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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 NURSING SERVICES was out of compliance.

A-0395 RN SUPERVISION OF NURSING CARE. A registered nurse must supervise and evaluate the nursing care for each patient.
Based on document review and interviews, the facility failed to ensure patients were assessed for alcohol withdrawal according to provider orders, facility policy, and nursing practice guidelines. Also, the facility failed to ensure patient observations were completed and documented according to provider orders and facility policy in one of four patients reviewed (Patient #3). Additionally, the facility failed to ensure nursing interventions were performed according to provider orders in five of five patients reviewed (Patients #1, #2, #3, #4, and #5).

Based on document review and interviews, the facility failed to ensure patients were assessed for alcohol withdrawal according to provider orders, facility policy, and nursing practice guidelines. Also, the facility failed to ensure patient observations were completed and documented according to provider orders and facility policy in one of four patients reviewed (Patient #3). Additionally, the facility failed to ensure nursing interventions were performed according to provider orders in five of five patients reviewed (Patients #1, #2, #3, #4, and #5).

Findings include:

Facility policies:

The Withdrawal Management policy read, its purpose was to establish standards to ensure the facility provides for withdrawal management in a safe and supportive environment. It is the responsibility of the medical staff to diagnose and direct the treatment of alcohol and drug withdrawal. It is the responsibility of nursing staff to screen for, monitor, and administer treatments for alcohol and drug withdrawal. The facility will provide evidence-based withdrawal management practices to patients. Medical staff and nursing staff will utilize the Clinical Institute Withdrawal Assessment (CIWA) scale to assess, monitor, and inform interventions for alcohol withdrawal. The facility will maintain established protocols for common withdrawal situations including alcohol and opioids. CIWA is a screening tool used to provide general assessment guidelines specific to the care and safety of individuals who may experience alcohol withdrawal, which creates a rubric for the determination of the necessity of pharmacological intervention.

The Observation (Enhanced and Standard) policy read, its purpose was to define how the facility will ensure appropriate monitoring of all patients to maintain a safe and secure environment. Staff members are responsible for ensuring the safety of the patients and the facility by observing and reporting any issues that may arise. This includes patient behavior, door security, prohibited items, property damage, etc. Staff should communicate with the nurse promptly if they notice any safety concerns in the hallways or the patient care areas. Observations will be direct, not via video, and will begin upon admission and be continuous through discharge. Observations will be documented in the Client Observation form in the electronic health record or downtime paper form. All patients will be monitored by standard or enhanced observations based on clinical presentation and provider's order.

Standard observation is for all patients not assessed to need enhanced observations. Standard observation requires direct visual, face-to-face, contact with the patients at a minimum of every 15 minutes, not to be completed via camera or other electronic monitoring devices. Standard observation requires verbal and visual confirmation from patients when in the shower or toileting. Standard observation requires staff to confirm a patient's well-being while asleep (breathing and chest movement).

Enhanced observations are used to mitigate safety risks. A nurse may initiate enhanced observations for immediate safety concerns and follow up with a provider's order. Only a provider can discontinue enhanced observation. Enhanced observations include any observation order that changes, enhances, or modifies the standard intermittent 15-minute observation requirement such as one staff member assigned to one patient. Requires a provider's order with rationale for the order. Staff must maintain constant visual observation of the patient within close proximity and with a barrier so staff can immediately intervene in an emergency situation. Staff must visualize the patient while toileting, showering, and sleeping. Line of site (LOS) means staff may monitor more than one patient at a time. LOS requires a provider's order with rationale for the order. Staff must have the ability to observe the patient(s) at all times according to the provider's order. The LOS order must specify if the patient is to be observed while in the bathroom.
The Glucose monitoring policy read, this procedure establishes guidelines for obtaining glucose using a point-of-care blood glucose monitoring system. The results of this test are used for definitive purposes in the further care and treatment of patients with diabetes who may require sliding scale insulin injections. Nursing staff will document reading in the medical record.

