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Based on observations, interviews and review of hospital policy, the Long Term Acute Care (LTAC) Hospital failed to ensure Patient Identifier (PI) # 1's medical record was readily accessible and available. This affected one of fourteen sampled patients.

Findings Include:

PI # 1's closed medical record was requested at or around 3:00 PM on 9/15/10, the first day of the complaint investigation.

On 9/16/10 at 10:50 AM, during an interview with EI # 4, the Director of Clinical Services, (DCS) stated medical records are kept at the hospital for six months after the patient is discharged. Records older than six months are maintained in a storage facility located in another city. PI # 1's medical record was supposed to be at the hospital by 5:00 PM last night. The record was expected to be at the facilty this morning at 9:00 AM. However, the medical record remains unavailable and has not arrived at the hospital.

During an interview with the DCS (EI # 4), on 9/16/10 at 12:05 PM, the Director said the statement made earlier by staff that PI # 1's medical record was in route, is not correct. The surveyor requested notification of the time of arrival of the medical record.

PI # 1's medical record was provided to the surveyor at at 2:15 PM on 9/16/10.

Policy Review: Medical Records
Policy # HD-HI 1113.08
Effective Date: 5/1/08 Original Date: 1/2/02
No revision date is documented.

Policy: "It is the policy of (name of LTAC) to maintain a medical record on all residents who receive services, in accordance with applicable laws and regulations for each facility..."

This deficiency is cited as a result of the invetigation of Complaint Number AL00023067.

Based on observations, interviews, and review of policies and procedures, the Long Term Acute Care (LTAC) Hospital failed to maintain a clean and sanitary environment for patients as evidenced by:
- A black colored substance on the floors of patient rooms;
- Fifth floor nourishment room: a black colored substance in the corners of the room and threshold, brown colored splatters in the refrigerator, and splatters on the wall;
- A dirty sink at the fifth floor nursing station;
- IV poles splattered with a brown colored substance in a patient room.

Findings include:

Observations of the fifth floor on 9/15/10
Include:
- Pieces of trash (plastic wrappings removed from patient supplies) were observed on the floor in patient room 576 at 11:30 AM.
- At 11:40 AM, a build-up of a black colored substance was observed on the threshold between the bathroom and the patient's room (586) as well as the corners of the bathroom floor.

Observations of the fifth floor on 9/16/10
Include:
- The water in the mop bucket on the housekeeping cart was gray colored and contained a small clump of hair and trash at 9:30 AM.
- A buildup of a light brown colored substance around the faucet and sides of the sink at the fifth floor nurse's station at 9:40 AM.
- At 9:45 AM, in patient room 588, a build up of a dark black colored substance was observed on both sides of the threshold of bathroom floor. The surveyor wiped the substance with a clean Q-tip and the black substance transferred easily to the Q-tip. A blackish-gray color substance was observed on the floor in the patient's room. The substance was easily removed with a paper towel lightly moistened with water by the surveyor. Employee Number (EI) # 1, the Nurse Manager, verified the surveyor's findings.

At 12:25 PM, room # 581 was reported by staff to be clean and ready for a patient admission. However, dirt was observed around the baseboard at the head of the bed, and on the floor the air conditioner. The dirt was easily removed with a paper towel by the surveyor. A dark black substance covered multiple floor tiles in the bathroom, and was heavily concentrated on the tiles behind the toilet. Multiple cracks were observed on the surface of the floor tiles in the bathroom. EI # 2, a staff nurse, verified the surveyor's findings.

At 12:30 PM, drops of a light brown colored substance were observed on the IV pump and on the base of the IV pole in patient room 561. A dark brown colored substance was observed in the crevice of the left side rail of the patient's bed.

On 9/16/10 at 1:25 PM during an observation of the nourishment room on the fifth floor, a build up of a light to medium brown colored substance was noted around the sink. The build up was easily removed by the surveyor with a paper towel. A dark black colored substance was observed in the corner by the door. Splatters of a sticky, brown colored substance were observed in the refrigerator shelves and in the bottom of the refrigerator. The walls of the room were splattered with an light brown colored substance. There was no evidence of a cleaning log. The Nurse Manager, (EI # 1), verified the surveyor's findings and stated there is no cleaning log.

