HospitalInspections.org

Based on observation, interview, and record review, the facility's Governing Body (responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) failed to ensure the Condition of Participation for Governing Body was met as evidenced by:

1. The facility's Governing Body (GB, responsible for guiding the hospital's long-term goals and policies and assisting with strategic planning and decision-making), failed to ensure the Nursing Department's compliance with the facility's policy regarding the management of one of 30 sampled patients (Patient 5), on 5150 hold (an involuntary psychiatric hold in California for individuals who are considered a danger to themselves or others) outside of the mental health unit. Patient 5 was on a 5585 hold (an involuntary hold for minors under the age of 18 who are deemed a danger to themselves or others or are gravely disabled [unable to meet basic needs such as feeding, hygiene, etc.] due to a mental disorder, allowing for a 72-hour psychiatric evaluation [a mental health assessment to help diagnose and treat mental health problems]) due to suicidal ideation (SI, thoughts of causing one's own death), which involved thoughts or planning related to self-harm or suicide (death caused by injuring oneself with the intent to die). Patient 5 was not provided a 1:1 sitter (a patient observer or constant observer, is a healthcare staff member assigned to monitor a single patient continuously) per policy.

This deficient practice had the potential to compromise patient safety and increase the risk of harm to Patient 5 and other patients and may also result in death. (Refer to A-0063)

2. The facility's Governing Body (GB, responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) failed to ensure the facility's contracted Managed Care personnel ensure the discharge planning process (the process of preparing a patient to leave a healthcare facility, and ensuring a smooth and safe transition to the next phase of care such as going home, moving to a rehabilitation center, nursing home, or other healthcare setting) promoted safe, effective patient transition from hospital to their next level of care, for one (Patients 1) of 30 sampled patients.

This deficient practice had the potential to result in negative consequences for patients, post-discharge leading to higher patient re-admission rates and worsening of their conditions due to delays in care coordination or inadequate follow-up care set-up. In addition, this deficient practice violates patients' and their caregivers' rights when they were not involved in the discharge planning process. (Refer to A-0083)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments.

Based on observation, interview, and record review, the facility's Governing Body (GB, responsible for guiding the hospital's long-term goals and policies and assisting with strategic planning and decision-making), failed to ensure the Nursing Department's compliance with the facility's policy for 1:1 sitter (a patient observer or constant observer, is a healthcare staff member assigned to monitor a single patient continuously) regarding the management of one of 30 sampled patients (Patient 5) on 5150 hold (an involuntary psychiatric hold in California for individuals who are considered a danger to themselves or others) outside of the mental health unit. Patient 5 was on a 5585 hold (an involuntary hold for minors under the age of 18 who are deemed a danger to themselves or others or are gravely disabled [unable to meet basic needs such as feeding, hygiene, etc.] due to a mental disorder, allowing for a 72-hour psychiatric evaluation [a mental health assessment to help diagnose and treat mental health problems]) due to suicidal ideation (SI, thoughts of causing one's own death), which involved thoughts or planning related to self-harm or suicide (death caused by injuring oneself with the intent to die). Patient 5 was not provided a 1:1 sitter per policy.

This deficient practice had the potential to compromise patient safety and increase the risk of harm to Patient 5 and other patients and may also result in death.

Findings:

During a concurrent observation and interview on 10/29/2024 at 1:55 p.m. in the Emergency Department (ED, provides immediate care for patients with serious illnesses or injuries), in the area/room called the Main area, Patient 5 was observed inside the room, seated on a hospital gurney in the corner, with the gurney partially obscured by a privacy screen. Patient 5 did not have a 1:1 sitter (a patient observer or constant observer, is a healthcare staff member assigned to monitor a single patient continuously) or a security guard stationed next to Patient 5. The registered nurse (RN 3) was seated behind the desk in the room, while two security guards were positioned near the entrance. There were 4 patients in the room. RN 3 stated that Patient 5 was on a 5585 hold) due to suicidal ideation (SI, thoughts of causing one's own death), which involves thoughts or planning related to self-harm or suicide (death caused by injuring oneself with the intent to die).

