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Based on interview and record review, the facility failed to ensure Patient 22 received and signed for, "Condition of Admission/Registration, Treatment Authorization and Financial Responsibility," (form that establishes the conditions under which a patient is admitted for inpatient services) when he was hospitalized on November 6, 2024, through November 12, 2024.

This failure had the potential for Patient 22 to not understand his rights as an inpatient, and may fail to exercise his rights during hospitalization.

Findings:

On November 13, 2024, at 3:30 p.m., the Patient Access Services Manager (PASM) was interviewed regarding "Condition of Admission (COA)," for Patient 22. PASM stated the COA was not done. The document presented indicated the facility had attempted to complete the COA the day Patient 22 was discharged home.

On November 14, 2024, at 2:05 p.m., the PASM was interviewed. PASM stated COA is important and should have been done at the time of patient registration. PASM stated they have no COA policy, and they are currently using the California Hospital Association Manual (CHAM) for guidelines.

On November 14, 2024, at 2:25 p.m., Risk Manager (RM) was interviewed. RM stated COA is important so the patient can be made aware of their "Rights". RM stated patients are supposed to be provided with information they can understand, information on how to file a grievance, and it should had been done upon admission and registration.

A review of the facility document titled, "Conditions of Admission/Registration, Treatment Authorization and Financial Responsibility", dated April 2022, indicated, "...As the individual who will be receiving services...Patient's Bill of Rights and Patient's Responsibilities...carefully read and fully understand this Agreement and receive a copy for my records..."

Based on interview and record review, the facility failed to ensure the facility's policies and procedures (P&P) were implemented, for six of 30 sample patients (Patient 3, 7, 14, 16, 19, and 21), when:

1. For Patients 3, 16, and 21, pain assessment was not completed before and after pain medication administration.

2. For Patients 7, 14, and 19, the medication reconciliation was not completed when admitted.

These failures had the potential to compromise patient safety, result in inadequate pain management, and medication discrepancies that could have led to medication errors.

Findings:

1a. A review of Patient 3's record was conducted on November 12, 2024, at 10:02 a.m., with the Risk Manager (RM). A facility document titled, "ED (Emergency Department) Physician Record," dated November 11, 2024, at 9:05 p.m., was reviewed and indicated Patient 3 was admitted to the facility on November 11, 2024, for suicidal attempt (an act in which an individual tries to kill themselves but survives).

A facility document titled, "Medication Administration Record," dated November 12, 2024, was reviewed. The document indicated, "...hydrocodone-acetaminophen (Norco 10 mg-325 mg [a unit of measurement] oral tablet [by mouth] [pain medication]...1Tabs [Tablets], Tab [Tablet], oral, q4H PRN [every four hours as needed] pain 7 -10 [a pain scale measuring 10 as highest level of pain and zero the lowest] (Severe)..."

A facility document titled, "Med [Medication] Admin [Administration]- PRN [as needed]," was reviewed. On November 12, 2024, at 10:29 p.m., Norco 10 mg -325 mg Tylenol was administered and the patient's pain level prior to the administration was 7/10. Pain level was not reassessed after pain medication was given.

There was no documented evidence pain assessment was conducted after Norco was administered on November 12, 2024.

An interview was conducted on November 12, 2024, at 2 p.m., with the (RM). The RM verified pain reassessment was not conducted on November 12, 2024, after Norco was administered to Patient 3. The RM stated the pain level should have been reassessed after medication administration. The RM stated this was not done for Patient 3, the policy was not followed.

1b. A review of Patient 16's record was conducted on November 14, 2024, at 9:20 a.m., with the Quality Improvement Analyst (QIA). A facility document titled, "History and Physical (H&P)," dated November 12, 2024, at 8:18 a.m., was reviewed and indicated Patient 16 was admitted to the facility on November 11, 2024, for respiratory failure (a serious condition that occurs when the lungs have difficulty getting enough oxygen into the blood), pneumonia (a lung infection that causes the air sacs in the lungs to fill with fluid or pus) and generalized weakness (a feeling of decreased muscle strength in most parts of the body).

An untitled facility document was reviewed on November 12, 2024, at 8:34 a.m., and indicated Patient 16's pain level was acute, there was no indication of a numerical scale rating of pain.

A facility document titled, "Med Admin - PRN," was reviewed. On November 12, 2024, at 8:34 a.m., Norco 5 mg-325 mg Tylenol was administered and Patient 16's pain level prior to the administration was not documented. Pain level was not assessed prior to pain medication administration and not reassessed after pain medication was given to Patient 16.

An interview was conducted on November 12, 2024, at 9:20 a.m., with the QIA. The QIA stated pain level was not assessed on November 12, 2024, at 8:34 a.m. The QIA stated pain level should have been assessed prior to medication administration and reassessed after pain medication was given, the policy was not followed.