At 9/16/10 at 2:00 PM, during a telephone interview with an employee of the Chemical Company that manufactures the bathroom disinfectant, NADB (Non-Acid Disinfectant Bathroom), used by the LTAC, the employee stated the disinfectant is "ready to use." The disinfectant should not be diluted as dilution will decrease/eliminate the disinfectant property of the solution. The disinfectant should be applied and allowed to remain on surfaces for ten minutes and then rinsed.

During an interview on 9/16/10 at 2:10 PM, the Environmental Service (EVS) Coordinator, EI # 7, stated patient rooms are cleaned daily or more frequently if soiled. The coordinator verified NADB is the disinfectant used in patients' bathrooms. When asked if the disinfectant should remain on bathroom surfaces for any length of time, he said no. The coordinator stated nursing staff is responsible for cleaning the refrigerators in the nourishment rooms, but EVS staff is responsible for cleaning the walls, floors and sinks. EVS staff is also responsible for the cleaning of the nursing stations, including the sinks. According to the coordinator, no cleaning log is maintained by the facility.

This citation is written as a result of the investigation of Complaint Number AL00023055.

Based on interviews, medical record review and review of policies and procedures, the Long Term Acute Care (LTAC), Hospital # 1, failed to develop a discharge plan to reduce the risk of the development and or decompensation of undesirable changes in PI (Patient Identifier) # 1's physical condition, a patient with a known history of Multiple Sclerosis (MS), Respiratory Failure and Aspiration Pneumonia, until 11/11/09,
twenty days after admission. This plan failed to identify PI # 1's family's education/training needs and ensure the medical equipment, supplies and home health services ordered by the physician, were in place on November 25, 2009, PI # 1's discharge date. Less than six hours after PI # 1's discharge from Hospital # 1, the patient was admitted to Hospital # 2, an acute care hospital, with diagnoses of Shortness of Breath and RLL (Right Lower Lobe) Pneumonia. This affected one of 14 sampled patients.

Findings Include:

History and Physical 10/22/09 Includes:
Chief Complaint: Patient (PI # 1) with MS (Multiple Sclerosis) was admitted to (Hospital # 2) on 9/28/09 with increased lethargy and respiratory distress. Patient found to have aspiration pneumonia and placed on ventilator. History of aspiration pneumonia x 3. Present Illness: Patient transferred to LTAC (Hospital # 1) on 10/22/09 for continued intravenous (IV) antibiotic treatment and a prolonged course of ventilator weaning.

Past History:
Respiratory: Respiratory Failure on ventilator. Positive for cough and sputum. History of recurrent aspiration.
Physician Impression:
Acute Respiratory Failure
Aspiration Pneumonia
ARDS (Acute Respiratory Distress Syndrome)
Normochromic Normocytic Anemia
Protein Malnutrition
Trigeminal Neuralgia
Multiple Sclerosis
Neurogenic Bladder

Physician's Orders Include:
11/10/09 5:00 PM: 1. Please teach husband trach (tracheostomy) care/suctioning.
2. Please teach sitter trach care/suctioning...

11/17/09 7:00 PM: Please teach husband trach care and PEG (Percutaneous Endoscopic Gastrostomy) care...

11/19/09 5:00 PM: Consult discharge planning for possible discharge early next week.
1. Need Home Health Care / Home trach care and PEG care.
2. Make sure DME (Durable Medical Equipment) arranged.
3. Will need outpatient follow up with Pulmonary for trach arranged.

11/22/09 9:00 AM: Physician's Orders for home equipment for trach care:
1. Air compressor...
6. Trach care kits...
10. Trach collar mask (Adult)...
12. Pulse oximeter for continuos use...
13. Suction machine...

11/24/09 6:00 PM:
1. In AM, discontinue IV, lines...telemetry
2. Leave suprapubic catheter intact
3. Discharge home via ambulance in AM...
5. Please make sure patient scheduled with
primary MD in 1-2 weeks and
pulmonologist in 2-3 weeks.

11/24/09 6:15 PM: Home Health Orders:
...2. See orders for home trach supplies
3. Trach care b.i.d. (twice daily)
4. Suction trach prn (as needed) and mouth prn...

