Kindred Hospital Indianapolis

“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: 48061 Based on document review and interview, facility nursing staff failed to notify the patient’s primary care physician of a change in patient condition for 1 of 10 medical records reviewed. (P1) Findings include: 1. The Facility policy titled, CORE: Interdisciplinary Assessment and Re-Assessment, policy number H-PC 02-001, released date 06/2023, indicates under 15. Notification Responsibilities When an Assessment Reveals a Change or Suspected Change in Condition: a. The nurse assigned to the patient or supervising the care of the patient is responsible for notification and communication to the patient’s primary physician or designee using appropriate channels and chain of command for assuring that there is physician response. 2. Medical record review for patient (P1) indicated on 9/12/24 at 4:44 am the clinical impression of the patient indicated he/she was short of breath, had a Pulse Ox reading of 88 %, and displayed the use of accessory muscles to breathe. P1 was placed on supplemental oxygen. Medical record lacked documentation of provider notification of patient change in condition. 3. In telephone interview on 10/2/24 at approximately 10:00 am with MD1 (Medical Doctor) confirmed that he/she was not notified by facility nursing staff of P1’s change in condition related to a decrease in respiratory function requiring supplemental oxygenation on 9/12/24 and should have been.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 48061 Based on document review and interview, the facility failed to maintain documentation of incontinence management education or documented competencies for 7 of 7 nursing personnel files reviewed. (N1, N2, N3, N4, N5, N6, and N7) Findings include: 1. The Facility policy titled, CORE: Incontinence Diarrhea Management, policy number H-PC 03-002, released date 06/2022, indicates under POLICY: The policy of Kindred Hospital is to ensure the following: 4. Intra-anal management system. c. Clinicians should have competencies on file for the maintenance and insertion of the system. 2. MR review for patient (P1) indicated a Physician Order documentation of rectal tube placement by MD1 (Medical Doctor) on 9/8/24 at 12:42 pm, this order was acknowledged by N4 (Registered Nurse) on 9/8/24 at 12:51 pm, the rectal tube was placed by N1 (Registered Nurse, Day Shift Nursing Supervisor) at approximately 1:57 pm. The rectal tube was removed on 9/9/24 at 8:08 am by N7 (Registered Nurse) citing a lack of effectiveness even after flushing, there was notable leaking around the rectal tube. 3. Personnel file(s) were reviewed for N1 (Registered Nurse), N2 (Registered Nurse), N3 (Registered Nurse), N4 (Registered Nurse), N5 (Registered Nurse), N6 (Registered Nurse), and N7 (Registered Nurse) indicated lack of completed education and/or competencies for Incontinence Diarrhea Management including Intra-anal management systems currently used for patients. 4. In interview on 9/26/24 at approximately 11:45 am with A5 (Registered Nurse, Day Shift Supervisor) confirmed the nursing staff placing rectal tubes, did not, but should have had documentation of device specific education or completed competencies related to placing or removing rectal tubes.”

“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: 49709 Based on document review and interview the registered nurses failed to ensure supervision of nursing care of repositioning patients every two hours and failed to ensure patient re-weighs were completed for 2 of 11 medical records (MR) reviewed (P3 and P7). Findings include: 1. Review of policy/procedure “CORE: Clinical Guidelines for Pressure Injury,” H-PC 10-004, indicates the following: Policy: 5. Standard interventions for all patients can include but are not limited to: c. Repositioning orders (minimum every (Q) 2 hour turns) i. Consideration turning