West Gables Rehabilitation Hospital

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 45329 Based on interview, records review and policy review, the facility failed to measure, analyze, and track quality indicators related to pressure injuries present on admission for 2 (Patient #1 and #4) of 5 patient records reviewed. Findings include: Review of Patient #1’s record revealed the following documentation: On 06/12/2024 at 3:04 PM - Wound Care Progress Note documented Admission Braden Scale Score 11. Wound/Ulcer Assessment: Patient #1 has venous ulcers noted on bilateral lower extremities. Noted on the left lower extremity. Patient #1 has two venous ulcers (medial and laterally located) to the right lower extremity. Also noted on the front of the shin. Wound care was completed pending bilateral venous ultrasound. Recommendations: Maintain decubitus precautions offloading, repositioning, pressure relief. On 06/20/2024 at 4:05 PM - Wound Care Follow-up Note documented Patient #1 is awake, confused, and lethargic. Braden Scale Score 12. Wound/Ulcer Assessment: Skin reassessment done; picture updated. Patient #1 has a sacral area suspected deep tissue injury. Picture taken on admission now is open and dark purple color in center. New order given and new measure taken. Left lower leg wound in healing process. Recommendations: Prevention and safety measure taken [air mattress, reposition every 2 hours, heel protectors or offload. Reassess skin every shift. Instructed nurse in care of patient to continue to monitor. During a tour of the unit conducted on 08/05/2024, observed Patient #4 lying in bed with head of bed elevated, wearing oxygen. Tube feeding via pump, turned off. Physical therapist at bedside stating Patient #4 speaks Spanish only and is being treated for injuries sustained from a motor vehicle accident. Interview conducted with the Chief Nursing Officer (CNO) on 08/06/2024 at 10:30 AM revealed the CNO position is responsible for quality assessment and performance improvement (QAPI) activities within the facility. Hospital acquired pressure injuries (HAPIs) require an incident report to be entered and is reviewed by the risk management/quality improvement team, the wound care physician, nutrition service, and prevention measures are implemented. The CNO stated wounds that are present on admission are not captured in the incident reporting system and the facility was unable to provide the number of pressure injuries present on admission (POA) that worsened, improved, or healed with wound care prevention measures/treatment. The facility provided the New/Worsened Wound Dashboard for Inpatient Rehabilitation (IRH) - Quality Measure Detail for January 2024 - July 2024. The dashboard reflects data for pressure injuries. Per the CNO, wounds present on admission (POA) are not included in the data collection which represents hospital acquired pressure injuries (HAPIs) only. Review of the facility’s Policy Number: RH-QU-116 (Florida) entitled Risk Management Plan (Florida); Last Revised: 10/01/2023 included but wasn’t limited to: The focus of the risk management plan is to provide an ongoing, comprehensive, and systematic approach to reducing risk exposures. Risk management activities include risk identification, risk assessment, risk mitigation, risk emergency planning, and risk tracking and reporting. Incident Reporting The risk management program includes an incident reporting system that is used to identify, report, track, and trend patterns of events with the potential for causing adverse patient outcomes or other injuries to people, property or other assets of the organization. The risk manager tracks and trends incident report data in order to report those findings to the quality/performance improvement department and the department(s) involved in the events for follow-up action. Review of the facility’s Policy Number: RH-QU-105 entitled Patient Safety Plan; Last Revised 07/01/2023 included but wasn’t limited to: The Grid of Patient Safety Events identified Stage II pressure ulcer not present on admission (not worsened from an existing stage) and Stage Ill or IV pressure ulcers not present on admission, not worsened from an existing stage, and is not related to vascular compromise or neuropathy as incidents. Review of the facility’s Policy Number: RH-QU-106 entitled Quality Assessment and Performance Improvement Plan; Last Revised 01/01/2023 included but wasn’t limited to: The Director of Quality Management {DOM) is the Hospital lead and coordinator of QAPI activities in the Hospital. He or She will participate in and provide support for: 1. Data collection; 2. Measurement and assessment; 3. Leading the Hospital’s QAPI efforts in identifying issues; 4. Establishing measures, benchmarks and criteria for evaluating clinical outcomes and patient experience; 5. Develop data collection tools and reports; 6. Monitor local, state and federal regulations. The facility failed to follow policies related to trending of data, establishing priorities measured by metrics and measuring outcomes and sustained improvement of pressure injuries present on admission.”