During a review of Patient 5's medical record (MR) titled, "Behavioral Health Forms," dated 10/28/2024, the MR indicated that on 10/28/2024, Patient 5 was brought into the facility's ED by the Los Angeles Sheriff's Department (LASD) and placed on a 5585 hold for suicidal ideation (SI) and cutting wrists. The MR also indicated that Patient 5 stated they had a specific suicide plan and that they required to be transferred to an age-appropriate psychiatric facility.

During a concurrent interview and record review on 10/30/2024 at 3:35 p.m. with the Clinical Quality Coordinator (CQC), Patient 5's medical record (MR) titled, "Psychosocial Assessment" flowsheet, dated from 10/28/2024 through 10/31/2024, was reviewed. The CQC verified that the MR did not contain a "Suicidal Ideation Risk Assessment," completed by ED nurses for Patient 5 to assess and evaluate the patient for present thoughts about self-harm and suicide.

During an interview on 10/31/2024 at 3:41 p.m. with the Emergency Department Charge Nurse (CN 2), the CN 2 described the setup for managing psychiatric patients (patients with mental health issues) in the ED. CN 2 stated, "In the ED, we place all psychiatric patients in the same area. We have security guards assigned to that area, typically 2-3 guards, depending on the number of patients, and one or two licensed nurses, also depending on the number of patients in the room. There is not one security guard per patient. They are all tasked with monitoring for any aggression. They are there to de-escalate (to reduce the intensity of a potentially violent situation) situations and assist the nurse as needed."

During an interview on 10/31/2024 at 4:25 p.m. with the Senior Director of Nursing Administration (SDNA) also known as house supervisor, the SDNA outlined the process and requirements for ordering a 1:1 sitter. The SDNA stated, "We usually know all the holds. My team is aware of all the patients-we know when they come in, their details, and if they are on a hold. We proactively check with the charge nurse to determine if a sitter is needed, even before an official hold is placed."

During the same interview on 10/31/2024 at 4:25 p.m. with the SDNA, the SDNA also stated, "A 1:1 sitter assists a specific patient, ensures the area is safe, and does not leave the bedside without someone to relieve them. They work closely with the team and must document every 15 minutes. We have safety attendants, patient observation attendants, and nurse techs (technician). Security guards can also serve as sitters, but they don't provide clinical care and still need to document every 15 minutes. For patients with suicidal ideation (SI), these patients are evaluated and placed on a hold. We enter the room, secure the environment, immediately assign a sitter within arm's length, and screen visitors to ensure safety."

During an interview on 10/31/2024 at 4:45 p.m. with the Emergency Department Manager (EDM), the EDM described the facility's approach to managing patients with psychiatric mental health issues. The EDM stated, "We typically place all patients with psychiatric mental health issues in one room, referred to as the Main area, which has 8 beds with no dividers and no curtains." The EMD also stated, "Typically we assign 1 RN and 1 LVN for 6 patients, and 2 RNs for 8 patients. Security coverage is determined by security leadership, with a minimum of 2 security guards assigned. We use security to prevent patients from wandering away from the area and to ensure the patients' safety."

During the same interview on 10/31/2024 at 4:45 p.m. with the EDM, the EDM also stated, "We sometimes call for sitters for patients with suicidal ideation (SI) or homicidal ideation (HI, the act of thinking about, considering, or planning to kill another person). We contact the house supervisor to request a sitter, but they don't always provide one due to availability issues. If no sitter is available, we then call security to see if they have enough staff to sit with the patient. If neither is available, we assign a technician to sit with the patient. However, not all patients on holds require a 1:1 sitter or receive one."

