Select Medical Rehabilitation Hospital at Lutheran

“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: 47186 Based on document review and interview, nursing services failed to assess patient transfer needs with patient reported weakness and failed to document patient education, rationale, or alternative plan when patient declined to use a walker during a transfer in one of 10 medical records reviewed (Patient 1). 1. Review of policy titled: Fall And Injury Prevention, Policy Number: RH-CL-114, last revised 1/01/26 , indicated under: Policy B. Patients have the right to refuse interventions identified as necessary for safety. However, staff are responsible to identify the basis for the refusal, present rationale about why the interventions are important, offer an alternative plan as appropriated, and document the actions taken. 2. Review of P1’s MR lacked documentation of interdisciplinary staff communication when patient’s increased need for assistance with mobility was observed during an OT (Occupational Therapy) session on 3/01/26. 3. Review of P1’s MR lacked documentation of patient’s mobility assessment prior to a transfer on 3/01/26 at 4:00 pm when patient reported weakness to N2 (RN). 4. In a telephone interview on 4/29/26 at approximately 2:02 pm to 2:18 pm, N2 patient had been minimal assist/mostly independent with toileting in the morning, patient’s mobility status as a 1-nurse assist had not been changed, and they were not notified of patient’s weakened condition with transferring prior to patient’s fall on 3/01/26. N2 indicated patient refused to use the walker and they assisted patient to feet with the gait belt, patient then fell onto them as they could not regain balance. N2 did not indicate patient education was provided prior to patient’s fall regarding the use of patient’s walker for transfer.”

“DELIVERY OF SERVICES CFR(s): 482.56(b)(2) The provision of care and the personnel qualifications must be in accordance with national acceptable standards of practice and must also meet the requirements of §409.17 of this chapter. This Standard is not met as evidenced by: 47186 Based on document review and interview, Occupational Therapy (OT) services failed to update the plan of care and did not inform nursing of change in patient mobility in 1 of 10 medical records reviewed (Patient 1). 1. Review of policy titled: Fall And Injury Prevention, Policy Number: RH-CL-114, last revised 1/01/26, indicated under: Procedure: A. Admission, Assessment and Patient Family Education. 8. b. All appropriate information will be updated whenever the patient’s status changes. The level of independent patient activity recommended by the interdisciplinary team will be regularly communicated/updated with the patient during therapy sessions and during nursing care activities. 2. Review of P1’s MR at 2:19 pm on 3/01/26, indicated OT treatment session where patient reported lower extremity weakness and completed multiple task/stand transfers with moderate to maximum aid to boost to stand from sitting position, and with all transfers during the session. MR indicated session was limited by patient’s decreased lower extremity strength and difficulty completing sit to stand transfers and patient’s summary plan of care remained unchanged. 3. Review of P1’s MR lacked documentation of interdisciplinary staff communication when patient’s increased need for assistance with mobility was observed during an OT (Occupational Therapy) session on 3/01/26. 4. In a telephone interview on 4/29/26 at approximately 2:02 pm to 2:18 pm, N2 (RN) patient had been minimal assist/mostly independent with toileting in the morning, patient’s mobility status as a 1-nurse assist had not been changed, and they were not notified by OT staff of patient’s weakened condition with transferring prior to patient’s fall on 3/01/26.”

“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: 32952 Based on document review and interview, the nursing staff failed to ensure a patient’s urinary output amount was documented per physician order for 1 of 12 medical records reviewed. (Patient #1); and nursing staff failed to notify physician of urine output that was outside of the parameters per physician orders and/or facility policy for 1 of 12 medical records reviewed. (Patient #1) Findings include: 1. Facility policy titled “Guidelines and Protocols: Inpatient Rehabilitation Hospitals” Policy Number: RH-NU-114 with issue date of 10/1/23 indicated the following: “POLICY: A. To ensure quality patient care, certain standards of care must be upheld. D. A specific physician order will supersede the minimum frequencies noted below. PROCEDURE: Nutrition and Fluids, Routines/Guidelines: Intake and output (I & O) totaled. Minimum Frequency: Per MD order, total each shift.” 2. Review of patient #1’s medical record indicated the following: The patient was admitted on 5/18/24 at 11:49 a.m. (A.) A physician order dated 5/18/24 at 11:59 a.m. and discontinued on 5/22/24 at 12:30 a.m. indicated to notify the physician of urine output less than 100 milliliters in 4 hours. (B.) A review of nursing flowsheets for Patient #1 indicated the following urine output: and estimated urine amount: On 5/19/24 at 4:26 p.m. - urinary occurrence of continent and estimated urine output amount was small. On 5/19/24 at 6:23 p.m. - urinary occurrence of continent and estimated urine output amount was small. On 5/19/24 at 7:30 p.m. - urinary occurrence of continent and estimated urine output amount was medium. On 5/19/24 at 9:55 p.m. - urinary occurrence of continent and estimated urine output amount was medium. (C.) The medical record lacked documentation of measured urine output in milliliters for Patient #1, therefore was unable to determine if the patient had a urine output of greater than and/or lesser than 100 milliliters with each urinary occurrence. 3. During an interview with A1 (Director of Quality Management ) on 7/19/24 at approximately 2:00 p.m., he/she verified the medical record information for patient #1. 4. During a phone interview with N1 on 7/23/24 at 3:32 p.m., N1 verified that they toileted Patient #1 prior to going on break on 5/19/24 at approximately 9:45 p.m. and did not measure Patient #1’s urine.”

