SSM Health Rehabilitation Hospital-Okc

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 50779 Based on record review and interview, the hospital failed to ensure the patient received safe delivery of care for one (pts. #1) of 20 patients reviewed. Findings: Pt #1 A review of medical record showed the patient was admitted to the facility on 08/21/2024 and had a complete skin assessment that showed no wound to posterior area. A skin assessment completed on 09/23/24 showed a wound to poterior area that measured 6cm x 3cm x 0.2cm. Documentation showed no wound documented between 08/21/2024 and 09/22/2024. Documentation showed no indication of when wound developed. During an interview on 12/11/2024 at 11:00 pm, Staff member O stated they performed the initial skin assessment at which time the patient’s posterior side was clear with no wounds noted.”

“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: 50779 Based on record review and interview, the hospital failed to ensure the nursing plan of care was implemented and documented in the medical record for 17 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17) of 20 patients reviewed. Findings A review of medical records showed 17 (Pt #1 - #17) of 20 records reviewed had no plan of care developed or documented for the following patients: Pt. #1 admitted on 08/21/24 showed no PoC as of DC date 09/24/24. Pt. #2 admitted on 02/04/24 showed no PoC as of DC date 02/10/24. Pt. #3 admitted on 03/04/24 showed no PoC as of DC date 03/06/24. Pt. #4 admitted on 03/14/24 showed no PoC as of DC date 03/20/24. Pt. #5 admitted on 04/15/24 showed no PoC as of DC date 05/01/24. Pt. #6 admitted on 04/29/24 showed no PoC as of DC date 05/04/24. Pt. #7 admitted on 05/09/24 showed no PoC as of DC date 05/17/24. Pt. #8 admitted on 05/28/24 showed no PoC as of DC date 06/05/24. Pt. #9 admitted on 06/15/24 showed no PoC as of DC date 06/25/24. Pt. #10 admitted on 07/01/24 showed no PoC as of DC date 07/12/24. Pt. #11 admitted on 07/05/24 showed no PoC as of DC date 07/11/24. Pt. #12 admitted on 07/19/24 showed no PoC as of DC date 08/01/24. Pt. #13 admitted on 07/30/24 showed no PoC as of DC date 08/11/24. Pt. #14 admitted on 09/12/24 showed no PoC as of DC date 09/12/24. Pt. #15 admitted on 08/01/24 showed no PoC as of DC date 08/15/24. Pt. #16 admitted on 09/28/24 showed no PoC as of DC date 10/04/24. Pt. #17 admitted on 10/31/24 showed no PoC as of DC date 11/14/24. During an interview with Staff O on 12/11/2024 at 9:00 am., they stated the nursing plans of care were not documented as required.”

“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: 46714 Based on record review and interview, the hospital failed to ensure a Registered Nurse supervised, evaluate, assessed, and monitored the consistency in charting wound location and treatment of the LPN - Wound Care Coordinator, per facility requirements for six of twelve patients (Records #1,3,4,5,6, and 11). A review of “Appendix A” stated in part “a RN must evaluate the care for each patient upon admission and when appropriate and when appropriate on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy...Evaluation would include assessing the patient’s care needs, patient’s health status/conditioning, as well as the patient’s response to interventions.” This failed practice has the likelihood to result in a delay of healing and opportunity for initiation of other interventions. A review of a policy titled “Nursing - Wound Care Program” documented requirements for the Wound Care Coordinator to assess wounds as part of the comprehensive initial assessment and will document all clinical findings as per agency policy. The wound care nurse will document a description of the wound(s) and provide the dressing change. She will document a description of the wound bed, drainage, signs and symptoms of infection, healing, and wound skin condition. At least weekly the wound care coordinator will perform and document wound measurements. On 03/04/24 at 2:25 PM, Staff A reviewed the medical record for patient #1 and stated when nurses change dressings, they were expected to describe the wound to identify if wound was worsening and that did not occur on 02/28/2024. On 03/04/2024 at 2:40 PM, Staff B stated as the Wound Care Coordinator, wound care is performed per physician orders. Staff B states patient wound care is performed and documented on the Wound Care Coordinator flow sheet for tracking. Staff B states there is not a designated time frame used to document description of the wound bed, drainage, signs and symptoms of infection, healing, and wound skin condition. On 03/04/2024 at 2:45 PM, Staff C stated the wound care protocol has been approved by the Medical Executive committee and will be utilized as a guide for the Wound Care Coordinator and other members of the multidisciplinary team to treat and manage wounds. All wound care activity is to be documented in the patient Electronic Medical records according to the Wound Care Program policy and procedures.”