HospitalInspections.org

Based on record review and interview the hospital failed to ensure a Registered Nurse supervised and assessed a patient's care needs by: 1.failing to assess and identify bilateral posterior knee pressure sores developed by a patient admitted to the hospital for 1 of 12 sampled patients (#3); 2. failing to ensure weight loss was monitored and evaluated for a patient with a documented weight loss of 9.4 lbs in 16 days for1of 12 sampled patients (#3); 3. failing to assess and document that TED (antiembolism) stockings were removed daily for 1 of 12 sampled patients (#3); 4. failing to document daily PEG tube site assessments per physician orders on 5 of 22 days the patient was in the hospital for 1 of 12 sampled patients (#3); 5. failing to assess and document that daily baths were documented as completed for 1 of 12 sampled patients (#3). Findings:
1. failing to assess and identify bilateral posterior knee pressure sores developed by a patient admitted to the hospital for 1 of 12 sampled patients (#3).
Review of Patient #3's Pre-Admission Screening Medical Record Review dated 04/20/10 revealed, in part, "Wound Types/Locations: No Skin Breakdowns".
Review of Patient #3's History and Physical dated 04/21/10 at 7:38 a.m. revealed, in part, "Physical Examination: Skin: Warm, dry, no skin breakdown".
Review of Patient #3's 24 Hour Care Record and daily nursing progress notes from 04/20/10 (Admission Date) through 05/11/10 (Discharge date) revealed no documented evidence that the hospital nursing staff had assessed and identified wounds that Patient #3 had developed to the bilateral posterior knees during the hospital admission.
Review of Patient #3's 24 Hour Care Record dated 05/11/10 revealed the patient was discharged to Facility A on 05/11/10 at 1300 (1:00 p.m.). Further review revealed the patient's skin condition was documented to be warm, dry, smooth, and thin, with no wounds present.
Review of Facility A's Treatment Nurses Notes dated 05/11/10 at 5:30 p.m. revealed, in part, "A head to toe skin assessment was completed. The resident was noted to have TED (antiembolism) hose to the Right lower extremity that was partially pulled down the leg and the TED hose on the other leg had been removed by the staff nurse. The Left Posterior knee was noted to have approximately 2 inches of dark scabs. The Right Posterior knee was noted to have an unstageable pressure ulcer, 4cm in length, 2.5cm width, and approximately 0.2cm deep. A small amount of bloody drainage was noted. No odors present. 90% slough noted to wound bed. Tendon was visible in the center of the wound bed". Further review revealed that Patient #3 was discharged from Facility "A" back to the hospital for further wound evaluation on 05/12/10 at 1:00 p.m.
Review of the Hospital Wound Care Evaluation completed on 05/12/10 upon readmission revealed "Wound #1: Wound Location- Right Posterior Knee, Shape- Round/Oval, Wound Type- Traumatic, Wound Stage- Unable to stage, Tissue Layer- Full, Size- 4cm length x 2.5cm width, depth- obscured by necrosis". Further review revealed "Wound #2: Wound Location- Left Posterior Knee, Shape- Round/Oval, Wound Type- Traumatic, Wound stage- Unable to determine deep tissue injury, Size- 2.5cm x 1.8cm, Depth- Partial skin loss involving epidermis &/or dermis".
In interview on 07/01/10 at 9:00 a.m. S5, RN, indicated that a full head to toe assessment of Patient #3 was done at the beginning of the shift on 05/10/10. S5 further indicated that wounds were not identified to the bilateral posterior knees of Patient #3.
In a telephone interview on 07/01/10 at 9:10 a.m. S6, RN, indicated that a full head to toe assessment of Patient #3 was done at the beginning of the shift on 04/21/10. S6 further indicated that wounds were not identified to the bilateral posterior knees of Patient #3.
In interview on 07/01/10 at 9:45 a.m. S10, RN, indicated that a full head to toe assessment of Patient #3 was done at the beginning of the shift on 04/23/10. S10 further indicated that wounds were not identified to the bilateral posterior knees of Patient #3.
In a telephone interview on 07/01/10 at 10:25 a.m. S14, RN, indicated that she completed the admission assessment for Patient #3 on 04/20/10. S14 further indicated that Patient #3 did not have any wounds upon admission to the hospital.
In a telephone interview on 07/01/10 at 10:35 a.m. S22, LPN, indicated that she was assigned to Patient #3 on 05/08/10. S22 indicated that she removed Patient #3's TED stockings to assess the patient's skin condition. S22 indicated that she did not remember assessing wounds on the legs of Patient #3. S22 indicated that she did remember Patient #3 having contractures to the upper and lower extremities.
In interview on 07/02/10 at 9:00 a.m. S21, Family Nurse Practitioner, indicated that he did not perform a complete head to toe assessment on Patient #3. S21 indicated that he depends on the nursing staff's accurate documentation and communication for changes in a patient's condition. S21 indicated that Patient #3 was contracted, unresponsive, and had co-morbidities which made her at a higher risk for wounds. S21 stated, "medicine is unable to stop the natural process".
In interview on 07/02/10 at 11:35 a.m. S13, MD, Internal Medicine, indicated that she was the attending physician for Patient #3. S13, MD, confirmed there was no documented evidence in the medical record to indicate that the patient had developed wounds to the posterior bilateral knees. S13, MD, indicated the Registered Nurses are responsible for conducting complete head to toe daily assessments and further indicated that she was never notified that Patient #3 had developed wounds.
In interview on 07/01/10 at 1:30 p.m. S1, RN, Clinical Administrator, indicated that the registered nurse who discharged the patient to Facility "A" had been terminated by the hospital for not performing a complete assessment upon discharge. S1 confirmed that the hospital failed to identify wounds that Patient #3 had developed to the posterior bilateral knees before discharging the patient to Facility "A".
Review of the hospital policy titled: "Wound/Skin Care, Prevention of Breakdown" revealed, in part, "A. Assessment- 1. Initial assessment of skin integrity risk is performed by the admitting nurse as soon as possible upon patient arrival on the unit and will be completed within twelve (12) hours and, as appropriate, a wound care referral is initiated. 2. A Braden Scale for Predicting Pressure Sore Risk is: a. Verified/completed by the Wound Care Nurse within 24 hours of receiving wound care program order for consult. b. Completed by the Wound Care Nurse or floor nurse weekly. c. Completed by nursing staff or Wound Care Nurse if there is any significant change in skin integrity."
2. failing to ensure weight loss was monitored and evaluated for a patient with a documented weight loss of 9.4 lbs in 16 days for 1 of 12 patients (#3).
Review of documented weights for Patient #3 revealed the following:
Week of::
04/26/10 127.6 pounds
05/03/10 118.2 pounds. This documentation revealed a documented weight loss of 9.4 pounds in 16 days. There was no documented evidence the Physician was notified of the weight loss or the Patient Plan of Care addressed the weight loss.

