of P4's medical chart demonstrates that the, "Nursing Admission Assessment," marked the patient for a regular diet rather than a diabetic diet.

G. Record review of P4's medical chart demonstrates that the, "Psychiatric Evaluation," written by the psychiatric physician denotes in the patient's medical history that the patient "suffers diabetes mellitus" and the medication reconciliation acknowledges the metformin 500 mg (milligrams) twice a day (page 200).

H. Record review of facility's policy 01/2024, "DS.1.02 Meeting Dietary Needs of All Patients" states:
III.1.a. On the admission assessment, the Registered Nurse shall complete nutrition screening and notify the Dietitian if the patient qualifies for a nutrition consult.
2.b.c. Physician's orders for therapeutic diets shall generate a dietitian consult for patient education.

I. Record review of facility's policy dated 01/2024, "DS.1.07 Nutritional Screen and Assessment" states:
I . PROCEDURE:
A. At the time of admission, the admitting nurse on each patient completes a Nutritional Risk assessment.
B. If the patient scores 10 or greater on the Nutritional Risk Screening a Dietary Consult for Nutritional Assessment is requested and the form is placed in the Registered Dietician box.
C. The nutritional screen is done within 24 hours of admission.

J. Record review of P4's medical record does not have a Nutritional Risk Screening completed.

Based on record reviews and interviews the facility failed to communicate discharge planning with the patient's representative and the accepting facility of 1(P[patient] 1) out of 6 patients (P1 through P6) reviewed. This deficient practice could lead to the representative and the accepting facility not knowing the discharge instructions and how to care for the patient at discharge. This deficient practice could affect all patients being discharged from the facility, with the care takers not knowing how to care for the patients.

The findings are:

A. Record review of the facility's policy titled "Aftercare/Discharge Plan Acute Hospital" dated 01/2025, it states "The facility ensures that each client and as appropriate family has participated in and understands their discharge plan and discharge instructions". "The Discharge Planner/ Case Manager, or designee addresses discharge planning with the family and client during family therapy sessions and conferences on an ongoing basis. This is documented throughout the course of treatment in the medical record, case management notes." "The Discharge Planner/ Case Manager or Associate, if appropriate, coordinate discharge planning with the community agency to which the client is referred".

B. Record review of P1's medical file under, "Communication Log" there was no documentation of communication by the Case Manager or Nurse with the patients guardian or the accepting facility.

C. During an interview with S(staff) 10, (clinical) on 09/10/25 at 1:52pm it was confirmed that S10 discharged P1 and did not notify the patients guardian or the accepting facility at discharge. S10 stated that the Case Manager is the staff member to contact the patients guardian / family and the receiving facility when a patient is to be discharged.

D. During an interview with S (staff)12, (non-clinical) it was confirmed that communication with patient's guardian or the accepting facility is documented under the communication log section of the patient's chart. S12 confirmed there was no documentation of communication in the communication log with the guardian or the accepting facility of P1. Also, at discharge patients nurse is the one to call the guardian and the accepting facility.

E. During an interview with P1's guardian on 09/11/25 at 4:38 pm, the guardian confirmed that there was no notification of discharge and found out P1 was discharged when P1 arrived at the accepting facility.

F. During an interview with the Administrator of the accepting facility on 09/08/25 at 1:25 pm, the administrator stated P1 just arrived with no notification from the discharging facility. P1 arrived via a transport company and the facility was not expecting her.