Our Lady of Lourdes Regional Medical Center, Inc.

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to ensure accountability of the medical staff for the quality of care provided to patients. This deficient practice is evidenced by failure of the provider to document changes in the diagnosis and care plan for 1 (#1) of 3 (#1-#3) patient records reviewed. Findings: Review of the hospital “Bylaws, Rules and Regulations of the Medical Staff,” last revised 03/11/2025, revealed in part: “Rules and Regulations: F. Attending Practitioner Requirements: All patients who are admitted to the Hospital will be duly informed by their attending Practitioner as to their diagnosis and care plan. G. Medical Records: The attending Practitioner shall be responsible for the preparation of a complete medical record for each of his/her patients. The medical record shall include unique patient identification data; admission and discharge dates; complete history and physical examination; provisional admitting diagnosis and final diagnosis; medical staff orders; progress notes; nursing documentation and care plans; a record of all medications, medical care and treatments; discharge summary; clinical laboratory, pathology, nuclear medicine, radiology and diagnostic reports; consultation reports, if applicable; pre-anesthesia note, anesthesia record and post-anesthesia note, if applicable; operative report, if applicable; autopsy report if applicable; discharge plan; consents; and any other reports pertaining to the patient’s care.” A review of Patient #1’s medical record revealed Patient #1 was admitted on 01/16/2025. Review of Patient #1’s admit History and Physical revealed in part: Patient arrived for ICU services for respiratory failure. 60 year old male with PMH of CVA with hemorrhagic conversion s/p craniotomy in 2022, chronic RLE DVT, Paroxysmal Atrial Fibrillation, Ventricular Tachycardia. Patient was intubated and had reported seizure activity prior to arrival. Patient started on levophed drip. Assessment/Plan: Principal Problem: Acute Respiratory Failure with Hypoxia and Hypercapnia Active Problems: Shock Circulatory, Chronic DVT, Morbid Obesity, Seizures, Acute CHF Full Code Physical Exam: Skin: Warm and dry, no rashes. A review of Nurse Assessment documentation for Patient #1 revealed in part, the following skin and pressure Injury documentation: 01/16/2025 5:50 PM- Skin Condition: Warm; Dry. Foam Dressing to Sacrum. 01/17/2025 8:30 AM- Incontinence Protective Devices: Absorbent pad. Skin Care: Foam dressing to sacrum. 01/29/2025 8:00 AM- Wound Pressure Injury Left Buttock. Pressure Injury Stage: Deep Tissue; Wound Bed Description: Maroon/Purple area of intact skin; Wound Color: Purple; Peri-wound Assessment: Dry, Intact, Blanchable; Wound Bed Edges: Attached edges. 02/05/2025 2:58 PM- Wound Pressure Injury Left Buttock. Pressure Injury Stage: Deep Tissue; Wound Bed Description: Maroon/Purple area of intact skin; Wound Color: Maroon, Purple; Treatments: Cleansed with warm water; Dressing: Bordered Foam. Education on pressure injury prevention complete? Answer: Yes with wife. 02/11/2025 8:00 PM- Wound Pressure Injury Left Buttock. Pressure Injury Stage: Unstageable; Wound Bed Description: Eschar; Wound Color: Black; Peri-wound Assessment: Blanchable; Treatments: Zinc-Oxide paste; Dressing: Open to air. A review of Patient #1’s wound care consult from 02/11/2025 at 9:00 AM revealed in part: Consult Orders: Inpatient consult to wound care nurse ordered by S5MD at 02/11/2025 at 3:26 AM. Wound care consult received for pressure injury. Patient noted laying in bed, intubated. Wife at bedside. Head-to-toe skin assessment completed. Wound care provided. Patient tolerated well. Report and recommendations given to patients nurse. Wound Care Recommendations: Wound care 2 times daily and PRN, First occurrence on Tuesday 02/11/2025 at 10:51 AM. Incontinent patient Instructions: Remove Pressure Ulcer Prevention (PUP) dressing if present because of contraindication, Apply Zinc oxide cream to sacrum, buttock, perianal area, and bilateral groin. For Prevention and Treatment: For use in skin folds, sacrum, buttocks, perianal area, groin. For treatment of pressure injury to left buttock: Apply zinc oxide paste BID and PRN to area due to fecal incontinence. Skin area instructions: