Schwab Rehabilitation Hospital

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 34411 Based on document review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482. 23, Nursing Services. Findings include: 1. The hospital failed to monitor the patient’s vital signs and notify physician of vital signs outside of ordered parameters. (See A-395 A) 2. The hospital failed to ensure the registered nurse completed wound assessments, as required. (See A-395 B) 3. The hospital failed to ensure patients with pressure ulcers were turned and repositioned every 2 hours. (See A-395 C) 4. The hospital failed to ensure the nursing care plan included education on post discharge urinary catheter care. (See A-396)”

“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: 40079 A. Based on document review and interview it was determined that for 1 of 3 patient (Pt.#1) clinical records reviewed for for monitoring vital signs, the hospital failed to ensure that patients’ vital signs were monitored as ordered and that the physician was notified of vital signs outside of parameters as ordered. Findings include: 1. The “Registered Nurse Job Description/Performance Appraisal and Competency Evaluation” (revised 3/2020) was reviewed and required, “Essential Functions and Duties ... 1.2. Monitors and recognizes obvious deviations from normal ... recognizes subtle alterations in the patient’s physiological and psychological status that may indicate potential or actual patient problems ... 5.0 Clinical Practice 5.1 Observes and records vital signs ... other diagnostic measurements and report changes or abnormalities to physician ...” 2. On 12/26/23, the clinical record for Pt.#1 was reviewed. Pt. #1 was admitted to the Hospital on 8/21/23 with a diagnosis of spinal cord injury and was discharged to home on 10/02/23. The clinical record included the following: -Physician order dated 09/05/23 at 5:45 PM, included, “Vital signs every 6 hours; Notify MD if P > (pulse greater than) 100 ... DBP < (diastolic blood pressure less than) 60.” -The Vital signs Flowsheets dated 9/5/23 at 4:24 PM through 10/2/23 at 9:45 AM, were reviewed and indicated that vital signs were not completed every 6 hours as required on the following dates: 9/5/23 at 4:24 PM - 9/7/23 at 8:38 AM (greater than 8 hours); 9/8/23 at 12:00 AM to 9/8/23 at 3:30 PM (greater than 14 hours), next vital signs were checked on 9/9/23 at 7:34 AM - 9/10/23 a 8:00 AM (greater than 24 hours); next set of vital signs were checked on 9/11/23 at 7:35 AM (greater than 22 hours); 9/13/23 at 3:00 PM to 9/13/23 at 1:51 AM (greater than 9 hours); 9/18/23 at 6:16 PM to 9/19/23 at 8:17 AM (greater than 14 hours). -Nursing Progress notes dated 8/22/23 through 10/02/23, were reviewed. The clinical record lacked documentation that the physician was notified of pulse and DPB outside of parameters (pulse greater than 100; diastolic blood pressure less than 60) for the following dates: 9/07/23 at 8:38 AM: Pulse 112; 9/9/23 at 8:15 AM: Pulse 120, BP 81/54; 9/13/23 at 9:45 AM: Pulse 117, and at 1:51 AM Pulse: 135; 9/15/23 at 9:00 AM: BP 83/52; 9/18/23 at 9:45 AM: Pulse 119, BP 89/59; 9/26/23 at 9:45 AM: Pulse 120, BP 70/53; 9/27/23 at 9:45 AM: Pulse 126, BP 68/38; 10/2/23 at 7:00 AM: Pulse 126, BP 87/51; 10/2/23 at 9:45 AM: Pulse 126, BP 80/50. 3. On 12/28/23 at 12:25 PM, an interview was conducted with the Nurse Manger (E#6). E#6 stated that nurses are given parameters for vital signs and are required to report any variances to the Attending Physician. For low bp, such as 87/51, the nurse should call the physician and document it in the clinical record. B. Based on document review and interview, it was determined that for 2 of 3 (Pt.#1 and Pt.#2) clinical records reviewed for wound care management, the hospital failed to ensure that a registered nurse completed wound assessments, including appearance and measurements, as required. Findings include: 1. The hospital’s policy titled, “Skin Care Program” (revised 5/2020) was reviewed and required, “1. A skin assessment is completed by the nurse within 24-hours of admission ... in collaboration with physicians. The patient is assessed for any skin impairment, including surgical wounds, pressure ulcers ... 