“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: 32952 Based on document review and interview, the Registered Nurse failed to supervise the care of providing patient incontinence care, ensure a patient was assisted with repositioning/turning every two hours, pain level assessments/reassessments were completed per physician orders and/or facility policy for 1 of 10 medical records reviewed. (Patient #1) Findings include: 1. Facility policy titled “Pain Management” last reviewed/revised on 10/1/23 indicated the following: “POLICY: Pain assessment and pain management is an essential part of rehabilitation care of patients and is a priority in the hospital setting. PROCEDURE: 8. Re-assessment after initiating treatment: a. Pain will be assessed prior to pain interventions. b. Pain will be re-assessed approximately 30-60 minutes following a pharmacologic pain intervention, including the patient’s perception of relief, improved functional status, etc. 2. Facility policy titled “Pressure Injury Prevention” last reviewed/revised 4/1/23 indicated the following: “Prevention: All patients admitted will be considered at risk for the development of pressure injuries. Mobility deficit: Patients that are bed bound or with limited activity should be repositioned at least every two hours. Moisture/Incontinence: All patients will be cleaned as soon as possible after soiling.” 3. Facility policy titled “Guidelines and Protocols: Inpatient Rehabilitation Hospitals” last reviewed/revised 10/1/23 indicated the following: “Purpose: To outline clinical routines, guidelines and protocols of patient care. Policy...outlines basic tasks and designates the minimum frequency with which these tasks must be performed to maintain quality care. Hygiene: Bed linen changed, every other day and PRN (as needed). Draw sheets, incontinent pads, gown changed, daily and PRN. Peri-care every 12 hours and PRN. 4. Review of patient #1’s medical record indicated the following: The patient was admitted on 11/30/23 at 6:36 p.m. and discharged on 12/18/23 at 11:45 a.m. The patient had diagnoses that included but were not limited to cerebral infarction due to thrombosis of unspecified middle cerebral artery and displaced bimalleolar fracture of left lower leg. (A.) A physician order dated 11/30/23 at 6:40 p.m. indicated to cleanse the patient with bath wipes after incontinence and/or as needed for soiling/saturation with a start date of 11/30/23 at 6:40 p.m. and end date of 12/18/23 at 2:05 p.m. A physician order dated 11/30/23 at 6:40 p.m. indicated to assess the patient’s pain every four hours with a start date of 11/30/23 at 8:00 p.m. and an end date of 12/18/23 at 2:05 p.m. A physician order dated 11/30/23 at 6:40 p.m. indicated to turn the patient every two hours to start on 11/30/23 at 8:00 p.m. and was discontinued on 12/18/23 at 2:05 p.m. (B.) A review of intake and output flowsheets indicated Patient #1 had episodes of urine incontinence on 12/3/23 at 7:00 p.m., 12/4/23 at 12:48 a.m. and 3:03 a.m., 12/9/23 at 7:00 a.m. and 12/10/23 at 10:00 a.m. The medical record lacked documentation of linen changes, incontinence care being provided to the patient and/or patient refusal of linen changes/incontinence care. (C.) The medical record lacked documentation of a pain level assessment on the following dates and times: On 12/1/23 at 1:03 a.m. and 9:30 a.m. On 12/2/23 at 1:26 