During the same interview on 10/31/2024 at 4:45 p.m. with the EDM, the EDM reviewed the facility's policy titled, "Involuntary Detention (Holds), dated 5/2024 and stated, "The policy is correct stating that each patient on a hold must be provided with 1:1 or security supervision. However, we do not follow this exactly. Instead, we place all patients in one room with security because it is considered a ligature-free environment (a space designed to eliminate or minimize potential ligature (something used to bind or tie. Example: belts, shoelaces, etc.) points, such as areas where a person could attach a cord, rope, or other material to inflict self-harm through strangulation (compression of the neck that may lead to unconsciousness or death) or hanging. This type of environment is crucial in healthcare settings, especially in psychiatric units or emergency departments where patients may be at risk of suicide or self-harm)."

During an interview on 11/1/2024 at 12:48 p.m. with the Senior Director of Operations (SOD) regarding the facility's policy titled, "Involuntary Detention (Holds)," dated 5/2021, the SOD stated, "This policy is primarily for inpatient patients, but since it does not differentiate, it applies to all patient care areas." The SOD explained, "On the inpatient floors, if a patient is on a hold, they are assigned sitters. In behavioral health, it's managed differently. In the emergency department, we try to keep all patients with psychiatric mental health issues, whether on a hold or not, in the same area called the Main area. These are ED patients, not BHU (Behavioral Health Unit, provides treatment and stabilization for patients with mental health issues) patients, even if they're on a hold. They are meant to remain under direct observation in the main room, so they're constantly in sight."

During an interview on 11/1/2024 at 2:21 p.m. with Risk Management (RM) and the Quality Management Manager (QMM) about the facility's latest performance improvement projects in the Emergency Department (ED), the RM stated that the performance improvement team recently identified a need to strengthen processes for managing patients with suicidal ideation and other high-risk patients in the ED. The RM stated, "We're looking at how we are screening in triage (categorize patients based on the severity of their injuries), how we protect patients, especially those who are high-risk, how we're documenting safety checks and addressing ligature risks. We're also examining our process for obtaining sitters for high-risk patients. We reached out to our electronic health record (HER. Digital version of paper chart) provider to see if they could incorporate built-in tools to help improve our screening process to identify patients with suicidal ideation."

During the same interview on 11/1/2024 at 2:21 p.m., the RM further explained, "A big part of this work is about identifying patients with suicidal ideation (SI). We've (Risk Management team) started auditing those SI patients over the past few weeks to identify any gaps, like missed orders or medications. We're also discussing order sets and looking at ways to proactively push the sitter order, so it doesn't have to be manually pulled." The RM added, "We're revising the policy to ensure it aligns with evidence-based practice because, ultimately, we want to make sure we're providing the best possible care." The RM stated that this process is collaborative, with a multidisciplinary team, including ED education, ED leadership, and all key stakeholders.

During an interview on 1/11/2024 at 3:58 p.m. with the Chief Executive Officer (CEO), the CEO described the responsibilities of the Board of Directors, stating, "The Board oversees the operations and quality of care at the hospital. Department heads, executives, and the Board are responsible for overseeing policies and their implementation within each department. This oversight ensures that each department follows established guidelines and remains compliant with organizational standards and regulations. The Board holds ultimate accountability, working closely with department leaders and executives to ensure policies are effectively implemented and consistently followed across the organization."

In the same interview on 11/1/2024 at 3:58 p.m. with the Chief Executive Officer (CEO), the CEO described the process and responsibilities for reviewing and implementing policies. The CEO stated, "The policies are reviewed annually, I think. The owner of the policy, the director or the head of the department is responsible for the policies in their departments. If it is nursing, the Director of Nursing signs off on them. Some of the policies go to the Board of Directors, but not all of them."