Review of the Registered Dietician (RD) Nutrition Notes dated 05/04/10 revealed in part, "noted (05/03/10) wt. 118.2#; (04/26/10) wt.127.6# Rec.reweighing pt. Will f/u." There was no documented evidence the patient was weighed again until 05/10/10 (6 days after the RD recommendation) with a documented weight of 121.0 pounds. Patient #3 was discharged from the hospital on 05/11/10 to the Nursing Home (Facility A). Review of the Admission Nursing Assessment for Facility A on 05/11/10 at 5:15 pm revealed a documented weight of 90 pounds which was a loss of 37.6 pounds since 04/26/10. Further there was documented evidence of a Stage IV pressure ulcer to the right posterior knee. Patient #3 was readmitted back to the hospital on 05/12/10 for treatment of the wound.
Review of the Nutrition notes, dated and signed by the Registered Dietician, (RD) 04/21/10 revealed documented evidence Patient #3 was at a moderate nutrition risk 2nd to being on tube feeding, diagnosis and medication history. The patient's BMI (Body Mass Index) was documented as 20 which indicated the patient was at normal weight and not malnourished on admit. Further documentation revealed the patient was noted to not have any wounds and the RD recommendation was to discontinue Juven (nourishment) and vitamins. Plan was to increase the tube feeding as tolerated to a goal rate of 50 ml/hr and to monitor the tube feeding tolerance, weights and laboratory reults.
Review of the Nutrition Notes dated 05/12/10 at 3:00 pm, following Patient #3's readmission back to the hospital, revealed the RD documented the patient was at a high nutrition risk, 2nd to being underweight with a documented BMI of 17.6, (significant of weight loss and being underweight; score on previous admit was 20) being on tube feeding and diagnosis. The RD recommendation was to change the Tube Feeding to Jevity 1.5 at 50ml/hr to provide 1800 calories daily, 77gm ProMod and 912 ml fluid daily and adding Juven one pack twice daily to provide 156 calories daily and 28 grams daily L-Arginine/Glutamine) to promote wound healing and weight gain. The RD also recommended to add 15 ml MVI, 500mg Vitamin C twice daily, 220 mg Zinc daily per PEG. Further review of the Nutrition Assessment revealed Pre-albumin dated 04/21/10 of 17.5 and 04/27/10 26.6. (Normal reference 17 to 42)
S20, Registered Dietician was interviewed face to face on 07/01/10 at 2:15pm. S20 reviewed the Nutrition Notes. S20 indicated the initial weight was documented as 122.3 pounds in the initial Nurse's Assessment (unable to locate assessment in the record; and weight documented on the CNA weight form was127.6 pounds on 04/26/10).
She had noted a BMI of 20 which was normal for Patient #3 and indicated she discontinued vitamins and Juven. Further there were no reports of wounds and S20 added if she had been consulted for development of wounds her recommendations would have been different. Further she had reevaluated Patient #3 when she was readmitted on 05/12/10 and changed her recommendations when she was made aware of the wound. Further the BMI was at this time 17.6 (significant of weight loss and being underweight). S20 further indicated she would not have discontinued vitamins and supplements if a wound had been reported. Further she had requested the patient be reweighed on 05/4/10 and this was not done as recommended.
S22, LPN was interviewed per telephone on 07/01/10 at 10:45am. S22 indicated Patient #3 was weighed on a bed scale as she was bed bound. Further a weight loss greater than 10 pounds should be reported to the physician.
S15, LPN was interviewed face to face on 07/01/10 at 10:55am. She indicated weights are done weekly and the weights are documented in the weight book by the aide. Further a weight loss greater than 10 pounds should be reported to the physician.
S7, RN Quality Manger was interviewed face to face on 07/01/10 at 11:05am. S7 indicated the nurse should have reweighed and revaluated the weight of Patient #3 when a weight of 121 pounds was reported the week of 05/10/10 as this could have been an inaccurate weight. Further there was no documented evidence Patient #3 was reweighed on 05/04/10 per the RD recommendation.
S3, Director of Nursing was interviewed face to face on 07/01/10 at 2:00 pm. S3 indicated they had identified there were discrepancies with weights and staff had been trained on the use of the bed scale (ie to zero the scale and make sure nothing was lying on the bed) when the patient was weighed. Further he could not provide written documentation of training or a policy to operate the bed scale.
The policy entitled "Weights, Patient" with a revised date of 05/2009, presented as the hospitals's current policy, revealed in part,
Procedure: Patients are weighed:
a. Upon admission to the facility
b. Each week ( Note: Physician orders supercede these guideline)
Patient order:
a. Physician order may initiate patient weighing
b. RN'S may initiate patient weighing based on assessment data i.e. increase in edema, poor intake, and/output, diagnoses of CHF, utilization of diuretics, etc.
"Patients weights are documented :
a. On weight binder by the C.N.A
b. Transcribed to the 24 hour Care Record by the nurse providing patient care

