Encompass Health Rehab Hospital of Toledo

“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: 29000 Based on medical record review, policy review, and staff interview, the facility failed to monitor fluid intake for residents on physician ordered fluid restrictions. This affected three (#3, #4 and #8) patients with the potential to affect all patients on fluid restrictions. Findings include: 1. The medical record for Patient #3 revealed an admission date of 09/10/24 at 9:11 PM from an outside facility with a diagnosis of post operative right pelvic fracture with repair. The history and physical further stated this patient had high blood pressure, cirrhosis of the liver and lipidemia. Orders were placed by Staff E on 09/14/24 for fluid restrictions of 1500 milliliters (ml). There was no documentation of oral intake until 09/15/24 when 120 ml Juven supplement was documented for the twenty-four hour day. Intake on 09/16/24 had the supplement Juven 50 ml at 5:00 PM and again on 09/17/24 at 7:00 AM. There was no other documentation of oral fluid intake in the record. Intravenous (IV) fluids were documented when given. Review of the facility policy titled “Fluid Restriction,” dated 08/23/23, stated it is the policy of the nutrition department that fluid restriction orders will be implemented with the cooperation of the nursing department. The tray menu slips will be marked “fluid restriction” and adjustments made on selections. Nursing will monitor and record the fluid intake on the Intake and Output (I&O) in the medical record. Interview with Staff D on 1/28/25 revealed IV medications cross over from the medication record for total intake. Staff D verified the medical record lacked documentation of any fluid intake for 09/20/24 or 09/21/24 with a one time Ensure documented on 09/22/24 and no oral fluid intake on 09/23/24, even though this patient was eating three meals per day. There was no documentation the staff were monitoring the fluid intakes to ensure it met the ordered restrictions. 2. The medical record for Patient #4 revealed an admission on 12/07/24 after having a mitral valve replaced and post operative stroke with weakness on the left side and congestive heart failure. Physician orders on admission were for 1200 ml fluid restriction. The record revealed the first documented intake was on 12/09/24 at 10:44 AM of 240 ml, then not again until 12/11/24 at 8:45 AM of 400 ml. There was no other documentation of the patient’s fluid intake. The findings of not monitoring fluid intakes for the patient’s ordered restrictions was verified with Staff A, B and D on 01/28/25 at 12:10 PM. 3. The medical record for Patient #8 revealed an admission on 10/20/24 at 8:20 PM from an outside hospital with a diagnosis of myopathy post coronary artery bypass. Physician orders were written on 10/22/24 at 9:17 AM for 1200 ml fluid restriction along with orders for I&O. The medical record contained a twenty-four hour oral fluid intake documented on 10/23/24 as 2060 ml, which was greater than the 1200 ml ordered fluid restriction. Output was documented as continent with frequency but no volume of output was measured as the policy instructs. Patient #8 was independent with meals provided three times per day with no consistent documentation of fluid intake. The findings of not monitoring the patient’s fluid intake, not documenting intake and output, and not following physician ordes for fluid restrictions was verified with Staff D on 01/29/25 at 10:00 AM.”