a.m., 1:00 p.m., 5:00 p.m. and 9:00 p.m. On 12/3/23 at 5:37 p.m. On 12/4/23 at 3:00 a.m., 7:00 a.m. and 4:03 p.m. On 12/5/23 at 4:25 a.m. and 6:25 p.m., On 12/6/23 at 6:47 p.m. On 12/7/23 at 1:00 a.m., 1:43 p.m. and 5:43 p.m. On 12/8/23 at 6:31 a.m. On 12/9/23 at 12:34 a.m., 4:34 a.m., 8:34 a.m. and 12:34 p.m. On 12/10/23 at 1:00 a.m., 9:26 a.m., 1:26 p.m. and 7:13 p.m. On 12/11/23 at 1:02 p.m. and 6:43 p.m. On 12/12/23 at 12:10 a.m. On 12/13/23 at 9:14 a.m. and 7:01 p.m. On 12/14/23 at 1:17 a.m., 9:38 a.m. and 6:36 p.m. On 12/15/23 at 8:52 a.m. On 12/16/23 at 6:08 p.m. On 12/17/23 at 1:17 p.m. (D.) A review of Patient #1’s Medication Administration Record indicated medications were administered that included but were not limited to the following: On 12/1/23 at 5:24 a.m., Tylenol 650 milligrams 1 tablet by mouth. The medical record lacked documentation of a pain level reassessment 60 minutes after a pain intervention at 6:24 p.m. On 12/1/23 at 9:26 p.m., Tylenol 1300 milligrams by mouth. The medical record lacked documentation of a pain level reassessment 60 minutes after a pain intervention at 10:26 p.m. On 12/8/23 at 9:03 a.m., Norco 5/325 milligrams 1 tablet by mouth. The medical record lacked documentation of a pain level reassessment 60 minutes after a pain intervention at 10:03 a.m. On 12/11/23 at 2:43 p.m., Norco 5/325 milligrams 1 tablet by mouth. The medical record lacked documentation of a pain level reassessment 60 minutes after a pain intervention at 3:43 p.m. On 12/12/23 at 9:28 a.m., Norco 5/325 milligrams 1 tablet by mouth. The medical record lacked documentation of a pain level reassessment 60 minutes after a pain intervention at 10:28 a.m. On 12/13/23 at 11:05 a.m., Norco 5/325 milligrams 1 tablet by mouth. The medical record lacked documentation of a pain level reassessment 60 minutes after a pain intervention at 12:05 p.m. (E.) The medical record lacked documentation of patient repositioning/turning every two hours and/or patient refusing repositioning/turning every two hours for the following dates and times: On 11/30/23 at 10:00 p.m., 12/1/23 at 8:00 p.m., 9:00 p.m., 10:00 p.m., 11:00 p.m., 12/2/23 at 2:00 a.m. and 5:00 a.m. The patient was documented as being in the supine position on 12/1/23 at 12:00 a.m., 1:00 a.m., 2:00 a.m., 3:00 a.m., 4:00 a.m., 6:00 a.m., 7:00 a.m., 12/2/23 at 12:00 a.m., 1:00 a.m., 3:00 a.m., 4:00 a.m., 6:00 p.m., 7:00 p.m., 8:00 p.m., 9:00 p.m., 10:00 p.m., 11:00 p.m., 12/5/23 at 6:00 a.m., 7:00 a.m., 8:00 a.m., 9:00 a.m. and 10:00 a.m. The patient was documented as being in the sitting position on 12/2/23 at 9:00 a.m., 11:00 a.m., 12:00 p.m. and 1:00 p.m. The patient was documented as being in the semi-fowler’s position on 12/3/23 at 10:00 p.m., 11:00 p.m., 12/4/23 at 12:00 a.m., 1:00 a.m., 2:00 a.m., 3:00 a.m., 4:00 a.m., 4:59 a.m., 12/5/23 at 12:00 a.m., 1:00 a.m., 2:00 a.m., 3:00 a.m. and 4:00 a.m. (F.) A review of a physical therapy evaluation note dated 12/2/23 at 8:30 a.m., indicated that Patient #1 required total assistance/dependent and moderate verbal cues related to bed mobility. A review of physical therapy weekly progress note dated 12/5/23 at 6:39 a.m., indicated that Patient #1 was a moderate assist for bed mobility. 5. During an interview with A3 (Chief Nursing Officer) on 1/23/24 at approximately 4:45 p.m., he/she verified the medical record information for patient #1.”