3. Skin inspection should be performed every day. New and existing wounds should be documented two times each week on the Wound Management Intervention ... Electronic Medical Record.” 2. The “Registered Nurse Job Description/Performance Appraisal and Competency Evaluation” (revised 3/2020) was reviewed and required, “Essential Functions and Duties ... 1.2. Monitors and recognizes obvious deviations from normal ... recognizes subtle alterations in the patient’s physiological and psychological status that may indicate potential or actual patient problems ... 5.0 Clinical Practice 5.1 Observes and records ... other diagnostic measurements and report changes or abnormalities to physician ...” 3. The “Skin/wound Assessment and Documentation” (revised 2020) was reviewed and required, “Wound documentation: Nursing interventions used in pressure injury prevention... Proper skin assessment on admission and throughout patient stay... turn/reposition every two hours or as scheduled, with proper documentation... Accurate EPIC skin/wound documentation... Report new/worsening wounds timely... Measure all wounds and document...” 4. On 12/26/23, the clinical record for Pt.#1 was reviewed. Pt. #1 was admitted to the Hospital on 8/21/23 with a diagnosis of spinal cord injury and was discharged to home on 10/02/23. The clinical record included the following: -History and Physical dated 08/21/23 at 2:23 PM, included, “ ... (Pt.#1) with morbid obesity 343 lbs. ... traumatic spinal cord injury ... Physical Exam ... Skin: Right heel: Stage I ulcer-non-blanchable; Left posterior thigh-bulla (large blister containing serous fluid); Left ischial-skin abrasion/tear-pressure injury; Sacral ulcers: Central stage III sacral ulcer: 2.5cm l (centimeters length) x 2.8cm-w (width) x 1cm-d (depth); middle: 3.5cm(w) x 2.2 cm (l) x 0.2 cm (d); lateral: 4 cm (w) x 5cm (l) x 0.2cm (d) ...” -Skin/Wound Care Flowsheets dated 08/22/23 through 10/02/23, were reviewed and indicated that wound care was being completed per physician orders. However, the flowsheets lacked documentation of wound measurements and/or appearance of wounds by nursing staff. -Flowsheets for daily skin assessments dated 08/22/23 through 10/02/23, were reviewed. The flowsheets did not indicate the presence of a new pressure injury/wound to the right lower extremity that was addressed by the physician (MD#1) on 10/02/23. -Progress Note (MD#1) dated 10/02/23 at 12:33 PM, “(Pt.#1) seen and assessed in room ... Alert sitting up in wheelchair; Integumentary: linear medical device related unstageable pressure injury with dark hard eschar on the lateral aspect of distal right leg. No pus. No surrounding erythema. No induration ... Plan: Patient likely acquired this (unstageable pressure injury) due to her weight/size pressing against the lower leg of the wheelchair when in prior Prafos... Cover with Mepilex .. home with mother today.” 5. The clinical record for Pt #2 was reviewed on 12/27/2023. Pt #2 was admitted on 12/19/2023, with a diagnosis of nontraumatic spinal cord disorder incomplete paraplegia. - Pt #2’s History and Physical (dated 12/19/2023), included, “...Impairments: paraplegia, impaired skin integrity...Potential complications/at risk for: pressure injury/worsening pressure injuries...PT [physical therapy]: skills in assisted bed mobility...transfer skills...Right anterior thigh wound” - Pt #2’s clinical record lacked documentation from 12/19/2023-12/26/2023, of the wound assessment, including wound measurements and appearance of wound. 6. On 12/27/23 at 10:30 AM, an interview was conducted with a Registered Nurse (RN/E#4). E#4 stated, “Patients that are admitted to hospital are examined by the nurse for a head-to-toe assessment; wounds are documented and includes measurements; wound base color; drainage and details under skin assessment... Wound measurements are done on admission and depending on the orders...” 