The Quality Assessment and Performance Improvement (QAPI) plan read, the Quality Improvement Committee (QIC) assured that the following functions took place: QIC provided oversight to promote measurable improvement in indicators with a demonstrated link to improved health outcomes. QIC oversaw the analysis of medical errors and other adverse events within the facility to promote the identification of underlying root causes and contributing factors. QIC oversaw the effectiveness of actions taken to correct high priority root causes and contributing factors. QIC oversaw the collection and analysis of quality indicators and assured that they addressed the scope of services provided by the organization. It ensured that indicators addressed high-risk, high-volume and problem-prone processes.

References:

The Alcohol Withdrawal Assessment Scoring Guidelines (CIWA-ar) read, Procedure: 1. Assess and rate each of the 10 criteria of the CIWA scale. Each criterion is rated on a scale from 0 to 7, except for "Orientation and clouding of sensorium" which is rated on a scale of 0 to 4. Add up the scores for all ten criteria. This is the total CIWA-Ar score for the patient at that time. Prophylactic medication should be started for any patient with a total CIWA-Ar score of 8 or greater (i.e. start on withdrawal medication). If started on scheduled medication, additional PRN medication should be given for a total CIWA-Ar score of 15 or greater. 2. Document vitals and CIWA-Ar assessment on the Withdrawal Assessment Sheet. Document administration of PRN medications on the assessment sheet as well. 3. The CIWA-Ar scale is the most sensitive tool for assessment of the patient experiencing alcohol withdrawal. Nursing assessment is vitally important. Early intervention for CIWA-Ar score of 8 or greater provides the best means to prevent the progression of withdrawal.

The assessment protocol from the Alcohol Withdrawal Assessment Scoring Guidelines read, the assessment includes initial vital signs and CIWA assessment. If the initial score is greater than or equal to 8, repeat every hour for 8 hours. Then, if stable, repeat every two hours for eight hours, then if stable, every four hours. If the initial score is less than 8, assess every four hours for 72 hours. If the score is less than 8 for 72 hours, discontinue the assessment. If the score is greater than or equal to 8 at any time, repeat every hour for eight hours. Then, if stable, repeat every two hours for eight hours, then if stable, every four hours. If indicated, administer prn medications as ordered and record on the medication administration record (MAR).

The Lippincott Alcohol Withdrawal Management resources read, signs and symptoms of alcohol withdrawal can begin within six hours after the patient stops drinking and usually resolve in 24 to 48 hours. The patient initially experiences minor withdrawal signs and symptoms, including anorexia, nausea, anxiety, headache, insomnia, diaphoresis, tremulousness, and palpitations. Major motor seizures (alcohol withdrawal seizures) can also occur in the first 12 to 48 hours but rarely occur after that. Alcoholic hallucinations can develop 12 to 24 hours after the patient stops drinking and usually resolve in 24 to 48 hours. Delirium tremens (also called alcohol withdrawal delirium) - including hallucinations, disorientation, tachycardia (high heart rate), hypertension (high blood pressure), hyperthermia (high temperature), agitation, and diaphoresis (sweating) - usually begins 48 to 96 hours after the patient stops drinking and lasts one to five days.

Healthcare professionals should be skilled in assessing and monitoring patients at risk for withdrawal signs and symptoms. If you know that the patient has a history of chronic alcohol use, using the CIWA-Ar assessment tool may help predict the severity of withdrawal symptoms. In addition to indicating withdrawal, a high score can predict whether seizures and delirium are likely to develop. The CIWA-Ar measures 10 signs and symptoms. The maximum score is 67. A patient who scores less than 10 usually does not require additional medication for withdrawal. The CIWA-Ar requires only about 5 minutes to administer.
Reassess the patient's vital signs and condition frequently, as indicated by the withdrawal process. Patients with severe symptoms may require reassessment every 10 to 15 minutes. Use a facility-approved assessment tool to guide and evaluate the effectiveness of treatment.

1. The facility failed to ensure patients were assessed for alcohol withdrawal according to provider orders, facility policy, and nursing practice guidelines.