schedule of Q1 hours if patient is unable to turn and reposition self, has poor nutrition, multiple wounds, a recent change of condition (acute decline in hemodynamics), poor cognition, skin is moist or at risk for friction/shear injury. Definition: 5. High risk: A Braden Risk Score of 10 - 12 6. Severe risk: A Braden Risk Score of 9 or less This policy/procedure was last reviewed/revised 06/2022 2. Review of policy/procedure “CORE: Clinical Guidelines for Non-Pressure Related Wounds,” H-PC 10-005, indicates the following: Policy: 4. Standard interventions for all patients can include but are not limited to: c. Wound care consult e. Repositioning (minimum Q2 hour turns) i. Turn and reposition the patients at a frequency based on the patient’s individual needs. ii. Consideration turning schedule of every 1 hours if patient is unable to turn and reposition self, has poor nutrition, multiple wounds, a recent change of condition (acute decline in hemodynamics), poor cognition, skin is moist or at risk for friction/shear injury. This policy/procedure was last reviewed/revised 06/2022 3. Review of P3 MR indicated the following: Patient was admitted on 04/20/24. On 04/22/24 wound care consult indicated the patient had a stage II pressure ulcer to right buttock with 2.3-centimeter (cm) x 3.0 cm x 0.1 cm and an unstageable to sacrum 6.9 cm x 2.7 cm unable to determine depth. P3 had Braden completed on 04/22/24 with score of 11 indicated high risk. On 06/25/24 P3’s sacral wound measured 8.4 cm x 6 cm. P3 pressure ulcer care plan indicated turn and reposition Q2 hours. Physician order on 04/20/24 at 1428 hours indicated the following: reposition using at least 2 staff persons, reposition using wedge/pillows. Assess skin and lines while repositioning. Change chux/linen if needed. Apply barrier to high-risk areas as needed. Document all refusals, bath, linen change, output. Start on 04/20/24 at 1600 hours, Q2h. P3’s MR indicated patient was in the following positions: 04/20/24 1716 hours to right side 04/20/24 2000 hours to left side 04/21/24 0400 hours to left side 04/21/24 0638 hours to right side 04/21/24 0925 hours to right side 04/21/24 1157 hours to left side 04/21/24 1430 hours to right side 04/22/24 0600 hours to supine 04/22/24 0830 hours to left side 04/22/24 1533 hours to left side 04/22/24 1847 hours to supine 04/22/24 2105 hours to left side 04/22/24 2200 hours to left side 04/23/24 0056 hours to right side 04/24/24 1558 hours to right side 04/24/24 1848 hours to supine 04/24/24 2150 hours to left side 04/25/24 2000 hours to right side 04/25/24 2317 hours to left side 04/29/24 0626 hours to supine 04/29/24 0926 hours to left side 04/30/24 0616 hours to supine 04/30/24 0917 hours to right side 05/02/24 0559 hours to right side 05/02/24 0848 hours to right side 05/02/24 1015 hours to left side 05/02/24 1301 hours to supine 05/02/24 1710 hours to right side 05/02/24 1959 hours to right side 05/02/24 2254 hours to left side 05/03/24 0146 hours to left side 05/03/24 0400 hours to right side 05/03/24 1543 hours to right side 05/03/24 1847 hours to left side 05/05/24 0200 hours to right side 05/05/24 0843 hours to right side 05/05/24 1939 hours to right side 05/05/24 2225 hours to left side 05/06/24 0109 hours to left side 05/06/24 0408 hours to right side 05/06/24 1425 hours to left side 05/06/24 1851 hours to right side 05/07/24 0931 hours to left side 05/07/24 1306 hours to right side 05/08/24 0000 hours to left side 05/08/24 0400 hours to left side 05/08/24 0845 hours no side listed 05/09/24 0540 hours to right side 05/09/24 0820 hours to left side 05/09/24 1449 hours to left side 05/09/24 2045 hours to right side 05/11/24 1959 hours to right side 05/11/24 2259 hours to left side 05/14/24 1340 hours to right side 05/14/24 1637 hours to left side 05/15/24 2208 hours to left side 05/16/24 0102 hours to supine 05/17/24 1348 hours to right side 05/17/24 1638 