Physician Progress Notes Include:
11/21/09 :(Pulmonary) ...Respiratory Failure- TC (Trach Collar) - 28%...
secretions better- try talking valve.

11/22/09: (Pulmonary) Secretions better...sat 98...home soon.

11/23/09: (Internal Medicine) Resting in bed in no apparent distress, "ready to go home."
Temp: 98.8, Pulse: 108, Respirations: 18, BP 120/60.
Telemetry: SR (Sinus Rhythm)
Oxygen Saturation: 100%...Bilateral Breath Sounds clear to auscultation...

11/24/09: (Internal Medicine): Resting in bed in no distress...ready to go home....Overall much improved...plan discharge in am...

PI # 1's Discharge Summary dated 1/23/10 Includes:
Primary Discharge Diagnoses:
1. Acute Respiratory Failure
2. Aspiration Pneumonia, Recurrent
3. Paralytic Ileus
4. Acute Respiratory Distress Syndrome
5. Normochromic Normocytic Anemia
6. Protein Malnutrition, status post Percutaneous
Gastrostomy placement
7. Trigeminal Neuralgia
8. End-stage Multiple Sclerosis
9. Neurogenic Bladder, status post
suprapubic catheter placement
10. Chronic Constipation

Hospital Course: PI # 1 was admitted in critical condition to Hospital # 2, an acute care hospital, on 9/28/09 with End-Stage MS, increased lethargy and respiratory distress. The patient was found to have aspiration pneumonia and developed acute respiratory failure. The patient has a history of aspiration pneumonia.

On 10/22/09, PI # 1 was transferred to Hospital #1, a Long Term Acute Care Hospital, on intravenous (IV) antibiotics and a ventilator.
IV Vancomycin and Levaquin were continued for treatment of aspiration pneumonia. Low dose Tegretol was continued for trigeminal neuralgia. Tube feedings were implemented for nutritional sustenance.

On 10/28/09 titration of the ventilator rate was initiated. The following day, the patient was placed on pressure support ventilation.

On 11/1/09, PI # 1 developed a post-PEG tube placement ileus that spontaneously resolved.

On 11/2/09, pressure support ventilation was titrated downwards. IV antibiotics for aspiration pneumonia were discontinued on 11/4/09.
Trach collar trials were initiated on 11/8/09.

By 11/14/09 the patient was on the trach collar 24/7, with no additional ventilatory support.

By 11/25/09 PI # 1's status had stabilized. She had been weaned off the ventilator and was tolerating the tube feedings well. The patient was discharged home with the assistance of home health care and home respiratory therapy.

Nurse's 24 Hour Assessment and Progress Record:
11/18/09 8:00 AM, 12:00 PM and 4:00 PM: Oxygen Therapy: 30 % via Trach Collar.

11/21/09: 8:00 PM, 12:01 AM, 4:00 AM: Cough: productive. Oxygen Therapy: 28 % via Trach Collar.

Narrative Nurse's Notes Addendum:
11/21/09: "...Productive cough present...Has difficult time clearing secretions...
12:00 PM: ...Productive cough present...
8:00 PM: ...has productive cough, large amounts of sputum noted...
12:01 AM: ...continues to have large amounts of secretions per trach...
4:00 AM:....continues on trach collar...continues to have lots of secretions..."

11/24/09 7:00 AM: ...Productive cough present with large amounts of secretions noted...
1:00 PM: Education provided to sitter regarding suctioning and tube feeding.
3:00 PM: ...RT (Respiratory Therapy) educated sitter on suction and sitter demonstrated back to Respiratory Therapist. Patient plans to be discharged home 11/25/09...
7:00 PM: ...Cough noted and productive with frothy white sputum...

11/25/09 8:00 AM: "Alert, lungs congested, productive cough, greenish tan...trach O2 at 25 %...family member present."
Vital Signs: 98.8, 93, 28, 139/67.

11/25/09 10:45 AM: Patient taken by ambulance home...(The RN who documented this assessment is no longer employed by the hospital
and could not be interviewed).

Multidisciplinary Patient/Family Education
Record (10/22/09 - 11/15/09) reveals no documentation on this form that trach and or PEG care was provided to the patient's husband or sitter as ordered by the physician.

