Northside Hospital

“ORGANIZATION OF REHABILITATION SERVICES CFR(s): 482.56(a) The organization of the service must be appropriate to the scope of the services offered. This Standard is not met as evidenced by: 52769 Based on review of facility policies and procedures, medical record review, and staff interviews, it was determined that the facility failed to ensure that staff provided physical therapy (PT) and occupational therapy (OT) as ordered for one patient (P) (P#1) of four sampled patients (P#2, P#3, and P#4). Specifically, P#1 was hospitalized from 2/19/25 to 3/22/25 and failed to receive six days of OT and seven days of PT as ordered. Findings include: A review of the facility’s policy titled “Prioritization of Patient Care,” policy # 10153, last revised 3/18/25, revealed that the purpose was to determine prioritization of patient care for all therapy patients when necessary. 1. Patients, unless prohibited by medical status, received assessment and/or treatment as ordered by the physician. A review of the facility’s policy titled “Documentation Guidelines,” policy # 24285, last revised 5/5/25, revealed that a patient’s refusal of treatment, reason unable to treat patient, if clinician determined treatment should be withheld, cancellation of treatment, or a failure to appear for appointment was documented in the patient’s medical record. A review of the facility’s policy titled “Rehabilitation Services Scope of Services - Systems,” policy# 14519, last revised 5/5/25, revealed that in-patient clinical services were to be provided at the facility that were ordered by referrals from licensed physicians, non-physician practitioners, physician assistant, advanced practice registered nurse practitioners, and neuropsychologist for all occupational, physical, and speech language pathology therapy. A review of the medical record for P#1 revealed an order for Occupational Therapy (OT) Acute Treatment dated 2/20/25 for every morning beginning 2/21/25 at 4:00 a.m. The order was discontinued on 3/22/25 at 3:01 p.m. In addition, a review of “Orders” dated 2/21/25 at 6:24 p.m. revealed an order for Physical Therapy (PT) Acute Treatment beginning 2/22/25 at 4:00 a.m. every morning. The order was discontinued on 3/22/25 at 3:01 p.m. Further review of the medical record for P#1 failed to reveal documentation of P#1 receiving OT or deferment of therapy on the following dates: 2/22/25 2/23/25 3/9/25 3/14/25 3/19/25 3/20/25 A continued review of the medical record for P#1 failed to reveal documentation of P#1 receiving PT or deferment of therapy on the following dates: 2/22/25 2/23/25 3/2/25 3/5/25 3/9/25 3/16/25 3/19/25 An interview was conducted on 9/10/25 at 1:20 p.m. with Physical Therapist (PT) AA in the facility’s conference room. PT AA stated that physicians placed therapy orders after which PT AA assessed the patient, established a plan of care, and set the frequency of the therapy. PT AA explained that if a patient declined to participate in therapy, PT AA explored the reasons, created an alternate plan, and rescheduled. PT AA stated that if both patient and/or family refused, PT AA stated that she always attempted to go back later in the day and see the patient. PT AA said she documented all therapy deferrals in the medical record. An interview was conducted with Director of Rehabilitation Services and Interventional Pain and Spine (DRS) CC on 9/10/25 1:57 p.m. in the conference room. DRS CC stated that PT and OT therapists were provided with a list of patients to see each day. Her expectations were that therapist should try to see all patients on their scheduled list. If unable to provide therapy to a patient due to time restraints, the therapist should inform their manager at the end of the day. DRS CC said no documentation was completed for the patient who was unable to be seen due to scheduling. DRS CC said that if therapists were unable to see a patient due to refusal by the patient/family or a health concern prevented the patient from participating in therapy, it should be documented in the patient’s medical record under deferment. A telephone interview was conducted with PT DD on 9/10/25 at 2:15 p.m. PT DD explained that if PT was deferred for a patient, documentation was entered in the patient’s medical record. In addition, any missed PT visits were also documented accordingly. An interview was conducted with Manager of Rehabilitation Services (MRS) EE on 9/10/25 at 2:47 p.m.in the conference room. MRS EE’s expectations were that therapists try to see all patients on their daily schedule. If a therapist did not have time to see a patient, the therapist should inform their manager at the end of the day. No documentation would be completed in the patient’s medical record if the patient was not seen due to scheduling. MRS EE stated a list was collected at the end of each day that consisted of patients who were not seen. MRS EE continued to reveal that the late therapist could access the list and see the patient if time allowed. The department scheduler would print a list of patients from the automated system each morning for patients who were scheduled for therapy. The patients who did not receive therapy the day prior would be on the printed list and that therapists would prioritize patients by the acuteness of condition and need. MRS EE stated that if it were not appropriate for a patient to receive therapy, the therapist would document in the deferred notes section of the patient’s medical record. In addition, if a patient and/or family member refused therapy services, MRS EE stated that he expected therapist to document the refusal in the patient’s medical record.