Guideline for monitoring of weights: a. The nurse caring for the patient shall monitor and track the weights for fluctuation variances. b. The physician shall be notified of any significant weight loss or gain. c. Consult the dietitian if there is a patient loss or gain plus or minus 5 pounds any one week period. d. Notify the physician and care management team of significant weight variances.
3. failing to assess and document that TED (antiembolism) stockings were removed daily for 1 of 12 sampled patients (#3).
Review of the entire medical record for Patient #3 revealed that a Physician's order for the use of TED (antiembolism) stockings was not written.
Review of the Nursing Progress notes dated 04/20/10 at 6:10 p.m. revealed that Patient #3 had TED stockings in place.
Review of Patient #3's 24 hour care records revealed the following documented for TED stockings on/off: On the dates of 04/20/10 through 05/11/10 there was no documented evidence Patient #3's TED stockings were removed.
In interview on 07/01/10 at S9, CNA, indicated that the patient's TED (antiembolism stockings) should be removed once a day during the patient's bath. S9 further indicated that if she removed the patient's TED stockings then the nurse on duty would be notified. S9 indicated that the nurse is responsible for documenting removal of the patient TED stockings.
In interview on 07/01/10 at 9:00 a.m. S5, RN, indicated that a physician's order is needed for TED stockings to be applied. S5 indicated that she was not familiar with the hospital policy and procedure for applying or removing TED stockings. S5 indicated that she was assigned to Patient #3 on 05/10/10 and had not documented removal of the patient's TED stockings.
In a telephone interview on 07/01/10 at 9:10 a.m. S6, RN, indicated that a physician's order is needed for TED stockings to be applied. S6 indicated that the medical record should have documentation of when TED stocking are removed and reapplied. S6 indicated she was assigned to Patient #3 on 04/21/10 and had not documented removal of the patient's TED stockings.
In interview on 07/01/10 at 9:20 a.m. S8, LPN, indicated that a physician's order is needed for TED stocking to be applied. S8 indicated that the medical record should have documentation of when TED stockings are removed and reapplied. S8 indicated she was assigned to Patient #3 on 04/21/10 and had not documented removal of the patient's TED stockings.
In interview on 07/01/10 at 9:50 a.m. S10, RN, indicated that a physician's order is needed for TED Stockings to be applied. S10 indicated that the medical record should have documentation of when TED stockings are removed and reapplied. S10 indicated she was assigned to Patient #3 on 04/23/10 and had not documented whether or not the patient's TED hose were removed.
In a telephone interview on 07/01/10 at 10:25 a.m. S14, RN, indicated that she completed the admission assessment for Patient #3 on 04/20/10. S14 further could not remember if the patient had TED stockings on upon admission to the hospital. S14 indicated that a physician's order is needed for TED stockings to be applied. S14 indicated that TED Stocking should be removed daily and documented in the medical record.
In a telephone interview on 07/01/10 at 10:35 a.m. S22, LPN, indicated that she was assigned to Patient #3 on 05/08/10. S22 indicated that a physician's order is needed for TED stockings to be applied. S22 indicated stated that the patient's TED stockings were removed to assess the patient's skin condition. S22 indicated that removal of the TED stockings should be documented in the patient medical record.
In interview on 07/02/10 at 11:35 a.m. S1, RN, Chief Clinical Officer, and S13, MD, Internal Medicine, confirmed that Patient #3 did not have a physician's order for the use of TED (antiembolism) stockings. S1 further indicated that the hospital failed to develop a policy and procedure for the use of TED antiembolism stockings. S1 confirmed there was no documentation in the medical record to verify that the patient's TED stockings were removed every day.
4. failing to document daily PEG tube site assessments per physician orders on 5 of 22 days the patient was in the hospital for 1 of 12 sampled patients. (#3)
The medical record for Patient #3 was reviewed for PEG tube site care revealed the following documentation:
Physician's Order dated 04/20/10 at 17:20 (5:20 p.m.) for protocol for PEG tube site care. Review of the ordered protocol revealed: 1. Cleanse PEG tube, bumper, and peri-PEG skin with warm damp cloth or gauze and foam cleanser. 2. If necessary, place warm, damp cloth or gauze over dry, adherent exudates for 3-5 minutes to ease exudates removal. 3. Apply a thin layer of anti-fungal barrier cream to intact skin extending outward for the per-wound area to the circumference of no greater than 3cm. 4. Apply a liquid copolymer by pledget to outer circumference of up to 6 cm. Allow area to dry. 5. Bifurcate, then cut a circular opening at the center of a round, foam dressing to secure with skin-friendly adhesive. 6. Date and initial newly applied dressing. 7. Reassess PEG tube and dressing daily. 8. Change dressing weekly and PRN (as needed) for heavy soiling or if unable to maintain security.
Review of Patient #3's 24 Hour Care Record and daily nursing progress notes revealed the following:

04/20/10- Tube Type: PEG- documented patent and intact;
04/21/10- No documentation charted related to PEG tube site status;
04/22/10- Nurses Note- Documented PEG tube patent;
04/23/10- Tube Type: PEG- documented patent and intact;
04/24/10- Tube Type: PEG- documented intact;
04/25/10- Tube Type: PEG- documented patent and intact;
04/26/10- Tube Type: PEG- documented patent and intact;
04/27/10- No documentation charted related to PEG tube site status;
04/28/10- No documentation charted related to PEG tube site status;
04/29/10- Tube Type: PEG- documented patent and intact;
04/30/10- Tube Type: PEG- documented patent and intact;
05/01/10- No documentation charted related to PEG tube site status;
05/02/10- charted surgical site PEG Tube, dry and intact;
05/03/10- Tube Type: PEG- documented patent and intact;
05/04/10- Tube Type: PEG- documented patent and intact;
05/05/10- Tube Type: PEG- documented patent and intact;
05/06/10- Tube Type: PEG- documented patent and intact;
05/07/10- Tube Type: PEG- documented patent and intact;
05/08/10- Tube Type: PEG- documented patent and intact;
05/09/10- Tube Type: PEG- documented patent and intact;
05/10/10- Tube Type: PEG- documented patent and intact;
05/11/10- No documentation charted related to PEG tube site status.
Review of the entire medical record revealed no documented evidence of any complications with the PEG tube site.