A. Review of the facility's safety event log from 7/6/24 to 1/6/25 revealed a trend in patients who had not been assessed according to the CIWA protocol as ordered by their providers. Examples included:

i. On 9/18/24 at 12:29 a.m., CIWA assessments were ordered by the provider for alcohol withdrawal/dependency for an adult patient. A CIWA score of 10 was documented at 8:00 p.m. and medication was administered as ordered. The next CIWA assessment was due at 9:00 p.m. and not conducted until 10:35 p.m., one hour and 35 minutes later.

ii. On 9/25/24 at 4:51 p.m., CIWA assessments were ordered by the provider for alcohol withdrawal/dependency for an adult patient. No CIWA assessments were documented until 11:00 p.m. Two CIWA assessments over a six hour period were missed.

iii. On 10/22/24 at 8:27 p.m., CIWA assessments were ordered by the provider for alcohol withdrawal/dependency for an adult patient. A CIWA score of 12 was documented by the RN on 10/22/24 at 8:00 p.m. Medications were administered as ordered. The next CIWA score was documented on 10/23/24 at 0100, however, facility investigation revealed the registered nurse (RN) had falsified this documentation and was not observed entering the patient's room from 12:30 p.m. to 4:48 a.m. The next CIWA assessment occurred on 10/23/24 at 4:48 a.m. Nearly nine hours had elapsed between CIWA assessments.

These examples were in contrast to the assessment protocol from the Alcohol Withdrawal Assessment Scoring Guidelines which read, if the score was greater than or equal to 8, the assessment should have been repeated every hour for eight hours.

These examples were also in contrast to the Lippincott Alcohol Withdrawal Management nursing practice guidelines which read, patients' vital signs and condition should have been reassessed frequently, as indicated by the withdrawal process. A facility-approved assessment tool should have been used to guide and evaluate the effectiveness of treatment.

iv. A review of the facility's safety event log from 7/6/24 to 1/6/25 also revealed more than 25 similar reports had been filed related to late and missed CIWA assessments.

These examples were in contrast to the Withdrawal Management policy which read, it was the responsibility of nursing staff to screen for, monitor, and administer treatments for alcohol and drug withdrawal.

B. Interviews

i. On 1/8/25 at 1:04 p.m., an interview was conducted with RN #1. RN #1 stated CIWA assessments were how clinicians assessed patients for alcohol withdrawal. RN #1 stated gaps in CIWA assessments might have been due to newer staff who had not been well-trained on CIWA assessments. RN #1 stated CIWA assessments were used to measure the severity of alcohol withdrawal. RN #1 stated alcohol withdrawal could have been life-threatening.

ii. On 1/8/25 at 1:46 p.m., an interview was conducted with medical director (Physician) #3. Physician #3 stated CIWA assessments had occasionally been late or missed. Physician #1 stated the electronic medical record (EMR) did not alert staff when it was time for a CIWA assessment.

iii. On 1/8/25 at 3:41 p.m., an interview was conducted with Director #2. Director #2, who was also the quality director, stated some incidents of missed CIWA assessments had been reported even though the patients had not experienced a poor outcome. Director #2 stated the facility had provided clinical staff with education on CIWA assessments every few months. Director #2 stated education had been provided through competency assessments and at skills fairs held in October and December. Director #2 stated nursing supervisors had audited CIWA assessments in real-time. Also, Director #2 stated CIWA compliance had been tracked on the QAPI scorecard over the past year and the facility had been in the green (an indicator of good compliance). Director #2 stated audits indicated a potential trend of missed CIWA assessments around shift changes. Director #2 stated accurate CIWA assessments were important for early intervention in withdrawal management to keep patients from having poor outcomes.

This was in contrast to the QAPI scorecard indicator, CIWA assessment completed at appropriate frequency through entire stay based on score and order, which revealed for the time period 12/22/24 to 12/31/24 the facility was in the red (an indicator of poor compliance) with a 63% compliance rate.

This was also in contrast to the QAPI plan which revealed the QIC assured that the following functions took place: QIC provided oversight to promote measurable improvement in indicators with a demonstrated link to improved health outcomes. QIC oversaw the analysis of medical errors and other adverse events within the facility to promote the identification of underlying root causes and contributing factors. QIC oversaw the effectiveness of actions taken to correct high priority root causes and contributing factors. QIC oversaw the collection and analysis of quality indicators and assured that they addressed the scope of services provided by the organization. It ensured indicators addressed high-risk, high-volume and problem-prone processes.

Furthermore, this was in contrast to the 2025 QAPI plan Department Metrics Data Dictionary 2025, which revealed CIWA assessments were no longer identified as an indicator to be tracked.