hours to left side 05/17/24 1743 hours to supine 05/17/24 2115 hours to right side 05/23/24 0600 hours to supine 05/23/24 0849 hours to right side 05/23/24 1600 hours to right side 05/23/24 2000 hours to right side 05/24/24 0148 hours to right side 05/24/24 0618 hours to supine 05/24/24 1600 hours to right side 05/24/24 1854 hours to supine 05/30/24 0216 hours to supine 05/30/24 0608 hours to right side 05/31/24 1338 hours to supine 05/31/24 1624 hours to left side 06/02/24 0119 hours to right side 06/02/24 0409 hours to left side 06/03/24 0521 hours to supine 06/03/24 0830 hours to right side 06/03/24 1527 hours to left side 06/03/24 1818 hours to right side 06/04/24 1800 hours to left side 06/04/24 2112 hours to right side 06/08/24 0958 hours to left side 06/08/24 1345 hours to right side 06/10/24 0344 hours to right side 06/10/24 0636 hours to left side 06/11/24 1708 hours to right side 06/11/24 2000 hours to right side 06/12/24 1801 hours to right side 06/12/24 2109 hours to right side 06/13/24 0506 hours to left side 06/13/24 0800 hours to left side 06/13/24 2031 hours no side listed 06/13/24 2328 hours to left side 06/14/24 1327 hours sitting up in chair 06/14/24 1752 hours to left side 06/18/24 0538 hours to left side 06/18/24 0836 hours to left side 06/19/24 0011 hours to right side 06/19/24 0316 hours to right side 06/19/24 2000 hours to right side 06/20/24 1549 hours to left side 06/20/24 1846 hours to right side 06/22/24 2130 hours to left side 06/23/24 0026 hours to right side 06/26/24 0541 hours to left side 06/26/24 0830 hours to right side 4. Review of P7 MR indicated the following: Patient was admitted on 07/26/24. On 07/29/24 wound care consult indicated the patient admitted with deep tissue pressure injury to right sacrum 1.8 cm x 2.0 cm. On 08/21/24 P7 acquired an open blister to their right lateral thigh measuring 5 cm x 5 cm x 0.1 cm. P7 had Braden completed on 09/07/24 with score of 9 indicated high risk. On 09/17/24 P7’s open blister wound measured 8.4 cm x 6 cm. P7 pressure ulcer care plan indicated turn and reposition Q2 hours. Physician order on 07/26/24 at 1626 hours indicated the following: reposition using at least 2 staff persons, reposition using wedge/pillows. Assess skin and lines while repositioning. Change chux/linen if needed. Apply barrier to high-risk areas as needed. Document all refusals, bath, linen change, output. Start on 07/26/24 at 1800 hours, Q2h. P7’s MR indicated patient was in the following positions: 07/29/24 0200 hours to left side 07/29/24 0448 hours to right side 07/29/24 1118 hours to supine 07/29/24 1423 hours to right side 07/29/24 1935 hours to left side 07/29/24 2337 hours to left side 07/30/24 0957 hours to right side 07/30/24 1244 hours to supine 07/30/24 1947 hours to right side 07/30/24 2326 hours to left side 07/31/24 0130 hours to right side 07/31/24 0422 hours to left side 07/31/24 0505 hours to right side 07/31/24 0805 hours to left side 07/31/24 1730 hours to supine 07/31/24 2019 hours to right side 08/02/24 0356 hours to left side 08/02/24 0652 hours to supine 08/02/24 0800 hours to right side 08/02/24 1101 hours to left side 08/03/24 0148 hours to right side 08/03/24 0446 hours to left side 08/03/24 2008 hours to right side 08/03/24 2257 hours to left side 08/04/24 1805 hours to supine 08/04/24 2122 hours to left side 08/09/24 1801 hours to right side 08/09/24 2054 to right side 08/10/24 1753 hours to left side 08/10/24 2104 hours to right side 08/12/24 0524 hours to supine 08/12/24 0900 hours to right side 08/14/24 1834 hours to supine 08/14/24 2318 hours to left side 08/16/24 1124 hours to supine 08/16/24 1400 hours to right side 08/18/24 1811 hours to supine 08/18/24 2117 hours to right side 08/19/24 0021 hours to supine 08/19/24 0713 hours to supine 08/19/24 2311 hours to supine 08/20/24 0205 hours to right side 08/20/24 1114 hours to right side 08/20/24 1400 hours to left side 08/22/24 