In interview on 07/01/10 at 9:00 a.m. S5, RN, indicated that she was assigned to care for Patient #3 on 05/10/10. S5 indicated that a head to toe assessment was performed and no problems were noted to the PEG tube site. S5 indicated that the assessment of the PEG tube site was documented on the medical record.

In interview on 07/01/10 at 9:20 a.m. S8, LPN, indicated that she was assigned to care for Patient #3 on 04/21/10. S7 indicated that her assessment of the PEG tube site should be documented in the medical record.

In a telephone interview on 07/01/10 at 10:25 a.m. S14, RN, indicated that she was assigned to care for Patient #3 on 04/20/10. S14 indicated that she completed the initial nursing assessment for Patient #3. S14 indicated there were no problems with the PEG tube site. S14 indicated her assessment of the PEG tube site should be documented in the medical record.

In interview on 07/01/10 at 1:30 p.m. S1, RN Chief Clinical Officer, indicated that all patient assessments should be documented in the medical record.

5. failing to assess and document that daily baths were documented as completed for 1 of 12 sampled patients (#3).
Review of the entire medical record revealed no documented evidence of the times or dates that Patient #3 received a daily bath.
In interview on 07/01/10 at 1:30 p.m. S1, RN, Chief Clinical Officer, indicated that patient daily baths are not documented in the medical record. S1 further indicated the patient daily baths are documented in a seperate binder. S1 further indicated the certified nursing assistant (CNA) would sign the form in the binder once the daily bath was completed. The binder documenting patient baths was requested for Patient #3.
Review of the binder for patient baths revealed a bath was not documented as done on the following days: 04/21/10, 04/22/10, 04/25/10, 04/28/10, 04/29/10, 04/30/10, 05/03/10, 05/04/10, 05/05/10, 05/06/10, 05/08/10, and 05/09/10.
On 07/01/10 at 11:30 a.m. S1, RN, Chief Clinical Officer, reviewed the binder and confirmed that the baths were not documented as done on the above days.

Based on record review and interview the hospital failed to ensure a nursing care plan was developed that addressed the nursing care needs of a patient by failing to identify and include specific goals and interventions in the nursing care plan for wound care, contractures, congestive heart failure, pulmonary edema, TED stockings (antiembolism stockings) care and PEG (Percutaneous Endogastric) tube care for 1 of 12 sampled patients (#3).
Findings:

Review of the medical record for Patient #3 revealed the patient was admitted to the hospital on 04/21/10. Review of the medical record revealed the patient was admitted with a diagnosis of acute respiratory failure. Further review of the medical record revealed that Patient #3's medical condition on admit included the following: 1. a wound to the right hip that had multiple small pustules; 2. multiple contractures and bedbound status related to a previous CVA (cerebrovascular accident); 3. congestive heart failure; 4. pulmonary edema; 5. TED stockings; 6. Percutaneous endogastric tube.

Review of Patient #3's medical record revealed the nursing care plan was developed on a form labeled "Interdisciplinary Staffing Record". Further review revealed the initial Interdisciplinary Staffing record was completed on 04/25/10. Review of the Interdisciplinary Staffing records dated 04/25/10, 05/03/10 and 05/10/10, revealed the nursing section addressed foley catheter care, pain management, and antibiotic administration.

Review of the entire Interdisciplinary Staffing record revealed the nursing care plan failed to include specific goals and nursing interventions for wound care, contractures, congestive heart failure, pulmonary edema, care of TED (antiembolism) stockings, and care of the patient's percutaneous endogastric tube.