2. The facility failed to ensure patient observations were completed and documented according to provider orders and facility policy.

A. Review of the facility's safety event log from 7/6/24 to 1/6/25 revealed a trend in late or missed patient observations. Examples included:

i. On 8/13/24 at 10:15 p.m., a patient was admitted to the inpatient unit from the psychiatric emergency department (PED). The last observation note recorded in PED had been on 8/13/24 at 10:12 p.m. The next observation note recorded was on 8/13/24 at 11:37 p.m. Five observations were missed during this time period.

ii. On 10/13/24 at 7:30 p.m., observations were missed on a pediatric patient. An observation had been documented for the patient at 7:15 p.m. The next observation was documented at 8:03 p.m. The pediatric patient with a history of self-harming behaviors and attempted suicide was not observed for a period of 48 minutes.

iii. On 10/31/24 at 3:15 a.m., observations on unit 100 were missed for all patients. The census on the unit at the time was eight patients. Observations had been documented by the mental health worker (MHW) at 3:04 a.m. The next observations were not documented until 3:36 a.m. Incident follow-up revealed the MHW missed the 3:15 a.m. observations and the charge nurse had not noticed the observations were missing. The MHW had not yet completed the observation competency.

These examples were in contrast to the Observation (Standard and Enhanced) policy which read, the purpose was to define how the facility ensured appropriate monitoring of all patients to maintain a safe and secure environment. Staff members were responsible for ensuring the safety of the patients. Patient observations should have been documented every 15 minutes in the Client Observation form in the electronic health record or on the downtime paper form.

B. A review of Patient #3's medical record revealed Patient #3 was admitted to the facility on 10/22/24. The provider placed an order for continuous 1:1 (one staff member with one patient) observation at 12:36 a.m. Medical record review revealed gaps in 1:1 observations during the following times:

i. On 11/18/24, observations were missing from 1:30 a.m. until 7:30 p.m., 18 hours.
ii. On 11/19/24, observations were missing from 5:30 a.m. until 11:59 p.m., 18 hours and 29 minutes.
iii. On 11/20/24, observations were only completed at 6:45 a.m. and 7:00.
iv. On 11/21/24 through 11/23/24, there were no observations documented in the EMR.
v. On 11/24/24, observations were only completed at 7:30 p.m. and 7:45 p.m.
vi. On 11/25/24 through 11/29/24, there were no observations documented in the EMR.
vii. On 11/30/24, observations were only completed from 3:45 a.m. through 7:15 a.m.
viii. On 12/1/24 through 12/7/24, there were no observations documented in the EMR.

These gaps in observations were in contrast to the Observation (Standard and Enhanced) policy which read, observations should have been documented every 15 minutes in the Client Observation form in the electronic health record or on the downtime paper form.

C. Interviews

i. On 1/8/25 at 1:04 p.m., an interview was conducted with RN #1. RN #1 stated an RN should have stepped in to assist if the MHW was not available to complete patient observations. RN #1 stated Patient #3 had been observed 1:1 during their stay.

This was in contrast to Patient #3's medical record review which revealed multiple gaps in observations.

ii. On 1/9/25 at 4:38 p.m., an interview was conducted with RN #4. RN #4 stated there were different levels of observation. RN #4 stated all patients were placed on standard observations which should have been documented every 15 minutes. RN #4 stated these observations would have been documented by MHWs and could have been documented by RNs. RN #4 stated enhanced observations included LOS (close proximity) and an MHW or RN could have had multiple patients on LOS. RN #4 stated the most restrictive, highest level of observations would have been 1:1, which was close proximity without barriers between the patient and the staff. RN #4 stated the level of observation was ordered by the provider. Also, RN #4 stated patient observation was important to ensure patients did not endanger themselves or others.