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 46188 50617 Based on a review of medical records, facility policies and procedures, and staff interviews, it was determined that medical records failed to indicate nursing documentation of turning and positioning for one patient (P) (P#1) of four (P#2, P#3, and P#4) sampled patients. As a result, it was identified that P#1 suffered a hospital-acquired pressure injury (injuries to the skin and underlying tissue that occur in patients during their stay in a healthcare facility). Findings Included: A review of medical records revealed that P#1 was admitted to the facility on 5/6/25 at 9:20 p.m. with the diagnosis of altered mental status (change in mental function), and diarrhea. A review of History and Physical (H&P) done on 5/6/25 at 10:02 p.m. revealed that P#1 was bedbound (not able to move around safely or comfortably), had history of dementia, PEG tube (percutaneous endoscopic gastrostomy that is feeding tube insertion through the skin and the stomach wall) in place for feeding support, dysphagia (difficulty swallowing). A review of initial Nursing Assessment of Integumentary (skin) system on 5/7/25 at 12:32 a.m. done by Registered Nurse (RN) AA revealed that P#1 came in with left toe wound due to ingrown toenail, wound dressing was clean, dry and intact. P#1 also had blister on the right elbow and P#1’s Braden Scale score was 13 (moderate risk) (Braden Scale Risk Assessment for pressure injuries: 16-18 low/mild risk, 13-15 moderate risk and 12 or less, high risk). Further review of medical records for P#1 revealed the routine wound care orders were placed on 5/7/25 at 7:51 a.m. and included moisture barrier cream with morning care and after each episode of incontinence. Continued review of P#1’s MR revealed initial Wound Care Consult done on 5/8/25 at 12:31 p.m. by Wound and Ostomy Care Nurse (WOCN) to evaluate the PEG insertion site. Continued review of P#1’s MR revealed Progress notes done by Registered Nurse on 5/11/25 at 5:53 a.m., 5/12/25 at 8:27 a.m., and 5/13/25 at 8:08 p.m., revealed that P#1 refused all every two hours turning and repositioning and that P#1 was educated. Review of Nursing Assessment of Integumentary (skin) system on 5/14/25 by Licensed Practical Nurse (LPN) BB revealed that P#1 developed a pressure injury in the sacral area, WOCN consult was placed for wound evaluation. P#1’s Braden Scale Score (scale used to predict a patients risk of developing a pressure injury) on 5/14/25 was 13 (moderate risk). A review of the “Wound Care Progress Notes,” on 5/14/25 at 2:14 p.m. completed by Wound and Ostomy Care Nurse (WOCN) RN CC for evaluation of wound between sacrum and base of vagina revealed that the deep tissue pressure injury was noted to P#1’s sacrum with purple non-blanchable (when pressed does not turn white) discoloration, and some open areas, red and yellow necrotic (dead) tissue was noted to the right side of sacrum, no signs of infection and there was some friction injury component. A review of flow sheets section titled “Activities of Daily Living” that includes “positioning,” failed to revealed documentation of P#1 being repositioned or turned every two to three hours for following dates: 5/7/25 (day and night shifts), 5/8/25 (day and night shifts), 5/9/25 (day and night shifts), 5/10/25 (day and night shifts), 5/11/25 (day and night shifts), 5/12/25 (day and night shifts), 5/13/25 (day and night shifts), 5/14/25 (night shift), and 5/15/25 (day shift). A review of the facility’s policy titled “Patient Assessment,” policy #20629, last reviewed 6/20/23, revealed that the purpose of the policy was to provide a standard approach throughout the organization for patient assessment; to include each patient’s physical, psychological, and social status. Continued review revealed, Reassessment: 1. Each patient is reassessed at regularly specified times related to the patient’s course of treatment. The objective of the reassessment is to assure that the patient’s status is periodically reviewed so care decisions remain appropriate. 3. Reassessment will be documented in the medical record. 4. Time of the assessment will be reflected in the medical record. A review of the facility’s policy titled “Skin Integrity Protection and Wound Management - SYSTEM,” policy #12402, last revised 3/24/25, revealed that the purpose of the policy was to provide consistent care for prevention and treatment of skin breakdown and the management of acute, chronic, traumatic, and surgical wounds in an optimal wound healing environment. Continued review revealed, Skin Integrity Interventions: 1. Assess skin every shift. 5. Reposition patient at least every two to three hours or based on individual patient need and tissue tolerance. Continued review revealed, routine skin assessment to be performed on all patients upon admission, every shift, and whenever patient’s condition or level of care changes. An interview was conducted with Licensed Practical Nurse (LPN) BB on 6/11/25 at 10:45 a.m. in the conference room of Five C (Medical/Surgical) Unit. LPN BB stated that she did recall P#1 and on 5/14/25 she received the report from the night shift that P#1 refused to be repositioned all night due to pain. LPN BB further stated that she gave pain medicine to P#1 and waited an hour before turning P#1 so she (P#1) would tolerate being turned. LPN BB also stated that when she turned P#1 on her side, LPN BB discovered pressure injury on her (P#1) sacral area, LPN BB applied the barrier cream and consulted WOCN. During an interview on 6/11/25 at 11:57 a.m., with Nurse Manager (NM) II in an office, NM II said that the expectation for nursing documentation of assessments is to be done every shift. NM II said that if skin changes or new wounds are noted during an assessment, then nursing staff should document it and escalate care to the Charge Nurse (CN) and physician for further direction. During an interview on 6/11/25 at 12: 32 p.m. with Clinical Documentation Specialist (CDS) JJ in an office, CDS JJ said that nurses are expected to document a full head-to-toe assessment every shift. CDS JJ said that for wounds and any lines or drains, such as a feeding tube, they must document on it once a shift. A phone interview was conducted with Wound Care and Ostomy Nurse (WOCN) CC on 6/12/25 at 1:59 p.m. WOCN CC stated that she had seen deep tissue injury develop in 24 to 72 hours. WOCN CC also stated that nurses can use barrier cream and mepilex (absorbent foam dressing) but if patient requires more than that then wound care consult would be required so the orders for dressing can be placed. An interview was conducted with the Director of Accreditation and Patient Safety (DAPS) KK and Quality and Accreditation Coordinator (QAC) LL on 6/11/25 at 2:45 p.m. in the facility’s conference room. DAPS KK and QAC LL reviewed several flow sheets in electronic medical record of P#1 and DAPS KK and QAC LL acknowledged that there were several gaps in the flow sheet in documenting turning and repositioning P#1 every two to three hours.”