Use a wedge for support and alignment of wound area, Heel lift boots on at all times. Continue use of bariatric bed, Turn Q2 hours, use wedge, float heals, use protective ointment in skin folds for erythema/rashes, Protective ointment to sacrum/buttocks if incontinent. Pressure Injury Buttocks Left: Pressure Injury Stage: Unstageable; Wound Bed Description: Eschar, Drainage; Drainage Amount/Description: Scant, Serosanguineous; Wound Color: Red/Black; Peri-wound Assessment: Blanchable, Excoriated; Wound Bed Edges: Attached edges; Wound Length/Width (cm): 9cm/9cm; Treatments: Cleansed, Zinc-oxide paste; Cleansed With: Soap and water. Pressure Injury Prevention Education: Yes. Review of Patient #1’s Discharge Summary revealed in part: Discharge Date: 02/19/2025 Primary Discharge Diagnosis: Acute respiratory failure with hypoxia and hypercapnia Secondary Discharge Diagnosis: Acute respiratory failure with hypoxia and hypercapnia, Chronic DVT, Shock Circulatory, Morbid obesity, Seizures, Acute CHF, Atrial Fibrillation Resolved Problems: No resolved hospital problems Discharge Condition: Stable Discharge Disposition: Home-Self Care Details of Hospital Stay Presenting Problem: Acute Respiratory Failure Hospital Course: 60 year old male with history of CVA requiring decompressive hemicraniectomy in 2022 left in a chronically dependent and poorly responsive state admitted with acute hypoxic respiratory failure requiring mechanical ventilation initially secondary to pneumonia. Unable to wean from mechanical ventilation no status post tracheostomy. Doing well with nocturnal volume ventilator support via tracheostomy and minimal supplemental O2 throughout the day. Stable for discharge home with all necessary equipment to continue current level of respiratory support in the home setting. Complications: None Activity Instructions: Normal activity as tolerated Other Instructions: Call MD for worsening symptoms, Follow-up with PCP as needed. Things you need to do: Follow-up with PCP as needed No future appointments. Time Spent for discharge: less than 30 minutes. Further review of discharge summary failed to reveal documentation related to pressure injuries. Review of provider progress notes for Patient #1 failed to reveal a documented assessment of the pressure injury to the left buttock. Further review of provider progress notes failed to reveal that the pressure injury to the left buttock was added to the provider’s ongoing diagnosis or in the provider’s care plan. In an interview on 04/14/2025 at 2:03 PM, S1DOQ and S3DPSR confirmed there was no documented assessment of the pressure injury to the left buttock by a provider in Patient #1’s medical record. S3DPSR confirmed the provider did not include the pressure injury to the left buttock in their diagnosis or care plan.”

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to ensure that the exercise of Patient Rights requirement was met. This deficiency is evidenced by failure of the hospital to provide the patient representative with treatment options, risks, and benefits through treatment plan review following a change in patient condition for 1 (#1) of 3 (#1-#3) patient records reviewed. Findings: A review of hospital form #83986 titled, “Patient’s Bill of Rights,” last revised 10/16, revealed in part: “ The patient has a right to be informed by the attending physician and other providers of health care services about any continuing healthcare requirements after his/her discharge from the hospital. The patient shall also have the right to receive assistance from the physician and hospital staff in arranging for required follow-up care after discharge.” Review of the hospital “Bylaws, Rules and Regulations of the Medical Staff,” last revised 03/11/2025, revealed in part: “Rules and Regulations: F. Attending Practitioner Requirements: All patients who are admitted to the Hospital will be duly informed by their attending Practitioner as to their diagnosis and care plan.” A review of Patient #1’s medical record revealed Patient #1 was admitted to ICU on 01/16/2025 with a diagnosis of Acute Respiratory Failure with Hypoxia and Hypercapnia. A review of Nurse Assessment documentation for Patient #1 revealed in part, the following skin and pressure Injury documentation: 01/16/2025 5:50 PM- Skin Condition: Warm; Dry. Foam