0042 hours to right side 08/22/24 0507 hours to left side 08/22/24 1102 hours to right side 08/22/24 1426 hours to left side 08/24/24 0000 hours to right side 08/24/24 0258 hours to left side 08/24/24 1200 hours to left side 08/24/24 1941 hours to right side 08/25/24 0119 hours to left side 08/25/24 0421 hours to left side 08/25/24 0630 hours to left side 09/08/24 0005 hours to supine 09/08/24 0557 hours to left side 09/08/24 1200 hours to supine 09/08/24 1459 hours to left side 09/08/24 2331 hours to right side 09/09/24 0250 hours to left side 09/09/24 0331 hours to right side 09/09/24 0655 hours to left side 09/09/24 1421 hours to left side 09/09/24 1721 hours to supine 09/09/24 1959 hours to right side 09/09/24 2253 hours to left side 09/10/24 0331 hours to right side 09/10/24 0657 hours to left side 09/11/24 1134 hours to left side 09/11/24 1443 hours shifted 09/11/24 1547 hours to right side 09/11/24 1847 hours to left side 09/12/24 1600 hours to supine 09/12/24 1855 hours to supine 09/13/24 0001 hours to right side 09/13/24 0306 hours to left side 09/14/24 1243 hours to left side 09/14/24 1541 hours to left side 09/14/24 1957 hours to right side 09/14/24 2245 hours to left side 09/15/24 0543 hours to left side 09/15/24 0931 hours to right side 09/15/24 1151 hours to left side 09/15/24 1510 hours to right side 09/15/24 2200 hours to right side 09/16/24 0200 hours to right side 09/16/24 0334 hours to supine 09/16/24 0636 hours to left side 09/16/24 1131 hours to supine 09/16/24 1404 hours to right side 5. Facility policy titled, “CORE: Weight Measurement,” H-PC 04-011, indicated the following: Procedure: 9. Weigh patient on the appropriate scale NOTE: If a patient has a 5 pound or more weight difference from the most recent weight, the scale shall be re-balanced, the rough calibration was completed, and the weight was taken again to confirm accuracy. Request a licensed nurse to verify re-weigh for accuracy and documentation purposes. This policy/procedure was last reviewed/revised 06/2021. 6. Review of P3 MR indicated the following: Patient was admitted on 04/20/24 with an admission weight of 212.3 pounds (lb). Physician order on 04/20/24 at 1648 hours indicated P3 was to have a daily weight. Start on 04/21/24 at 0500 hours. MR indicated P3’s weight had a documented difference greater or less than 5 pounds or more from the prior weight on: 04/21/24 204.6 lb 04/23/24 208.56 lb 04/24/24 203.5 lb 04/25/24 198 lb 04/28/24 192.5 lb 04/29/24 200.2 lb 04/30/24 178.2 lb 05/01/24 200.4 lb 05/02/24 180.4 lb 05/03/24 169.62 lb 05/05/24 175 lb 05/06/24 163.9 lb 05/07/24 169.4 lb 05/11/24 158.4 lb 05/12/24 166.1 lb 05/1424 165 lb 05/15/24 159.5 lb 05/18/24 155.1 lb 05/19/24 160.6 lb 05/20/24 158.4 lb 05/21/24 163.9 lb 05/25/24 161.7 lb 05/26/24 154 lb 05/27/24 160.6 lb 05/31/24 162.8 lb 06/01/24 157.3 lb 06/10/24 152.9 lb 06/11/24 185.9 lb 06/14/24 185.9 lb 06/15/24 195.8 lb 06/17/24 195.8 lb 06/18/24 182.6 lb MR lacked documentation of re-weigh and request of a licensed nurse to verify re-weigh for accuracy and documentation purposes per policy for above dates. 7. Review of P7 MR indicated the following: Patient was admitted on 07/26/24 with an admission weight of 140.8 lb. Physician order on 07/26/24 at 1702 hours indicated P7 was to have a daily weight. Start on 07/27/24 at 0500 hours. MR indicated P7’s weight had a documented difference greater or less than 5 pounds or more from the prior weight on: 07/29/24 138.38 lb 07/30/24 144.1 lb 07/31/24 137.5 lb 08/07/24 139.7 lb 08/08/24 187 lb 08/09/24 139.7 lb 08/10/24 146.3 lb 08/20/24 138.6 lb 08/21/24 145.2 lb 08/23/24 145.86 lb 08/24/24 140.8 lb 08/25/24 145.2 lb 08/26/24 136.4 lb 09/07/24 134.2 lb 09/08/24 127.6 lb 09/15/24 127.6 lb 09/16/24 133.1 lb MR lacked documentation of re-weigh and request of a licensed nurse to verify re-weigh for accuracy and documentation purposes per policy for above dates.”