7. On 12/27/23 at 11:15 AM, an interview was conducted with an RN (E#5). E#5 stated, “Wounds are assessed on admission by a physician and the nurse, measurements should be documented, I believe twice a week on Wednesdays and Sundays, but I’m not sure...” 34411 C. Based on document review and interview, it was determined that for 3 of 3 (Pt #1, Pt #2, Pt #10) clinical records reviewed for patients with pressure ulcers, the hospital failed to ensure that patients were turned and repositioned every 2 hours, as required, to prevent pressure ulcers. Findings include: 1. The Hospital’s policy titled, “Nurse Plan of Care (Care Plan)”, dated 4/2023, was reviewed, and required, “Each patient’s care, treatment, and services are guided by an individualized plan that addresses individual needs and goals...The plan of care includes patient goals and interventions based on assessment and patient’s condition...The Nurse documents the delivery of patient care in the medical record...”. A policy on pressure ulcer care/pressure injury was requested. The Hospital was unable to provide. 2. The Hospital’s annual nurse training titled, “Skin/wound Assessment & Documentation” (dated 10/2023), was reviewed, and included, “...Wound Documentation: Nursing interventions used in pressure injury prevention ...Turn/reposition every two hours or as scheduled, with proper documentation ...” 3. The clinical record for Pt. #1 was reviewed on 12/26/2023. Pt #1 was admitted on 8/21/2023, with a diagnosis of traumatic spinal cord injury. - The History and Physical (dated 08/21/2023), included, “ ... traumatic spinal cord injury ... Physical Exam ... Skin: Right heel: Stage I ulcer-non-blanchable; Left posterior thigh-bulla (large blister containing serous fluid); Left ischial-skin abrasion/tear-pressure injury; Sacral ulcers: Central stage III sacral ulcer: 2.5cm l (centimeters length) x 2.8cm-w (width) x 1cm-d (depth); middle: 3.5cm(w) x 2.2 cm (l) x 0.2 cm (d); lateral: 4 cm (w) x 5cm (l) x 0.2cm (d) ... Q (every) 2 hour turns to prevent further skin breakdown and worsening of ulcers.” - The Skin Injury Risk Care Plan (initiated 9/7/2023), included, “...Goal: Skin Health and Integrity: Relieve and redistribute pressure (e.g., scheduled position changes, weight shifts) ...” - Pt #1’s Braden score (risk for developing pressure injuries), included a score of 11, indicating high risk for pressure ulcers. -Pt #1’s Turning/Repositioning Flowsheets from 08/22/2023-10/02/2023 were reviewed. From 8/22/2023-9/6/2023, the clinical record included turning/repositioning documentation (from previous electronic medical record system), every 2 hours as required. However, from 9/7/2023-10/2/2023 (current electronic medical record system), there were only 3 repositioning entries documented (dated 9/9/23 at 10:00 PM, 9/10/23 at 9:20 PM, and 9/16/23 at 11:04 AM). The clinical record lacked any further turning/repositioning documentation. 4. The clinical record for Pt #2 was reviewed on 12/27/2023. Pt #2 was admitted on 12/19/2023, with a diagnosis of nontraumatic spinal cord disorder incomplete paraplegia. - The History and Physical (dated 12/19/2023), included, “...Impairments: paraplegia, impaired skin integrity...Potential complications/at risk for: pressure injury/worsening pressure injuries...PT [physical therapy]: skills in assisted bed mobility...transfer skills...Right anterior thigh wound” -The Skin Injury Risk Care Plan (initiated 12/19/2023), included, “...Goal: Skin Health and Integrity: Relieve and redistribute pressure (e.g., scheduled position changes, weight shifts) ...” - Pt #2’s initial Braden score was 17, indicating mild risk. - Pt #2’s repositioning notes, from 12/19/2023-12/27/2023, did not include any documentation of turning/repositioning the patient. 5. The clinical record for Pt #10 was reviewed on 12/27/2023. Pt #10 was admitted on 12/22/2023, with a diagnosis of quadriplegia (paralysis of all 4 limbs). - The History and Physical (dated 12/22/2023), included, “...Impairments: Quadriplegia...neuropathic pain...decubitus ulcer (pressure ulcer) of coccygeal region, stage 1...” - The Skin Injury Risk Care Plan (initiated 12/22/2023), included, “...Goal: Skin Health and Integrity: Relieve and redistribute pressure (e.g., scheduled position changes, weight shifts) ...” - Pt #10’s initial Braden score was 15, indicating mild risk. - Pt #10’s repositioning notes, from 12/22/2023-12/27/2023, included documentation of only one entry of repositioning on 12/27/2023 at 8:00 AM. The clinical record did not include any previous or subsequent repositioning notes. 