During an interview on 11/1/2024 at 4:09 p.m. with the Chief Nursing Officer (CNO), regarding the policy titled, "Involuntary Detentions (Holds)", dated 5/2021, the CNO stated that the policy was current and remained in effect, adding, "Until I know otherwise, it stands. If it's an involuntary hold, patients are automatically required to have a sitter. For patients on a hold who are identified as dangerous, additional safety measures are put in place. We are contracted with an outside company that provides sitters for each patient on a hold."

During an interview on 11/1/2024 at 4:09 p.m. with the Chief Nursing Officer (CNO) regarding policy implementation in the facility, the CNO stated, "We're validating implementation of policies through observations and documentation. Although, through our assessments, we've identified a need to develop an improvement project that is currently in progress."

During a review of the facility's policies and procedures (P&P) for the care of patients on 5150 holds, dated 5/2021, the P&P indicated that all patients on a hold require 1:1 sitter or a security guard assigned for direct observation. A review of the facility's policies also indicated a lack of policies or guidelines outlining the required assessments and documentation for nursing staff when caring for mental health patients on either 5150 (an involuntary psychiatric hold in California for individuals who are considered a danger to themselves or others) or 5585 holds who are awaiting transfer to a psychiatric hospital in the emergency department.

During an interview on 11/1/2024 at 4:16 p.m. with the Chief Nursing Officer (CNO), the CNO stated, "We have identified the issues with the way we manage psychiatric patients. We recognize the need for improvement in assessing and identifying gaps to provide the best care possible."

During a review of the facility's policy and procedure (P&P) titled, "Involuntary Detention (Holds)" dated 5/2021, the P&P indicated that all patients placed on 5150 holds, regardless of diagnosis, are to be assigned to a private or blocked room with a 1:1 observer (security sitter, nurse technician, or patient safety attendant) responsible for ensuring patient safety. The 1:1 observer will be positioned either in the room or directly outside, with a clear view of the patient at all times. If a private or blocked room is unavailable, the patient will remain in the Emergency Department (ED) under the supervision of a security guard, and transfer arrangements to a medical psychiatric facility will be initiated. Additionally, all in-house psychiatric patients located outside the mental health unit are to be assigned both a medical RN and a Mental Health RN to address their medical and mental health needs, along with a 1:1 sitter. If a Mental Health RN is unavailable, the patient will stay in the ED with a security guard to ensure their safety.

Based on observation, interview, and record review the facility's Governing Body (GB, responsible for guiding the hospital's long-term goals and policies, and assists with strategic planning and decision-making) failed to ensure the facility's contracted Managed Care personnel ensure the discharge planning process (the process of preparing a patient to leave a healthcare facility, and ensuring a smooth and safe transition to the next phase of care such as going home, moving to a rehabilitation center, nursing home, or other healthcare setting) promoted safe, effective patient transition from hospital to their next level of care, for one (Patients 1) of 30 sampled patients.

This deficient practice had the potential to result in negative consequences for patients, post [after]-discharge leading to higher patient re-admission rates and worsening of their conditions due to delays in care coordination or inadequate follow-up care set-up. In addition, this deficient practice violated patients' and their caregivers' rights when they were not involved in the discharge planning process.

Findings:

During a review of Patient 1's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 7/12/2024, the H&P indicated that Patient 1 was admitted due to shortness of breath (SOB, difficulty breathing), and found to have aspiration pneumonia (a lung infection caused by inhaling things other than air, such as saliva, food particles or stomach contents) and acute respiratory failure (ARF, an inability to maintain adequate oxygenation for tissues). The H&P also indicated that Patient 1 had past medical history (PMH, a record of their health status before their current problem) of stroke (clot in the brain) with chronic right sided deficit (problems that occur when there is damage to the right side of the brain. Example: weakness on the right side of the body, difficulty with memory, etc.), aphasia (a language disorder that makes it hard for you to read, write, and speak), percutaneous endoscopic gastrostomy (PEG, feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall).