Dressing to Sacrum. A review of Patient #1’s wound care consult from 02/11/2025 at 9:00 AM revealed in part: Pressure Injury Buttocks Left: Pressure Injury Stage: Unstageable; Wound Bed Description: Eschar, Drainage; Drainage Amount/Description: Scant, Serosanguineous; Wound Color: Red/Black; Peri-wound Assessment: Blanchable, Excoriated; Wound Bed Edges: Attached edges; Wound Length/Width (cm): 9cm/9cm; Treatments: Cleansed, Zinc-oxide paste; Cleansed With: Soap and water. Review of Patient #1’s Discharge Summary revealed in part: Discharge Date: 02/19/2025 Discharge Condition: Stable Discharge Disposition: Home-Self Care Presenting Problem: Acute Respiratory Failure Activity Instructions: Normal activity as tolerated Other Instructions: Call MD for worsening symptoms, Follow-up with PCP as needed. Things you need to do: Follow-up with PCP as needed No future appointments. Further review of the discharge summary failed to reveal documentation related to pressure injuries. Review of Patient #1’s medical record failed to reveal documentation that the attending physician informed the patient representative of treatment options, risks, and benefits following the hospital acquired pressure injury to the left buttock. Further review of Patient #1’s medical record failed to reveal follow-up wound care after discharge for the pressure injury to the left buttock. In an interview on 04/14/2025 at 12:55 PM, S1SDOQ and S3DPSR confirmed there was no documentation that the physician discussed pressure injury treatment options with the patient representative. S3DPSR also confirmed that there was no documentation that Patient #1 received follow-up wound care for the pressure injury to the left buttock.”

“DISCHARGE PLANNING EVALUATION CFR(s): The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative). This Standard is not met as evidenced by: 50453 Based on record review and interview, the hospital failed to establish an appropriate discharge plan for each patient. This deficient practice was evidenced by failing to assist/provide Patient #1 with a discharge plan that included discharge instructions/education for wound care. Findings: A review of hospital policy number PCS-111 titled, “Plan for the Delivery of Care & Discharge Planning,” last revision date 09/2021, revealed in part: “POLICY: 2. All members of the health care team who are involved in direct patient care will participate in the collection of assessment/reassessment data. 3. This assessment process will determine the need for care and/or treatment, the type of care to be provided and the on-going care to be provided through the continuum of care. 4. The goal of assessment/reassessment process is to ensure effective communication among all members of the health care team and to provide the patient the best plan of care and treatment possible. 5. Care and/or treatment provided by all health-care professionals will be based on each patient’s specific needs. 8. Discharge Planning and Educational needs are assessed and identified upon admission and continuously reassessed throughout the patient stay. C. Discharge teaching will be communicated to the patient/significant other, and will include information about: self-care after discharge; treatment plan; recommended lifestyle changes; managing continuing care, signs and symptoms of complications. D. Education will include instruction in specific knowledge and/or skills needed by the patient/significant other to meet the patient’s ongoing health care needs, and discharge teaching needs including appropriate: diagnosis, disease concepts, and related treatments; safe and effective use of medication and other treatments; safe and effective use of medical equipment; rehabilitative therapies; available hospital and community resources and education programs for health promotion and disease related care; continuity of care; signs and symptoms of potential physical and psychosocial responses related to disease/treatment; diagnostic testing; psychosocial strategies to facilitate adaptation to disease/treatment (and those symptoms which should be reported to a health care professional).” A review of Patient #1’s medical record revealed Patient #1 was admitted to ICU on 01/16/2025 with a diagnosis of Acute Respiratory Failure with Hypoxia and Hypercapnia. A review