6. On 12/26/2023 at 12:35 PM, an interview was conducted with a RN (E #7). E #7 stated that it is nursing standard of care to turn and reposition patients (who require mobility assistance), every 2 hours. E #7 stated that the nurses and certified nursing assistants take turns repositioning the patients. E #7 stated that there is no particular place that the nurses chart the repositioning in the new computer system. 7. On 12/27/23 at 11:15 AM, an interview was conducted with a Registered Nurse/RN (E#5). E#5 stated, “Turning and repositioning should be documented in the clinical record, including which position the patient is placed.””

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 40079 Based on document review and interview, it was determined that for 1 of 1 (Pt #1) clinical record reviewed for a patient who was discharged to home with a Foley catheter (indwelling urinary catheter), the hospital failed to ensure the patient’s plan of care included the provision of the appropriate education for catheter care post discharge. Findings include: 1. The “Registered Nurse Job Description/Performance Appraisal and Competency Evaluation” (revised 3/2020) was reviewed and required, “Essential Functions and Duties ... 2.1 Plans and constructs routine nursing activities with patient, family, significant others ... which meets the needs of the individualized patient including identification of patient learning needs, long and short-term goals and appropriate nursing interventions ... 2.2 Modifies patient’s plan of care ... “ 2. The hospital’s policy titled, “Admission Assessment” (revised 11/2023) was reviewed and required, “5. An initial systemic data collection based on individualized unique needs to include ... n. Discharge plans/community needs. O. Knowledge deficits/Educational needs ... 7. The admitting nurse initiates the plan of nursing care by choosing appropriate plan of care based on their initial assessment and patient’s needs and goals ...” 3. On 12/26/23, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital on 8/21/23 and discharged to home on 10/02/23. The clinical record included the following: -History and Physical dated 08/21/23 at 2:23 PM, included, “s/p (status post) multiple gunshot wounds to the neck and right shoulder resulting in ... traumatic spinal cord injury ... Plan: Neurogenic bladder ... indwelling Foley [urinary catheter] in place ...” -Care and Service Plan, updated 9/21/23 “Patient Active Problem list ... quadriplegic, complete ... Neurogenic bladder ... Ongoing training needed for ... bladder care. Interventions ... caregiver training with ... nursing ... Acute inpatient rehabilitation is required in order to maximize the patient’s functional independence ... bladder management and patient/family education ...” -Education Notes, dated 9/15/23, 9/20/23, and 10/01/23, included, “Title: CAUTI (catheter associated urinary tract infection)/Catheter Placement Learning Progress Summary: Indication for catheter; placement procedure; Infection prevention; Signs/Symptoms of infection; When to seek medical attention.” The documentation indicated that this education was provided to the patient. The clinical record lacked documentation that family was educated and trained on care of the Foley catheter with return demonstration, signs and symptoms of infection, or that the Foley catheter required to be changed every 28-30 days. On 12/28/23 at 12:25 PM, an interview was conducted with the Nurse Manger (E#6). E#6 stated that for patients with a Foley catheter, the expectation is to educate the family or caregiver about Foley catheter care and infection prevention, and symptoms of infection. In Epic (electronic documentation system) there is education that that can be printed and given to the family, also having the family/caregiver do a return demonstration is required.”