Case Management Discharge Planning:
11/11/09 10:00 AM: "As per (name of MD) instructions - DCP of home with vent training to be done. Patient and husband agree. Yesterday,
(name of physician) agreed with training husband and sitter for suctioning and trach care. They desire training esp. on Monday, Thursdays and Fridays."

11/12/09 11:10 AM: "Spoke with (name of Respiratory Therapist) at (name of Home Health Agency) re home vent - possibly and for sure
trach care @ home. He will visit with patient and husband later today." (There is no further documentation by case management.)

Ambulance Service: Patient Care Report
Date of Service: 11/25/09.
Patient transport began at 10:50 AM;
Arrived at PI # 1's residence at 11:50 AM.

Chief Complaint: Transfer - Non-emergency

Narrative: "...to Hospital #1 to find (age) female lying supine in bed. Patient was in the hospital due to Pneumonia and Respiratory Failure. Patient was on 8 lts (liters) via trach. Respiratory said she would not be on oxygen at home, but when I checked her O2 sat it was around 90-93...I put her back on oxygen...transported patient to residence. Left in care of husband."

Interviews:

During an interview with the complainant on 9/15/10 at 3:00 PM, he stated he observed green secretions around PI # 1's trach on the morning of discharge (11/25/09). The complainant reports he asked a "male nurse" (name unknown) about the secretions. Reportedly the nurse stated, "She's going home today," and did not answer the complainant's question. The complainant stated the patient was not as well at discharge as she had previously been. The complainant stated Hospital # 1 was, "Actively managing revenue flow instead of patients." After PI # 1 was discharged home, her O2 saturation could not be sufficiently maintained. The patient was transported to the ER at Hospital # 2 and admitted with "double pneumonia" on 11/25/09.

During an interview with EI # 3, Staff RN, on 11/17/10 at 9:50 AM, the RN stated there is no designated patient/family educator. According to the RN, both the respiratory therapists and the nurses receive copies of the physician's order for education of family regarding trach care. The education is documented in the assessment notes. "I would say it should be a week or two before they go home so they can feel comfortable with giving the care." The RN was asked how staff knows the specific education to provide. The RN said, "We have policies, but I don't know any specific guidelines we go by, but I personally use the policy guidelines." The RN was not sure what guidelines are used by other nursing staff or respiratory staff.

During an interview with the Director of Clinical Services, DCS, (EI # 4) on 9/17/10 at 9:15 AM, the Director stated the nursing staff is responsible to make sure family education is done. Nursing staff is responsible for notifying respiratory and other departments about the need for family education, "But no one person is responsible to make sure the families and or patients receive the education ordered by the doctor." The DCS was asked about the teaching criteria used by staff, where the teaching and names of persons educated is documented and and the specific information that is taught. According to the DCS, there are no specific guidelines.

During an interview on 9/17/10 at 11:15, EI # 5, the Corporate Director Clinical Operations, verified she was the Director of Clinical Services at Hospital # 1(LTAC) from 3/09 though 4/10. The Director states "staff" is responsible for family and sitter education when ordered by a physician.
Staff responsible includes Respiratory and Nursing staff. There is no dedicated patient/family educator. Patient/Family education
and return demonstration should be documented on the Multidisciplinary Patient/Family Education Record. "The POC (Plan of Care) doesn't tell me
anything...should be more specific." (The Director was referring to the education record where nursing staff documented "POC" (plan of care) to describe the content of the teaching provided to PI # 1's family/sitters in the medical record).

During an interview with the attending physician, EI # 6, on 9/17/10 at 3:00 PM, he stated PI # 1 is bed bound and prone to pneumonia. Prior to PI #1's admission to Hospital # 1, the patient developed Acute Respiratory Failure due to increased Tegretol. PI # 1 developed pneumonia and required ventilator support. PI # 1 has a history of Aspiration Pneumonia. According to the physician, he would not discharge a patient with a diagnosis of pneumonia "regardless of insurance."

LTAC (Hospital # 1's) Policies and Procedures:
Guideline: Education, Patient and Family
Policy # HD-RT 905.04
Original Date: 3/1/08 Revision Date: 7/15/10
I. "Guideline: Respiratory Care will provide appropriate education to patients and their families regarding their treatments, medications and equipment used while in the hospital to ensure their knowledge in treatment, procedures and equipment..."