“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: 45445 Based on medical record review, policy review, and staff interview, the facility failed to provide the appropriate care and services for the timely assessment and reassessments of wounds. Additionally, the facility failed to complete wound treatments as physician ordered. This affected five Patients (#5, #6, #7, #8 and #10) of ten patients reviewed for wounds. The facility censes was 30. See A395”

“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: 45445 Based on medical record review, policy review, and staff interview, the facility failed to provide the appropriate care and services for the timely assessment and reassessments of wounds. Additionally, the facility failed to complete wound treatments as physician ordered. This affected five Patients (#5, #6, #7, #8 and #10) of ten patients reviewed for wounds. The facility censes was 30. Findings include: 1. Patient #10 was admitted to the rehabilitation hospital on 11/09/23 at 9:29 P.M. from the acute hospital after a fall at home. Patient #10 suffered a displaced comminuted left acetabular fracture which required surgical repair occurring on 11/03/23. Patient #10 was discharged from the rehabilitation hospital to home on 11/17/23 at 5:47 P.M. Review of the preadmission screening for Patient #10 completed on 11/09/23 at 7:30 A.M. revealed Patient #10 had a surgical incision to the left hip. Review of the continuation of care paperwork printed on 11/09/23 at 4:05 P.M. revealed the abdominal dressing was noted to be intact with a scant amount of serosanguinous drainage with orders to maintain and reinforce as needed until seen by orthopedics on 11/17/23. Review of the physician history and physical completed on 11/10/23 and timed 8:26 A.M. revealed Patient #10 had an incision over the lower abdomen that was clean dry and intact and an incision over the left lateral hip. Review of the nursing admission assessment completed on 11/09/23 at 10:00 P.M. revealed Patient #10 was noted to have multiple bruises and a surgical incision. Further review revealed no documentation of descriptions of the bruises or the surgical wound. Review of the medical record for Patient #10 revealed no documentation of specific descriptions or measurements of surgical wounds and no skin assessments completed. Review of physician orders for Patient #10 revealed no orders for wound care/dressing change. Review of the treatment record for Patient #10 revealed no documentation of wound care/dressing changes. Interview on 03/11/24 at 3:30 P.M. with the Chief Nursing Officer (CNO) verified Patient #10’s admission nursing assessment from 11/09/23 did not contain descriptions or measurements of the wounds. The CNO verified there were no reassessments, including descriptions or wound measurements completed. The CNO verified there were no wound care orders in place for Patient #10. Additional interview with the CNO on 03/12/24 at 9:00 A.M. revealed the facility recognized wounds were not being properly managed and the facility was in the process of hiring a wound nurse. 2. Review of the medical record for Patient #5 revealed an admission date of 02/29/24 and a time of 3:15 P.M. Review of the pre-admission screening completed and signed on 02/29/24 at 1:08 P.M. revealed Patient #5 had a right hip surgical incision. Review of the admission physician orders for Patient #5 revealed an order to keep dressing on until seen by the surgeon and another that read “the hip” was to be cleansed with soap and water and covered with a nonadherent dressing. Nurses were to report increased drainage, and if dressing became soiled or saturated, replace dressing with island dressing. Further review of the medical record revealed no documentation of wound measurements or daily wound assessments. Review of the daily nursing documentation revealed upon admission on 02/29/24, Patient #5’s skin was not intact and gauze dressing was in place. On 02/29/24 at 6:08 P.M., skin was not intact and a gauze post operative dressing was in place. On 03/02/24 at 9:25 A.M., skin was intact with no abnormalities and a hydrocolloid dressing was noted to be dry and intact. On 03/02/24 at 9:25 P.M., skin integrity intact with abnormalities and the wound dressing was noted to be a hydrocolloid dressing that was intact and dry. On 03/03/35 at 9:06 A.M. skin integrity not intact, no further documentation noted. On 03/07/24 at 8:40 A.M., an Aquacel dressing was clean dry and intact to right upper thigh incision. On 03/10/24 at 11:18 P.M., a wound dressing was present and with drainage. On 03/11/24 at 10:45 A.M., the dressing was changed due to a moderate amount of serous drainage; the surgical incision was cleansed with wound cleaner and the appearance of the wound revealed attached edges with reddened skin and tissue around the surgical wound. Interview with the CNO on 03/11/24 during a review of the medical record for Patient #5 verified daily wound assessments were not completed nor was there a daily assessment of the dressing. The CNO verified several different types of dressings were documented to be in place and the only documented dressing change on 03/11/24 did not follow the written physician order. 