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Based on interviews and documentation review the Long Term Acute Care (LTAC) Hospital failed to ensure that: 1) repositioning was consistently documented in the medical record, and 2) the initial Social Services Assessment was completed timely, and information regarding Advanced Directives was documented in the medical record.

Findings included:

1) Review of the medical record documentation indicated that the Patient was admitted to the LTAC Hospital with multiple pressure ulcers/wounds. The Patient was placed on a specialty mattress and repositioning every 2 hours.

Staff assigned to the Patient were interviewed as follows: Nurse #1 was interviewed on 8/11/10 at 11:00 A.M.; Nurse #2 was interviewed on 8/12/10 at 11:06 A.M.; Nurse #3 was interviewed on 8/16/10 at 12:06 P.M., and Nurse #4 was interviewed on 8/16/10 at 12:15 P.M. Nurse #1 and Nurse #2 reported not remembering the Patient. Nurse #3 and Nurse #4 said they remembered the Patient. Nurse #1, Nurse #2, Nurse #3, and Nurse #4 said the Patient's room was located across from and was visible to the nursing station and therefore provision of care could be monitored. Nurse #1, Nurse #2, Nurse #3, and Nurse #4 said in addition, hourly rounding was performed and nursing assistants were assisted with repositioning to ensure patients were consistently turned and repositioned.

Review of the electronic medical record documentation in which repositioning was entered indicated that repositioning was not entered as being performed every 2 hours but was entered at the time the repositioning was performed and indicated the position the Patient was placed in (back, left/right side).

Review of the medical record documentation, dated 5/5/10 to 5/13/10, indicated that repositioning was inconsistently entered throughout the Patient's stay.

2) The Policy/Procedure titled Assessment/Reassessment-Interdisciplinary Patient indicated that the Case Management/Social Service Department was responsible for completing an assessment within 48 hours. The initial assessment included documenting information regarding Advanced Directives.

The medical record documentation indicated the Patient was admitted to the LTAC Hospital on 5/4/10 at approximately 6:30 P.M. Included in the discharge documentation forwarded from the acute care hospital was a copy of a document indicating that guardianship was pending.

Review of the Social Services Initial Assessment indicated that it was completed on 5/7/10 at approximately 3:15 P.M. Documentation indicated that family members were present and were spoken to regarding discharge planning however; Advanced Directives were not addressed and/or documented.

The medical record documentation indicated that on 5/10/10 the Physiatrist evaluated the Patient's pressure ulcers/wounds. Documentation indicated that the Physiatrist wanted to obtain permission to debride the sacral/left buttock pressure ulcer the following Friday (5/14/10) but could not locate an active Health Care Proxy. Documentation indicated that Case Management was asked to assist in the search.

The Case Manager at the LTAC Hospital was interviewed on 8/10/10 at 11:15 A.M. The Case Manager said after admission it was determined that there was no official Health Care Proxy in place and that there was a petition for guardianship which had not been finalized.

Review of the medical record documentation indicated that there was no documentation by Case Management/Social Service addressing the status of the Advanced Directives.