Additionally, RN #4 stated they were unaware of any issues with the EMR not recording observations. RN #4 stated they reviewed the MHW observations on the tablet. RN #4 stated it had been difficult to pull up the observations in the EMR. RN #4 stated if observations had been missed, it was most likely due to not staffing to acuity. RN #4 stated the facility staffed to ratios but did not utilize an acuity tool. RN #4 stated they had shared this concern with the nurse staffing committee.

iii. On 1/8/25 at 3:41 p.m., an interview was conducted with Director #2. Director #2 stated there had been issues with the documentation of observations such as difficulty opening them in the EMR and unsaved documents and notes. Director #2 stated this had been the reason for the missing days of observation documentation. Director #2 stated they did not know the data had not been saved. Director #2 stated an IT ticket had been placed on 11/26/24, however, the issue had not yet been resolved.

This was in contrast to the QAPI plan which read, the QIC oversaw the effectiveness of actions taken to correct high priority root causes and contributing factors.

3. The facility failed to ensure provider orders were followed for nursing interventions.

A. Document Review

i. Patient #1's medical record was reviewed and revealed on 11/14/24 at 12:40 a.m., upon admission to the facility, the provider had ordered vital signs (VS) to be assessed twice a day. Medical record review revealed gaps in VS readings. Examples included:

a. Morning VS were not assessed on 11/18/24, 11/19/24, 11/22/24, 11/25/24, 12/2/24, 12/5/24, and 12/10/24.

b. Evening VS were not assessed on 11/24/24. Blood pressure (BP) was not assessed on the evenings of 11/27/24, 11/28/24, 12/4/24, 12/5/24, 12/9/24, and 12/10/24.

c. There was no evidence VS were assessed on 11/26/24 and 12/3/24.

d. A provider note on 12/6/24 read, BP had not been taken for the last two shifts. The note also read, BP and pulse readings were crucial to assess the patient for the need to transfer to the hospital for hydration.

Medical record review also revealed Patient #1 had an unresponsive episode on the evening of 12/14/24 and had been emergently transferred out of the facility for care due to extremely low BP secondary to dehydration.

ii. Additional medical record reviews for Patients #2, #3, #4, and #5 revealed VS assessments were not consistently completed as ordered by the provider.

iii. Patient #1's medical record was reviewed and revealed on 11/21/24, 11/28/24, and 12/2/24, the provider had ordered blood sugar checks to be completed twice a day. The medical record revealed blood sugars had not been checked as ordered. Blood sugar levels were documented as follows:

a. On 11/22/24 at 6:53 a.m., the blood sugar level was 136. Patient #1's blood sugar was not assessed in the evening.
b. On 11/24/24 at 8:12 a.m., the blood sugar level was 94. Patient #1's blood sugar was not assessed in the evening.
c. On 11/29/24 at 5:46 a.m., the blood sugar level was 114. Patient #1's blood sugar was not assessed in the evening.
d. On 11/30/24 at 6:00 p.m., the blood sugar level was 139. Patient #1's blood sugar had not been assessed in the morning.
e. On 11/30/24 at 6:00 a.m., the blood sugar level was 152. Patient #1's blood sugar was not assessed in the evening.
f. On 12/1/24 at 6:30 a.m., the blood sugar level was 142. Patient #1's blood sugar was not assessed in the evening.
g. On 12/2/24 at 5:57 a.m., the blood sugar level was 129. Patient #1's blood sugar was not assessed in the evening.
h. On 12/14/24 at 10:51 p.m., the blood sugar level was 171. Patient #1's blood sugar had not been assessed in the morning.

Eight blood sugar levels had been checked over 25 days when 50 levels should have been checked. The provider's order for blood glucose checks had been followed only 16% of the time.

iv. Additional medical record review revealed Patient #5, who was a Type II diabetic on insulin, also had inconsistent blood glucose monitoring during their admission to the facility.

v. Patient #1's medical record was reviewed and revealed on 12/5/24 the registered dietician (RD) note read, Patient #1 had gone multiple days in a row with 0% meal intake. Patient #1 had an order for Boost Glucose Control nutritional supplement three times each day but it was unclear if Patient #1 had accepted the supplements. Further, the RD note read, Patient #1 had been at risk for severe malnutrition and recommended nurses document Patient #1's acceptance or refusal of the nutritional supplement. A review of Patient #1's medication administration record (MAR) revealed gaps in the administration of the nutritional supplement. Examples included:

a. On 12/8/24 the nutritional supplement was given at 10:12 a.m. and 2:49 p.m. The nutritional supplement was not given at 9:00 p.m.
b. On 12/11/24 the nutritional supplement was given at 9:18 a.m. and 8:50 p.m. The nutritional supplement was not given at 3:00 p.m.
c. On 12/12/24 the nutritional supplement was given at 9:24 a.m. and 2:43 p.m. The nutritional supplement was refused at 9:55 p.m.
d. On 12/13/24 the nutritional supplement was refused at 10:00 a.m. The nutritional supplement was not given at 3:00 p.m. or 9:00 p.m.
e. On 12/14/24 the nutritional supplement was not given at 8:30 a.m., 3:00 p.m., or 9:00 p.m.

Medical record review revealed, Patient #1 had an unresponsive episode on the evening of 12/14/24 and at 11:47 p.m. the provider had ordered Patient #1 emergently transferred out of the facility for care due to extremely low BP secondary to dehydration.

B. Interviews

i. On 1/8/25 at 10:32 a.m., an interview was conducted with RN #5. RN #5 stated it was important to follow provider orders because the orders were there for a reason. RN #5 stated the provider would have assessed the patient and determined the best care for the patient. RN #5 stated if the nurses had not carried out the provider orders, they would have failed to give the patient the monitoring and care required.

Also, RN #5 stated if provider orders were not followed there could have been a negative impact to the patient. RN #5 stated, for example, if a patient had required blood glucose checks that had been missed, the patient could have had an episode of low blood sugar. RN #5 stated symptoms of low blood sugar could easily have been confused with psychiatric symptoms. RN #5 stated if the low blood sugar symptoms had been missed, it could have been fatal to the patient. RN #5 stated if blood sugars had been too high, the patient might have had diabetic ketoacidosis (DKA) (a life-threatening condition in diabetics) which would have required transfer to a medical hospital. RN #5 stated missed blood sugar checks could have delayed patient care and/or prolonged hospitalization. RN #5 stated many things could have gone wrong for a diabetic patient if nurses had not monitored the blood glucose checks as ordered.

Additionally, RN #5 stated the provider would have ordered VS. RN #5 stated routine VS at the facility meant twice each day. RN #5 stated it was important for nurses to follow the provider's orders for VS. For example if the provider had been concerned about withdrawals, they would have ordered more frequent VS. RN #5 stated for a patient who might have been in withdrawals, it was important to follow changes in VS in case the patient needed to be treated. RN #5 stated withdrawals could have been severe and could have required admission to an intensive care unit (ICU). RN #5 stated another example of the importance of VS would have been a patient who needed oxygen. If the VS had not been monitored and the patient's oxygen level dropped too low, the patient could have had respiratory arrest and needed transfer to the hospital.

Finally, RN #5 stated if the provider had ordered a special diet for the patient, it would have been important for the nurses to follow those orders. RN #5 stated, for example, it had been common for patients to have a nutritional supplement ordered by the provider. RN #5 stated these orders would have been placed in the electronic MAR so the nurses would have known how often to give the nutritional supplement. RN #5 stated it was important for nurses to give the supplements as ordered to ensure patients received the correct amount of nutrition.

ii. On 1/8/25 at 3:41 p.m., an interview was conducted with Director #2. Director #2 stated they were unaware of missed blood glucose checks. Director #2 stated the providers had not mentioned missed blood glucose checks. Director #2 stated the MHW had been trained to do blood glucose checks last month and would have been able to help nurses get them done. Director #2 stated blood glucose checks should have been on the eMAR. Director #2 stated some of the missed blood sugar checks might have been on paper which had not made it into the EMR. Director #2 stated they might have been able to revise the eMAR to improve compliance with blood sugar checks. Additionally, Director #2 stated the EMR had recently been revised to add more checkboxes to help the nurses. Director #2 stated they might have been able to add other nursing interventions to the EMR to help the nurses comply with provider orders.

iii. On 1/8/25 at 1:46 p.m., an interview was conducted with Physician #3. Physician #3 stated they would have expected the nursing staff to follow provider orders. Physician #3 stated if the provider had not wanted the intervention completed they would not have ordered the intervention. Physician #3 stated for a diabetic patient on insulin, they would have ordered regular glucose checks and would have expected that they would have been done.