Rehabilitation Hospital of Atlanta

“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: 45841 Based on interview, records review, and facility protocol review, the facility failed to ensure staff adhered to policy and procedure of the hospital by failing to apply skin protectant cream for 3 (Patients #1, #2, and #3) of 3 sampled patients reviewed for skin breakdown prevention. The failure resulted in one patient acquiring moisture-associated skin damage. Findings included: An undated facility protocol titled, “Skin Protection Protocol,” indicated, “Intact Skin Management: 1. After cleansing, apply skin protectant cream. a. For non-irritated skin use a silicon barrier cream. b. For irritated skin use a dimethicone-based cream. c. Do not use moisturizing cream. 2. Apply gently, covering all skin likely to be exposed to moisture, urine, or feces. Moisture Associated Skin Damage (MASD) management: 1. After cleansing, apply [name]Moisture Barrier cream. a. Note: ensure all urine and fecal material is cleansed away. Some barrier creams may not be completely removed with cleansing. This is normal and aggressive scrubbing to remove may harm skin. 2. Apply gently, covering all skin likely to be exposed to moisture, urine, or feces.” Patient #1’s “History and Physical” dated 11/06/2025, revealed the facility admitted the patient on 11/05/2025 due to severe spinal cord injury due to epidural metastatic disease. Patient #1’s “Progress Notes” dated 11/16/2025 at 6:19 PM, revealed the patient was assessed to have moisture-related excoriation to the sacral area. Patient #1’s “Barrier Protection Applied” flowsheet revealed barrier protection was applied on 11/17/2025 at 12:22 AM and 6:48 AM. There was no further documentation of barrier protection being applied during the patient’s admission from 11/05/2025 to 11/17/2025. Patient #2’s “History and Physical” dated 11/29/2025, revealed the facility admitted the patient on 11/28/2025 due to debility leading to impairments in functional mobility, ambulation, and activities of daily living. Patient #2’s medical record did not reveal any evidence that barrier protection cream was applied during the patient’s admission from 11/28/2025 to 12/09/2025. Patient #3’s “History and Physical” dated 12/01/2025, revealed the facility admitted the patient on 12/01/2025 due to an acute cerebrovascular accident. Patient #3’s “Barrier Protection Applied” flowsheet revealed barrier protection was applied on 12/03/2025 at 2:56 PM. There was no further documentation of barrier protection being applied during the patient’s admission from 12/01/2025 to 12/15/2025. During an interview on 01/09/2026 at 10:45 AM, the Chief Nursing Officer stated the only documentation of barrier cream application for Patient #1 were on 11/17/2025 at 12:22 AM and 6:48 AM, for Patient #3 on 12/03/2025 at 2:56 PM, and there were no documentation of barrier cream application for Patient #2. During an interview on 01/09/2026 at 11:23 AM, Registered Nurse #10 stated if the patient was incontinent, staff would document skin breakdown precautions, but if the patient were alert and did not have risk factors, the precautions would not necessarily be documented.”

“PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS CFR(s): 482.13(d)(1) The patient has the right to the confidentiality of his or her clinical records. This Standard is not met as evidenced by: 52070 Based on staff and patient interviews, medical record review, and facility policy review, it was determined that the facility failed to protect the confidentiality of a patient’s medical record for one patient (P) (P#3) three patients reviewed for medical record confidentiality. Specifically, facility staff gave P#2 their discharge instructions but included P#3’s “Pre-admission Screening Form” as part of the packet which included protected health information (PHI). Findings included: The facility’s “HIPPA [Health Insurance Portability and Accountability Act] Policies and Procedures Manual,” “2021 Edition,” included a policy, titled, “101.2: SAFEGUARDING AND STORING PROTECTED HEALTH INFORMATION,” that indicated, “[The facility’s corporation’s name] will put in place reasonably safeguards to ensure that Protected Health Information (PHI) is not intentionally or unintentionally Used or Disclosed in a manner that would violate the Privacy Rule or any other federal or state regulation governing the confidentiality and privacy of PHI.” The policy revealed, “D. Safeguards for Written PHI. All documents containing PHI should be stored appropriately to reduce the potential for incidental Access, Use, or Disclosure. Documents should not be easily accessible to any unauthorized staff or visitors. Physical safeguards should be used such as locking drawers and offices, and minimizing the amount of paper left in public areas .” P#2’s “Facesheet” indicated the facility admitted the patient on 03/25/2025 and discharged the patient on 04/03/2025. P#3’s “Facesheet” indicated the facility admitted the patient on 04/03/2025 and discharged the patient on 04/15/2025. During a telephone interview on 05/27/2025 at 11:20 a.m., P#2 stated the nurse who reviewed their discharge instructions had left a couple pieces of paper that did not belong to them, and they were attached to the discharge instructions. P#2 stated the nurse told them that they did not need those papers, and thought the nurse took them, but they were still attached to the discharge instructions. P#2 stated the pieces of paper had another patient’s health information on them. An email from P#2 dated 05/27/2025 included attached images of P#3’s “Pre-admission Screening Form” from the facility. Information on the form included P#3’s demographic information, which included their name, address, phone numbers, date of birth, and gender; referring information, including the facility referring the patient to this facility, their admission date to the referring facility, the referral date, the patient’s primary care physician, and the referring physician; and insurance information, including their Medicare identification number. During an interview on 05/27/2025 at 1:43 p.m., Registered Nurse (RN) #1 stated his expectations were for no other patient’s medical record information to be left in another patient’s room or given to another patient. He stated that the only reason the “Pre-Screening Form” might have been left in another patient’s room was because a nurse printed it for an admission and the nurse who discharged P#2 printed out discharge instructions for P#2 using the same printer, and the nurse who discharged P#2 grabbed all the paperwork on the printer without noticing. During an interview on 05/29/2025 at 9:47 a.m., the Chief Nursing Officer (CNO) stated P#2 mentioned that they had a document that was left in their room when they were discharged but the patient did not give any specifics, such as name or who it was from, to take corrective action.”