II. Procedure
"...C. Home ventilator patients and family caregivers will be instructed by the therapist and Home Health Agency of their choosing on the proper techniques of suctioning, tracheostomy care and ventilator management if needed. The family caregiver should be able to demonstrate all techniques properly before the discharge of the patient.
D. Patient/family education will be documented on the Multidisciplinary Education Record in accordance with hospital procedure."

Policy #: HD-NUR 405.01
Original Date: 3/1/08
Effective Date: 3/1/08
I. "Guideline: ....the nursing department will establish and develop resource materials for patient/family education. The education resources will focus on...adults and elderly with acute and chronic medical conditions..".

"As education is provided, the clinician will document the content that was provided, the educational method, the patient's apparent comprehension of the of content, and the need for additional education or reinforcement in
the medical record...Educational resources are available to nursing personnel..." Hospital # 1's staff did not follow facility policies relative to discharge planning.

A review of the Emergency Transport System (ETS) document dated 11/25/09 revealed a call was received at 4:13 PM from PI # 1's residence. The chief complaint was Respiratory Distress. At 4:24 PM EMS responded to an "immediate emergency" for patient transport to
Hospital #2. "Pt. has new trach and her husband states he has had to suction it several times. Pt's low O2 sat. improved after suction...pt. treated per resp. distress protocol, suction and O2 (Oxygen) administered...pt. transported to Hospital #2 at 4:40 PM."

Hospital # 2 (Acute Care Hospital), Emergency
Department Record Includes:
ED Triage: 11/25/09 at 4:50 PM
Patient arrived via ambulance
Chief Complaint: "Excessive Secretions, Low O2 Sat. Pt. discharged today from Hospital # 1 after being weaned from vent. Spouse reports pt. has had excessive secretions today and sats kept dropping in 80's. ETS reports that O2 sat was 84% on their arrival, but after suctioning, sat
came up to 100%....Spouse thinks it may be something wrong with his suction equipment at home."

MD Evaluation: 11/25/09 7:59 PM:
Chief Complaint: Low oxygen saturation
History: "This patient was recently discharged
from (Hospital # 1) after being weaned
from the ventilator. She was at home...brought
here for evaluation...Upon arrival, she was still
having some drainage, discharge. Some of it
was green looking as was reported. They
were able to suction a lot of this out. Her sats
were up in the mid 90's, 95-97 range, while
on oxygen here. However, when off of the
oxygen, her sats were in the 87-90 range."

Physical Examination: Lungs - show diffuse rhonchi.

Medical Decision Making: The patient is here because of possible recurrent pneumonia and low oxygen saturation.

Hospital # 2's History and Physical
11/26/09 Includes:

History: ...Patient discharged from an LTAC (Long Term Acute Care), Hospital # 1, on the day of admission after being successfully weaned from the ventilator. She developed respiratory distress with decreased oxygen saturation and presented to the emergency department. She had an
abnormal chest x-ray and would decompensate when changed from supplemental oxygen over her tracheostomy to humidified air. Therefore, admission for evaluation and management was indicated.

Discharge Summary:
Date of Discharge: 12/21/09
Hospital Course: Patient required a stay in the intensive care unit. She did eventually wean from the ventilator and was treated for drug resistant pseudomonas. She still has pseudomonas colonization, but is felt not to have an active infection with pseudomonas at this time. She is at high risk for readmission due to aspiration pneumonia. She has a tracheostomy and a PEG tube and will be allowed home with trach care and PEG feeding.

During telephone interviews with an RN from the Home Health Agency on 9/27/10 at 12:25 PM and 12:50 PM, the RN stated the agency that would actually provide service to the patient received PI # 1's home health orders via fascimile on 11/25/09 around 1:00 PM. According to the RN, patients are usually seen by the agency the following day (the day after discharge). PI # 1 was not seen by the home health agency staff on
11/25/09. PI # 1 was first seen by the home
health agency in December 2009 after discharge
from Hospital # 2.

This citation is written as a result of the investigation of Complaint Number AL0002367.