In interview on 07/02/10 at 11:00 a.m. S1, RN, Chief Clinical Officer, indicated that the nursing plan of care should include interventions specific to the patient's health care needs. S1 could provide no explanation as to why the patient's nursing plan of care did not include specific goals and nursing interventions related to wound care, contractures, congestive heart failure, pulmonary edema, TED (antiembolism) stocking care, and percutaneous endogastric tube care.

Review of the hospital policy titled: "Assessment/Re-Assessment, Interdisciplinary" revealed, in part, "Policy: 1. Patients receiving inpatient services will have an initial assessment and appropriate follow-up assessments based upon their individual needs including physical, psychological, and social/cultural status. 2. The assessment process will determine the need for care and/or treatment utilizing Interqual Criteria for Long Term Acute Care, the type of care to be provided and the patient's needs through the continuum of care. 3. The goal of the assessment/reassessment process is to provide the patient with the appropriate care to meet individual needs. 4. Care and/or treatment provided by all health care professionals will be based on each patient's specific needs with respect to his/her right to privacy. 5. Relevant biophysical, psychosocial, and nutritional, self care, educational, environmental, and discharge planning needs will be the determining factors considered in the assessment process. 6. Assessments provided by health care professionals will be based upon and include: a. Data collected to assess the needs of the patient. b. Analysis of data to develop a plan to meet the patient's care needs. c. Prioritization of decisions based upon analysis of data regarding patient care needs. Decisions made regarding patient care or treatment are prioritized based on analysis of the informations collected."

Based on record review and interview the hospital failed to ensure the completed medical record for Patient #3 was retained as evidence by not being able to provide documentation of the initial nursing admission assessment. (#3) Findings:

Review of the entire medical record for Patient #3 revealed no documentation that an initial nursing admission assessment had been performed by a Registered Nurse on 4/20/10.

A telephone interview was held with S14 RN on 7/1/10 at 10:25 AM. She indicated she remembered completing the admission assessment for Patient #3. She further indicated she had stayed late on 4/20/10 to complete the paperwork following her assessment.

An interview was held with S1, RN Clinical Administrator. She indicated the hospital was unable to find the documentation of the initial admission nursing assessment for Patient #3 that was performed on 4/20/10.

Based on observation, record review, and interview the hospital failed to ensure drugs were secured by having syringes of Heparin Flush and Sodium Chloride (NACL) placed on tables in the patient's rooms for 2 of 2 patient rooms out of a total of 14 rooms on the 100 Hall. (Room "a"and Room"b") Findings:
Observation of Room "a"on 06/30/10 at 9:50am revealed a Heparin Flush 10cc syringe, with 5ccs remaining in syringe, lying on the meal table and 2 syringes of NACL Flush 10cc on the IV stand. Observation of room "b" at 10:00 am revealed a Heparin Flush 10 cc syringe, with 5ccs remaining in syringe, lying on the bedside table.
S11, RN was interviewed on 06/30/10 at 10:20am. S11 indicated the Heparin Flush syringes should not be left in the rooms and she wasn't sure if the syringes of NACL left in the room were a problem.
Review of the policy entitled "Drug Storages" presented as the hospital's current policy revealed in part, "3. For each nursing unit, as required, properly controlled drug preparation areas are designated and locked storage areas or locked medication carts are provided."

Based on record review and interview the hospital failed to transfer a patient with all of the necessary medical information and by failing to inform Facility "A" of the wounds developed by Patient #3 while admitted to the hospital for 1 of 12 medical records reviewed (#3).
Findings:

Review of Patient #3's Discharge Summary dictated by S13, MD, Internal Medicine revealed, in part, "Condition at the time of discharge: The patient is medically stable. She is afebrile with vital signs within normal limits. Oxygen saturation is 97% on room air". Further review revealed, in part, "Discharge Instructions: The patient will be discharged from the hospital and transferred back to Facility "A" under hospice as agreed by family. She will continue on medications and feedings".

Review of the "Interdisciplinary Staffing Record" dated 04/25/10 revealed, in part, "Case Management- Patient has not yet been evaluated, per chart. Patient resides in nursing home, plan F/U (follow up) with family for planning needs". Further review revealed the plan was to discharge the patient back to the nursing home. There was no documentation related to discussing the patient wounds with Facility "A".