During a review of Patient 1's Medical Record (MR) titled, "Discharge Summary," dated 7/24/2024, the MR indicated that Patient 1 was at high risk for re-aspiration (Re-aspiration refers to the repeated inhalation of food, liquid, saliva, or other foreign material into the lungs, which can lead to serious complications like pneumonia or respiratory distress. Patients at high risk for re-aspiration require careful monitoring and specific care measures to prevent further aspiration events), though the family wanted to take the patient home. The MR also indicated that Patient 1 required tube feeding, home health services, in-home physical therapy (treatment that uses a combination of techniques to help patients improve their movement, relieve pain, and strengthen muscles), supplemental oxygen, durable medical equipment (DME, medical equipment that can be used repeatedly and is intended to be used in a patient's home for a medical purpose), including a hospital bed.

During a concurrent interview and record review on 10/31/2024 at 9:35 a.m. with the Clinical Quality Coordinator (CQC), Patient 1's medical record was reviewed for discharge planning documentation. The record indicated that no case management notes were recorded in Patient 1's chart from 7/12/2024 through 7/22/2024, which the CQC confirmed. Additionally, the medical record contained a note titled, "Case Management (CM)," dated 7/22/2024, indicating that a case manager documented their first contact with Patient 1's family representative on 7/22/2024, only two days before Patient 1's discharge from the facility with an anticipation to discharge Patient 1 the following day, on 7/23/2024.

During an interview on 10/31/2024 at 11:26 a.m. with Registered Nurse (RN 2) regarding the facility's discharge process, RN 2 stated, "The case manager (CM) is responsible for relaying information about home health services, durable medical equipment (DMEs), and transportation arrangements." RN 2 further explained that, typically, the CM would call the nurse to inform them about any DMEs, and other arrangements. "Sometimes it's documented in the patient's chart and sometimes it's not," RN 2 added. "I'm not sure if I typically document this information after receiving a call from the CM."

During the same interview on 10/31/2024 at 11:26 a.m. with Registered Nurse (RN 2) regarding Patient 1's discharge instructions dated 7/24/2024, RN 2 reviewed the discharge instructions and stated, "Based on what is documented, arrangements were made for blood glucose (sugar) monitoring, an enteral feeding (a liquid nutritional formula is delivered through a tube that is inserted into the stomach or small intestine) pump, and a transfer aid for Patient 1. However, nursing, and physical therapy are noted as 'none arranged,' and I cannot recall if I received a call from the CM about those services. I also don't remember for certain if all the DMEs and services were arranged or which ones, as it's not documented."

During a review of Patient 1's MR titled, Case Management," dated 7/23/2024 at 4:43 p.m., the MR indicated Patient 1's discharge was delayed because a hospital bed had not yet been delivered. Patient 1's MR contained no additional notes recorded by the CM on any other days during Patient 1's hospital stay. The MR contained no recorded confirmation of delivery of the hospital bed and home health services in Patient 1's medical record either.

During an interview on 10/31/2024 at 12:00 p.m. with Director of Case Management services (DCM) regarding the facility's discharge planning process, the DCM stated that discharge planning begins within 24 hours of admission and involves case managers, nurses, and other healthcare team members. Case managers would complete the discharge planning screening within the first 24 hours and the process would include discussing patient needs post (after)-discharge, such as home health, durable medical equipment (DME), and other supports, and should be documented thoroughly. For instance, orders for home health services (such as nursing or wound care) should include contact information and the service start date. Similarly, DME orders (like oxygen) should specify requirements (e.g., oxygen levels) and coordinate delivery timing. Documentation should include the agency's contact details, insurance, and patient-specific requirements.

During the same interview on 10/31/2024 at 12:00 p.m. with the DCM, the DCM stated that there had been a challenge with documentation by contracted case managers, particularly with two contracted groups, as they often use separate systems for documentation. Although they have access to the facility's electronic medical records and they should follow hospital policies, documentation had been inconsistent. "We have reached out to contracted groups to improve documentation and facilitate physical visits (both contracted groups only conduct their case management visits remotely by phone and through chart reviews) by case managers. Despite some improvement after meetings with one of the contracted groups (CG 1), documentation continues to remain a concern, especially with the second contracted group (CG 2), who has not responded to meeting requests, including offers for virtual conferences."