3. Review of the medical record for Patient #6 revealed an admission date of 03/05/24 and a time of 2:53 P.M. Review of the preadmission assessment completed on 03/04/24 at 3:42 P.M. revealed Patient #6 had a surgical incision on the back.. Review of the nursing admission assessment dated 03/05/24 at 3:51 P.M. revealed Patient #6 had intact skin with no abnormalities. Review of the physician orders revealed an order dated 03/06/24 for the surgical wound back to be cleaned daily with sterile saline, skin prep around the wound, and nonadherent dressing applied, verification of dressing placement and date every 12 hours, and notify the physician of any worsening appearance of the wound, wound enlargement, wound drainage, pain, or signs of infection. Review of the treatment record for Patient #6 revealed dressing changes were completed on 03/09/24 at 4:22 P.M. and 03/10/24 at 4:35 P.M. Further review of the medical record revealed no documentation of wound appearance. There were no reassessments of the wound. Interview on 03/11/24 with the CNO during medical record review verified the nursing admission assessment for Patient #6 did not contain an assessment of the surgical wound. The CNO also verified reassessments were not completed and wound care was not completed daily as ordered. 4. Review of the medical record for Patient #7 revealed an admission date of 01/12/24 and a discharge to home with home health on 01/29/24. Review of the nursing admission assessment completed on 01/12/24 at 10:54 P.M. revealed Patient #7 was admitted to the rehabilitation facility with a dry and intact abdominal wound dressing with a wound vac in place. Assessment of the abdominal surgical wound revealed a length of 16.5 centimeters (cm), a width of 3.5 cm and a depth of 2 cm. Pictures of the wound was taken, wound care completed with black foam placed into the wound bed, and the wound vacuum was reapplied at 125 Millimeter of Mercury (mmHg). Review of the physician order dated 01/13/24 and timed 4:59 A.M. revealed the abdominal wound dressing was to be changed every Monday, Wednesday, and Friday with black foam replaced in wound bed and wound vacuum reapplied at 125 mmHg. Review of the daily nursing notes for Patient #7 revealed wound assessments and documented dressing changes occurred on 01/15/24 at 4:40 P.M., on 01/17/24 at 1:44 P.M., on 01/19/24 at 5:50 P.M., on 01/22/24 at 1:52 P.M., and on 01/25/24 at 1:33 P.M. Interview with the CON on 03/11/24 during record review verified no further documentation or assessments of Patient #7’s wound existed and no further dressing changes occurred after 01/25/24. 5. Review of the medical record for Patient #8 revealed an admission date of 12/20/23 and a discharge date of 01/02/24. Patient #8 was admitted to the acute rehabilitation hospital due to impaired mobility and activities of daily living secondary to a left above the knee amputation and severe ischemia. Review of the physician history and physical dated 12/20/23 and timed 5:09 P.M. revealed Patient #8 had bilateral groin incisions, a right leg surgical incision, necrotic tissue to the right foot, moisture associated damage to the coccyx, and an incision at the left leg amputation site. Review of the physician order dated 12/20/23 revealed the left leg surgical site was to be cleansed daily with soap and water, apply adaptic dressing over the steri-strips and wrap with gauze. Review of the treatment record for Patient #8 revealed dressing changes to the left leg surgical incision were completed on 12/20/23, 12/24/23, 12/26/23, and 12/27/23. Further review of the medical record revealed no documentation of wounds being assessed with measurements upon admission and no daily wound assessments. Interview with the CNO on 03/11/24 during record review revealed Patient #8 did not have measurements of wounds obtained upon admission, did not complete wound treatment as ordered to the left leg surgical incision, did not have daily wound assessments, and did not have ongoing documentation of monitoring for the bilateral groin incisions, the right leg surgical incision, the right foot and the moisture associated damage of the coccyx. Review of the facility policy titled, “Wound Assessment and Documentation,” revised 08/23/23 stated all patients admitted to the hospital will be screened within eight hours for risk of skin breakdown and for alteration in skin integrity by a Registered Nurse (RN). The RN will inspect each patient’s integument daily and as often as indicated. A full skin assessment within 8 hours of admission includes descriptions, measurements, and physician notification. Documentation of the assessment includes the RN describing the wound precisely, with each wound assigned a number, measurements taken for the length, width and depth, documentation of any exudate (drainage), the wound base color, type and proportion of tissue located at the wound base, wound edges, condition of the surrounding tissue and signs and symptoms of infection. Daily documentation of skin and wound inspection completed daily by the RN will include the skin condition, dressing integrity and description of wound drainage, odor, pain, or signs of infection, if present. Daily documentation will be recorded as part of the daily nursing assessment. Weekly documentation will include re-assessments, documentation of current treatment, changes in treatment since last update, improvement in patient’s skin condition and the plan of care documents the current risk for skin breakdown.”