Review of the "Interdisciplinary Staffing Record" dated 05/03/10 revealed, in part, "Case Management- Patient daughter discussing new nursing home secondary to desire for hospice, however fully cannot agree." Further review revealed the plan was to discharge the patient back to the nursing home. There was no documentation related to discussing the patient's wounds with Facility "A".

Review of the "Interdisciplinary Staffing Record" dated 05/10/10 revealed, in part, "Case Management- Patient to return to Nursing Home tomorrow (05/11); daughter agreeable to return to Facility "A" with hospice and without Do Not Resuscitate. Social Worker to Follow-Up". There was no documentation related to discussing the patient's wounds with Facility "A".

Review of Facility A's Treatment Nurses Notes dated 05/11/10 at 5:30 p.m. revealed, in part, "A head to toe skin assessment was completed. The resident was noted to have TED (antiembolism) hose to the Right lower extremity that was partially pulled down the leg and the TED hose on the other leg had been removed by the staff nurse. The Left Posterior knee was noted to have approximately 2 inches of dark scabs. The Right Posterior knee was noted to have an unstageable pressure ulcer, 4cm in length, 2.5cm width, and approximately 0.2cm deep. A small amount of bloody drainage was noted. No odors present. 90% slough noted to wound bed. Tendon was visible in the center of the wound bed." Further review revealed that Patient #3 was discharged from Facility "A" back to the hospital for further wound evaluation on 05/12/10 at 1:00 p.m.
In interview on 07/01/10 at 1:30 p.m. S1,RN, Chief Clinical Officer, she indicated that the registered nurse who discharged the patient to Facility "A" on 05/11/10 was terminated by the hospital for not performing a complete assessment upon discharge. S1 confirmed that the hospital failed to identify wounds that Patient #3 had developed to the posterior bilateral knees before discharging the patient to Facility "A".
Review of the hospital policy titled "Discharge Planning" revealed:
Policy:
Discharge planning begins during the pre-admission phase of the patient's care to assure that he patient is referred to a proper environment for continuity of care.
Procedure:
1. Discharge planning is begun during the pre-admission phase of the assessment process. Taking into account the patient's diagnosis, age, and assessment information, a probable discharge placement and goals will be identified.
2. The Social Worker/Case Manager (SW/CM) will work with the patient and family to ensure their participation in setting patient care goals and the decision-making process.
3. The interdisciplinary discharge plan will be initiated during the first patient care conference and will be documented on the TC Report/DC Plan/Summary form as a reference for the interdisciplinary team.
4. Each member will be responsible for providing input regarding patient's needs, goals, and accomplishments.
5. The interdisciplinary discharge plan will include expected discharge disposition, anticipated length of stay, prognosis for achieving long term goals, identification of obstacles to overcome and a continuing plan for action.
6. Each team member will be responsible for making timely recommendations for equipment and supply needs.
7. Each team member will be responsible for providing patient and family education.
8. Each team member will be responsible for documenting discharge plans and interventions completed by their respective service.
9. Discharge summaries will include medical condition, services provided to patient, and will be completed by disciplines within 72 hours of discharge.
10. Discharge summary copies will be provided to home health services if patient is being discharged home, to another facility if the patient is being discharged to lower level of care.If the patient is being discharged to another hospital, the discharging facility is exempt from meeting those standards.
11. Documentation regarding discharge planning is part of the permanent medical record.

Based on record review and interview the hospital failed to measure, analyze, and track quality indicators, including adverse patient events related to TED Hose application/removal, accuracy of nursing assessments related to identification of hospital acquired wounds, and weight loss.
Findings:

Review of the hospital's Quality Assurance data for 5/6/10, revealed no Quality Indicators were tracked, measured, and analyzed related to TED Hose application/removal, accuracy of nursing assessments related to identification of hospital acquired wounds, and weight loss.

An interview was held with S3 DON on 7/1/10 at 2:00 p.m. S3 further indicated the hospital could present no documentation of tracking and trending of data related to TED hose application/removal, accuracy of nursing assessments related to hospital acquired wound identificaton and weight loss. S3 indicated that chart checks had been implemented regarding nursing completing wound assessments. S3 could present no measureable data in order to verify that the hospital had demonstrated measureable improvement with the above identified quality indicators.