During the same interview on 10/31/2024 at 12:00 p.m. with the Director of Case Management (DCM), DCM stated that hospital staff, specifically the facility's case managers, frequently step in to address patient needs when contracted case managers do not follow through, aiming to prevent any delays in patient care. The DCM noted there was an ongoing effort to enhance compliance and improve documentation practices to ensure patient safety and continuity of care. Additionally, the DCM explained that oversight of contracts with medical groups regarding case management responsibilities lies with either the Senior Director of Operations (SOD) or the DCM, with final approval resting with the Chief Executive Officer (CEO).

During an interview on 10/31/2024 at 1:38 p.m., with Senior Director of Operations (SOD), member of the Governing Body, the SOD stated that oversight for contracted case managers was provided by themselves (referring to members of the GB) and the Director of Case Management. Multiple attempts have been made to reach out to the contracted groups, and recently there had been a meeting with CG 1, but there had been no response from CG 2. In addition, the SOD stated that since starting their role in late April/early June (2024), the SOD, along with DCM, had prioritized addressing these case management challenges, which had been ongoing. They had initiated outreach to the medical groups to improve service delivery and have taken steps to address the most urgent needs, particularly during night shifts when many patients arrive through the Emergency Department (ED) and required immediate case management contact. The SOD created two full-time equivalent (FTE) positions specifically to handle these issues. Two case managers had been hired to cover overnight shifts, where many issues arise, ensuring that case management was available during critical hours.

During the same interview with the SOD, the SOD mentioned that the contract with CG 2 was expiring, and renewal is uncertain due to service inconsistencies. The SOD emphasized that contracted case managers were expected to follow hospital policies, including documentation in patient charts. However, contracted case managers were currently on-call rather than on-site and do not consistently report their visits. The SOD noted that these case managers were once on-site but moved to remote work during COVID-19 (infectious disease caused by a virus), and requests for them to return to on-site work had been declined. The SOD also stated that the CEO and Chief Financial officer (CFO), both members of the GB, were actively involved in contract negotiations with both CG 1 and CG 2 and were fully aware of the challenges and service issues with these groups. The SOD had kept leadership informed of the difficulties in ensuring adequate case management coverage and documentation.

During an interview on 11/1/2024 at 3:38 p.m. with the Chief Executive Officer (CEO), the CEO was interviewed regarding addressing gaps in case management services and efforts to hold contracted case managers accountable with hospital policies and procedures. The CEO stated that as part of the facility's contract with CG 1 and CG 2, which "we revise every few years due to financial changes, these groups act as a provider network responsible for certain patient care tasks. Although the contract does not explicitly define specific duties, the expectation is for them to follow our facility's policies and procedures. If they fail to do their job correctly or violate any policies, the responsibility ultimately falls on the facility to ensure the job is completed and policies are adhered to." The CEO further stated, "As Director, I am responsible for ensuring that CG 1 and CG 2 follow our policies and procedures. If any issues arise regarding their compliance or performance, it remains my duty to address and correct them to maintain our organizational standards."

During the same interview on 11/1/2024 at 3:58 p.m. with the CEO, the CEO stated that department heads, executives, and the governing board were responsible for overseeing the policies and their implementation within each department. This oversight ensures that each department follows established guidelines and maintains compliance with organizational standards and regulations. The board holds the ultimate accountability, working with department leaders and executives to ensure policies are effectively put into practice and consistently followed throughout the organization.