of Patient #1’s wound care consult from 02/11/2025 at 9:00 AM revealed in part: Wound care consult received for pressure injury. Wound Care Recommendations: Wound care 2 times daily and PRN, First occurrence on Tuesday 02/11/2025 at 10:51 AM. For treatment of pressure injury to left buttock: Apply zinc oxide paste BID and PRN to area due to fecal incontinence. Skin area instructions: Use a wedge for support and alignment of wound area, Heel lift boots on at all times. Continue use of bariatric bed, Turn Q2 hours, use wedge, float heals, use protective ointment in skin folds for erythema/rashes, Protective ointment to sacrum/buttocks if incontinent. Pressure Injury Buttocks Left: Pressure Injury Stage: Unstageable; Wound Bed Description: Eschar, Drainage; Drainage Amount/Description: Scant, Serosanguineous; Wound Color: Red/Black; Peri-wound Assessment: Blanchable, Excoriated; Wound Bed Edges: Attached edges; Wound Length/Width (cm): 9cm/9cm; Treatments: Cleansed, Zinc-oxide paste; Cleansed With: Soap and water. Review of Patient #1’s After Visit Summary Discharge Instructions dated 02/19/2025 revealed in part: Instructions: Your medications have changed. Start taking: Calcium Carbonate, Sennosides-Docusate Sodium. Change how you take: Sotalol. Stop taking: Methylprednisolone. Review your updated medication list below. Your Nest Steps: Read these Attachments: After a Stroke: Your Self-Care Plan: Video (English) Activity Instructions: Normal activity as tolerated. Diet Instructions: Return to Previous Diet Other Instructions: Call MD for worsening symptoms; Discharge Condition: Stable; Follow-up with PCP as needed Ask your doctor where to pick up these medications: Calcium Carbonate, Sennosides-Docusate Sodium, Sotalol. Direct Oral Anticoagulant Prescription Information: Apixaban (Eliquis). Review of Patient #1’s Discharge Summary revealed in part: Discharge Date: 02/19/2025 Primary Discharge Diagnosis: Acute respiratory failure with hypoxia and hypercapnia Secondary Discharge Diagnosis: Acute respiratory failure with hypoxia and hypercapnia, Chronic DVT, Shock Circulatory, Morbid obesity, Seizures, Acute CHF, Atrial Fibrillation Resolved Problems: No resolved hospital problems Discharge Condition: Stable Discharge Disposition: Home-Self Care Details of Hospital Stay Presenting Problem: Acute Respiratory Failure Hospital Course: 60 year old male with history of CVA requiring decompressive hemicraniectomy in 2022 left in a chronically dependent and poorly responsive state admitted with acute hypoxic respiratory failure requiring mechanical ventilation initially secondary to pneumonia. Unable to wean from mechanical ventilation no status post tracheostomy. Doing well with nocturnal volume ventilator support via tracheostomy and minimal supplemental O2 throughout the day. Stable for discharge home with all necessary equipment to continue current level of respiratory support in the home setting. Complications: None Activity Instructions: Normal activity as tolerated Other Instructions: Call MD for worsening symptoms, Follow-up with PCP as needed. Things you need to do: Follow-up with PCP as needed No future appointments. Time Spent for discharge: less than 30 minutes. Review of Patient #1’s medical record failed to reveal discharge instructions that addressed education for wound care needs, related to the left buttock pressure injury. In an interview on 04/14/2025 at 12:38 PM, S3DPSR confirmed the above mentioned findings.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 44763 Based on observation and interview, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by non-functioning nurse call buttons on the hand rails of patient beds for 32 of 32 beds located in the inpatient unit at the offsite location. This failure had the potential to delay or prevent assistance from the nursing staff if the patient pressed the nurse call button on the bed hand rail rather than the hand held call light. Findings: In an observation on 07/02/2024 at 3:56 p.m. of the inpatient unit at the offsite location revealed the patient beds in rooms ‘a’ and ‘b’ had non-functioning nurse call buttons on the hand rails. In an interview during the observation S3SDN verified all 32 patient beds had non-functioning nurse call buttons on the hand rails.