There was no documented evidence pain assessment was conducted on November 12, 2024, prior to pain medication administration and reassessment of efficacy of pain medication administered to Patient 16.

1c. A review of Patient 21's record was conducted on November 13, 2024, with the Senior Clinical System Analyst (SCSA). The facility document "History and Physical," indicated Patient 21 was admitted to the hospital on November 5, 2024, for right knee pain status post (S/P) fall with injury, comminuted displaced tibial plateau fracture (severe knee injury requiring surgical intervention to realign and fix the fractured pieces using plates and screws).

A facility document titled, "Medication Administration Record (MAR)," was reviewed and indicated, "...HYDROmorphone (Dilaudid- pain medication) 1 mg IV Push (administered intravenously) q4H interval, PRN for Pain 7-10, administer over two minutes..."

On November 13, 2024, at 9:30 a.m., a concurrent interview and record review of the MAR dated November 6, 2024, at 5:46 p.m., was conducted with the SCSA. The MAR record indicated Patient 21 received HYDROmorphone 1 mg IV Push for complaint made for pain 9/10 scale. There was no documented evidence pain reassessment was conducted after HYDROmorphone was administered on November 6, 2024. SCSA stated pain reassessment should have been done an hour after patient was pain medicated to check if intervention was effective. SCSA further explained, it is generally a standard to conduct pain reassessment after pain medication was administered.

A review of the facility's P&P titled, "Assessment/Reassessment of Patient," revised June 2024, was conducted. The P&P indicated, "...Pain...Reassess and document efficacy..."

2a. A review of Patient 7's record was conducted on November 14, 2024, at 9:40 a.m., with the RM. A facility's document titled, "H&P," dated November 12, 2024, was reviewed. The document indicated Patient 7 was admitted to the facility on November 13, 2024, for back pain.

A facility document titled, "Medication History," dated November 11, 2024, was reviewed. The documents indicated Patient 7's medication reconciliation was not completed on admission.

A concurrent interview and record review were conducted on November 14, 2024, at 10:40 a.m., with the RM. RM stated the admitting physician is responsible for medication reconciliation once the patient is admitted. The RM stated the medication reconciliation was not completed by the physician on admission for Patient 7.

A concurrent interview and record review were conducted on November 14, 2024, at 2 p.m., with Physician 3. Physician 3 stated it is usually the admitting doctor who completes the medication reconciliation, this medication reconciliation was not completed.

2b. A review of Patient 14's record was conducted on November 13, 2024, at 3:10 p.m., with the Manager of Nursing Administration (MNA). A facility document titled, "H&P," dated November 7, 2024, at 10:09 a.m., was reviewed. The document indicated Patient 14 was admitted to the facility on November 7, 2024, for uncontrolled bilateral leg pain (pain not controlled on both legs of the body).

A facility document titled, "Medication History," dated November 6, 2024, was reviewed. The documents indicated Patient 14's medication reconciliation was not completed on admission.

A concurrent interview and record review were conducted on November 14, 2024, at 1:42 p.m., with Physician 1. Physician 1 stated, "...medication reconciliation's are done prior to admission...if the medication reconciliation is not done within 48 hours, they are notified..."

2c. A review of Patient 19's record was conducted on November 14, 2024, at 10:10 a.m., with the MNA. A facility document titled, "H&P," dated November 11, 2024, at 7:11 p.m., was reviewed. The document indicated, Patient 19 was admitted to the facility on November 9, 2024, for seizure (a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements, feelings, and levels of consciousness).

A facility document titled, "Medication History," undated, was reviewed. The document indicated Patient 14's medication reconciliation was not completed on admission.

A concurrent interview and record review were conducted on November 14, 2024, at 1:44 p.m., with Physician 2. Physician 2 stated, "...medication reconciliation's are done prior to admission...for Patient 19 the medication reconciliation was not completed, the physician assistant should have done it..."

A concurrent interview and record review were conducted on November 14, 2024, at 2:25 p.m., with the DOP. The DOP stated the medication reconciliation was not completed for Patients 7, 14, and 19 at admission. The DOP further stated the admitting provider is responsible for completion. If a Physician Assistant or Nurse Practitioner does not complete the medication reconciliation, it is ultimately the responsibility of the admitting physician per policy.

A review of the facility's P&P titled, "Medication Reconciliation Across the Continuum of Care," dated September 26, 2024, was conducted. The P&P indicated, "...The policy applies to the medical staff, nursing staff, allied professionals including, but not limited to...and all who may be involved in the medication reconciliation process...It is the policy to reconcile patient's medications at the time of admission, intradepartmental transfer, and at discharge or transfer to another facility. The completed list of medications is provided to the next caregiver upon transfer within the facility. The completed medication list is provided to the patient at the time of discharge..."