During a review of the facility's policy and procedure (P&P) titled, "Discharge Planning," dated 9/2024, the P&P indicated that the facility provides Discharge Planning for all patients according to federal and state regulatory requirements. Patients requiring complex discharge planning are referred to the Case Management department, which arranges necessary services and care based on available resources and authorizations. The P&P states that discharge planning should begin at the time of admission.
Additionally, case managers from local medical groups are involved in the discharge planning process and are required to document in the facility's electronic health record. The case manager (CM) is responsible for periodically reassessing patients with complex or high-risk discharge needs and must document these assessments in the patient's medical record.

During a review of the facility's Governing Body Bylaws (GBB), also known as "District Bylaws," last reviewed and approved on 2/24/2021, that govern the facility's [Organization], the GBB indicated that the Board of Directors is ultimately responsible for the quality of care provided by the [organization] such as mechanisms and policies designed to ensure the provision of quality patient care. The CEO of the institution shall have the responsibility to translate the Board of Director's policies into actual operations and shall have the authority to establish and communicate personnel policies and practices that adequately support sound patients care.

Based on interview and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by:

1. The facility failed to ensure one of 30 sampled patient's (Patient 1) physician was notified regarding Patient 1's change of condition (clinically important deviation from a patient's baseline in physical, cognitive [anything related to learning, thinking, and understanding], behavioral or functional domains), in accordance with the facility's policy and procedure regarding physician notification, when Patient 1's vital signs (the basic physiological measurements that reflect the essential functions of the body) indicated increased respiratory rate (38 and 24 breaths per minute; normal respiratory rate is 20) and a low blood pressure (105/53 mmHg [a unit of measurement]; Normal BP is 120/90) on the day of discharge. The facility also failed to re-assess and document Patient 1's latest vital signs prior to discharge, in accordance with the facility's policy and procedure regarding reassessment and documentation.

This deficient practice had the potential to result in delay of immediate interventions needed and may result in worsening of Patient 1's condition including complications such as respiratory distress (a serious lung condition that causes low blood oxygen), severe hypotension (extremely low blood pressure, and/or death. (Refer to A-0395)

2. The facility failed to ensure one of 30 sampled patients (Patient 1) was placed on a specialty bed (a low-air loss mattress a type of air mattress that helps prevent and treat pressure wounds by constantly circulating air and relieving pressure on the body) as per wound care nurse's recommendations.

This deficient practice resulted in Patient 1 developing pressure injury Stage II (a partial-thickness loss of skin that appears as an open wound, blister [a fluid-filled sac that forms on the skin], or abrasion [a minor injury to the skin that occurs when the surface layers of the skin are broken]). (Refer to A-0395)

3. The facility failed to ensure one of 30 sampled patient's (Patient 12) nursing care plan (plan that provides a framework for evaluating and providing patient care needs related to the nursing process) for chest tube care (a flexible tube that's inserted into the chest cavity to drain fluid, blood, or air) was initiated, in accordance with the facility's policy and procedure regarding care plans.
This deficient practice had the potential to result in delayed provision of care when the patient's (Patient 12) needs and risks were not identified.

This deficient practice also had the potential to result in complications such as infection, dislodgement of the tube, etc. which may worsen Patient 12's condition leading to prolonged hospitalization and recovery. (Refer to A-0396)

4. The facility failed to ensure one of 30 sampled patient's (Patient 13) nursing care plan for aspiration precaution (measures to prevent food, liquid, saliva, or foreign objects from entering the lungs) was initiated, in accordance with the facility's policy and procedure regarding care plans.

This deficient practice had the potential to result in delayed provision of care when the patient's (Patient 13) needs and risks were not identified. This deficient practice also had the potential to result in complications such as aspiration pneumonia (a lung infection caused by inhaling things other than air, such as saliva, food particles or stomach contents), etc. which may prolong Patient 13's hospitalization and recovery. (Refer to A-0396)

5. The facility failed to ensure one of 30 sampled patient's (Patient 14) nursing care plan regarding the use of incentive spirometry (a treatment that uses a handheld device to help patients improve lung function by breathing in slowly and deeply), was initiated, in accordance with the facility's policy and procedure regarding care plans.