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to ensure a nurse supervised and evaluated the nursing care for each patient. This deficient practice was evidenced by failure to document a complete IV assessment per hospital policy on 3 of 3 (#1, #2, #3) patients reviewed. Findings: Review of the hospital’s policy titled “Insertion, Maintenance, & Discontinuation of IV therapy for all lines in adults (18Y or older) Peripheral IV, Midline, Medi port, PICC, Central Lines, and Art lines, Intraosseous Access” revision date 07/2023, revealed in part, Peripheral IV policy: 2.) Assess site every 4 hours and document phlebitis scale, infiltration scale. Patient #1 Review of Patient #1’s medical record revealed an admission date of 06/28/2024. Further review revealed Patient #1 had a left wrist 20 gauge IV that was placed on 06/28/2024 at 12:50 p.m. and removed on 07/02/2024 at 3:00 p.m. Review of the IV assessments revealed there was no documentation of the phlebitis scale or the infiltration scale on the following assessments: 07/02/2024 at 8:00 a.m. 07/02/2024 at 12:00 p.m. Patient #2 Review of Patient #2’s medical record revealed an admission date of 05/14/2024. Further review revealed Patient #2 had a right foreman 20 gauge IV that was placed on 05/14/2024 at 7:07 p.m. and removed on 05/16/2024 at 3:24 p.m. Review of the IV assessments revealed there was no documentation of the phlebitis scale or the infiltration scale on the following assessments: 05/15/2024 at 12:00 a.m. 05/15/2024 at 3:39 a.m. 05/15/2024 at 8:00 p.m. 05/16/2024 at 12:00 a.m. 05/16/2024 at 4:00 a.m. Patient #2 had a left forearm 22 gauge IV that was placed on 05/14/2024 at 9:32 p.m. and removed on 05/16/2024 at 3:26 p.m. Review of the IV assessments revealed there was no documentation of the phlebitis scale or the infiltration scale on the following assessments: 05/15/2024 at 12:00 a.m. 05/15/2024 at 3:39 a.m. 05/15/2024 at 8:00 p.m. 05/16/2024 at 12:00 a.m. 05/16/2024 at 4:00 a.m. Patient #2 had a left hand 22 gauge IV that was placed on 05/16/2024 at 3:25 p.m. and removed on 05/22/2024 at 3:24 p.m. Review of the IV assessments revealed there was no documentation of the phlebitis scale or the infiltration scale on the following assessments: 05/16/2024 at 8:00 p.m. 05/17/2024 at 12:00 a.m. 05/17/2024 at 4:00 a.m. 05/17/2024 at 8:00 a.m. 05/17/2024 at 12:00 p.m. 05/17/2024 at 4:00 p.m. 05/17/2024 at 8:00 p.m. 05/18/2024 at 12:00 a.m. 05/18/2024 at 4:00 a.m. 05/18/2024 at 8:00 p.m. 05/18/2024 at 11:49 p.m. 05/19/2024 at 3:28 a.m. 05/19/2024 at 8:00 p.m. 05/19/2024 at 11:18 p.m. 05/20/2024 at 3:40 a.m. Further review revealed there was no documentation of an IV assessment every 4 hours on 05/19/2024 from 8:00 a.m. - 8:00 p.m. and on 05/20/2024 from 3:40 a.m. - 12:00 p.m. Patient #2 had a right hand 22 gauge IV that was placed on 05/16/2024 at 3:25 p.m. and removed on 05/22/2024 at 3:24 p.m. Review of the IV assessments revealed there was no documentation of the phlebitis scale or the infiltration scale on the following assessments: 05/16/2024 at 8:00 p.m. 05/17/2024 at 12:00 a.m. 05/17/2024 at 4:00 a.m. 05/17/2024 at 8:00 a.m. 05/17/2024 at 12:00 p.m. 05/17/2024 at 4:00 p.m. 05/17/2024 at 8:00 p.m. 05/18/2024 at 12:00 a.m. 05/18/2024 at 4:00 a.m. 05/18/2024 at 8:00 p.m. 05/18/2024 at 11:49 p.m. 05/19/2024 at 3:29 a.m. 05/19/2024 at 8:00 p.m. 05/19/2024 at 11:18 p.m. 05/20/2024 at 3:40 a.m. Further review revealed there was no documentation of an IV assessment every 4 hours on 05/19/2024 from 8:00 a.m. - 8:00 p.m. and on 05/20/2024 from 3:40 a.m. - 12:00 p.m. Patient #3 Review of Patient #3’s medical record revealed an admission date of 07/02/2024. Further review revealed Patient #3 had a right hand 20 gauge IV that was placed on 07/02/2024 at 1:38 a.m. and removed on 07/04/2024 at 11:40 a.m. Review of the IV assessments revealed there was no documentation of the phlebitis scale or the infiltration scale on the following assessment: 07/04/2024 at 8:00 a.m. Further review revealed there was no documentation of an IV assessment every 4 hours on 07/02/2024 from 1:39 a.m. - 4:00 p.m. In an interview on 07/08/2024 at 2:12 p.m. S2DR verified IV assessments should be documented every 4 hours. S2DR verified the nurse should have documented the phlebitis scale and infiltration scale every 4 hours according to hospital policy.”