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 49709 Based on document review and interview the facility failed to ensure that nursing staff were competent in the use of intra-anal management system for 7 of 7 (A5-Registered Nurse [RN], A10-RN, A11-RN, A12-RN, A13-RN, A14-RN, A15-Licensed Practical Nurse [LPN]) nursing personnel files reviewed. Findings include: 1. Facility policy titled, “CORE: Incontinence Diarrhea Management,” H-PC 03-002, indicated under Policy: The policy of Kindred Hospital is to ensure the following: 4. Intra-anal management system: c. Clinicians should have competencies on file for the maintenance and insertion of the system. This policy/procedure was last reviewed/revised 06/2022. 2. Review of 7 out of 7 (A5-RN, A10-RN, A11-RN, A12-RN, A13-RN, A14-RN, A15-LPN) nursing personnel education files lacked documentation of competency for intra-anal management system. 3. Interview with A7 (Registered Nurse, Educator), on 09/19/24 at approximately 1:45 p.m., confirmed intra-anal management system is not included in new hire training and/or annual training.”

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 48704 Based on document review and interview, nursing services failed to ensure that patient’s discharge instructions were signed and placed in patient’s medical record in 2 out of 3 (patient 1 and 2) medical records reviewed. 1. Review of policy titled, titled, “CORE: Discharge Planning”, approved 06/2023, indicated the nurse will have the patient or responsible family/caregiver sign the discharge instruction sheet attesting to receipt of the information and the nurse will sign and date the form. 2. Review of Patient 1’s medical record indicated patient was discharged on 01/08/2024. The medical record lacked documentation of discharge instructions signed by the patient or responsible family/caregiver and the nurse’s signature and date. 3. Review of Patient 2’s medical record indicated patient was discharged on 01/05/2024. The medical record lacked documentation of discharge instructions signed by the patient or responsible family/caregiver and the nurse’s signature and date. 4. Interview with A3 (Director of Case Management) on 02/14/2024 at approximately 11:15 am confirmed that Patients 1 and 2’s medical record lacked documentation of signed discharge instructions by the patient or responsible family/caregiver or the nursing staff.”

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 48704 Based on document review and interview, the facility failed to ensure that patient’s discharge planning included all patient treatments at the time of discharge in 1 out of 10 (patient 3) medical records (MR) reviewed. The cumulative effect resulted in the hospitals inability to ensure safe discharge planning.”

“DISCHARGE PLANNING TIMELY EVALUATION CFR(s): Any discharge planning evaluation must be made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. This Standard is not met as evidenced by: 48704 Based on document review and interview, the facility failed to ensure that patient’s discharge planning included all patient treatments at the time of discharge in 1 out of 10 (patient 3) medical records (MR) reviewed. Findings include: 1. Review of policy titled, titled, “CORE: Discharge Planning”, approved 06/2020, indicated the physician will document in the patient medical record the post-discharge plan of care; the case manager will document final preparation information including reassessment of medical condition; and if modifications for discharge are identified, document findings and changes in the progress notes. 2. Review of Patient 3’s MR lacked documentation of discharge plan of patient’s oxygen needs. Provider orders in the MR indicated staff to tritrate oxygen to maintain O2 saturations greater than 88% and attempt to wean. On 10/03/2023, MR indicated that patient had desaturations on room air, was placed back on O2 per nasal cannula, and that patient had need for O2 support to maintain documented O2 saturations above 88%. On 10/04/2023, MR indicated that patient remained on 2 liters of O2 prior to discharge. MR lacked documentation to discontinue O2 at discharge. 3. A1 (Director of Case Management), on 11/08/2023, at approximately 1:00 pm confirmed that home O2 was ordered on 10/2/2023 and the order was canceled. A1 confirmed that MR lacked documentation regarding reason for cancellation of the home O2 order. 4. A7 (Registered Respiratory Therapist and Respiratory Manager), on 11/08/2023, at approximately 1:30 pm, confirmed that the patient had been on O2 via nasal cannula on day of discharge. 5. A1, A2 (Director of Quality), and A3 (Chief Clinical Officer/Chief Operating Officer), on 11/08/2023, at approximately 1:40 pm, confirmed that there was no written order to discontinue O2 by the provider and the MR lacked documentation to determine if the patient’s need for oxygen was addressed prior to discharge. A3 confirmed the patient was discharged not wearing oxygen.”