This deficient practice had the potential to result in delayed provision of care when the patient's (Patient 14) needs and risks were not identified. This deficient practice also had the potential to worsen Patient 14's condition by not addressing the respiratory care needs, which may result in complications such as respiratory distress, etc. And may lead to prolonged recovery for Patient 14. (Refer to A-0396)

6. The facility failed to ensure one of 30 sampled patient's (Patient 15) nursing care plan to address cellulitis (a bacterial infection that affects the skin's deeper layers, including the dermis and subcutaneous fat) such as an infection related care plan, was initiated, in accordance with the facility's policy and procedure regarding care plans.

This deficient practice had the potential to result in delayed provision of care when the patient's (Patient 15) needs and risks were not identified. This deficient practice may also result in worsening infection, etc. and thus prolonging patient 15's hospitalization. (Refer to A-0396)

7. The facility failed to ensure staff followed and implemented the nursing care plan (plan that provides a framework for evaluating and providing patient care needs related to the nursing process) for one of 30 sampled patients (Patient 21), when staff did not monitor the daily weight of Patient 21, in accordance with the facility's policy and procedure regarding care planning.

This deficient practice had the potential for staff not being able to accurately monitor Patient 21's weight changes, which may also impact adjustments in treatment regarding Patient 21's nutritional status. (Refer to A-0396)

8. The facility failed to:
8.a. Ensure that nursing staff re-assessed (a re-evaluation of a patient's health status) and documented the pain level for one of 30 sampled patients (Patient 6) in accordance with the facility's policy and procedure regarding pain re-assessment , after the administration of Morphine (a narcotic pain medication used to relieve moderate to severe pain by acting on the central nervous system to alter the perception of pain) to Patient 6.

8.b. Ensure that nursing staff addressed the pain level for one of 30 sampled patients (Patient 6) in accordance with the facility's policy and procedure on pain management after the patient (Patient 6) reported being in pain.

8.c. Ensure that nursing staff assessed and documented the pain level for one of 30 sampled patients (Patient 6) at a minimum each time Patient 6's vital signs (includes temperature, blood pressure, respiratory rate, heart rate, pain level) were obtained and recorded, in accordance with the facility's policy and procedure regarding nursing assessment and vital signs check.

These deficient practices had the potential to result in delayed treatment and worsening of pain, negatively impacting the patient's (Patient 6) comfort and recovery. (Refer to A-0398)

9. The facility failed to:
9.a. Ensure one of 30 sampled patients (Patient 1) and/or their designated representative received the necessary information and resources for safe and effective post-discharge care, when personalized teaching plan to educate Patient 1 and/or designated representative regarding management of G-tube care and medication administration (the process of delivering medication to a patient through a gastrostomy tube [G-tube, a tube that is inserted into the nose or mouth and passed into the stomach or small intestine]) at home, was not developed and provided to Patient 1 and/or designated representative.

9.b. Ensure one of 30 sampled patients (Patient 1) and/or designated representative were provided with written and verbal discharge instructions for managing enteral feedings (a liquid nutritional formula is delivered through a tube that is inserted into the stomach or small intestine) and aspiration precautions (measures taken to minimize the risk of food, liquid, or other materials entering the lungs) to follow at home.

9.c. Ensure one of 30 sampled patients (Patient 1) and/or designated representative were provided with discharge instructions and necessary guidance on wound care and treatment (the process of evaluating and treating wounds to promote healing, prevent infection, and reduce complications).

These deficient practices had the potential for Patient 1 and/or designated representative not to receive the necessary education and guidance for managing Patient 1's complex care needs at home, potentially increasing the risk of complications and or hospital readmission due to insufficient discharge preparation. (Refer to A-0398)

10. The facility failed to ensure two of 30 sampled patients (Patient 3 and Patient 6) had their call light device (a device used by the patient to call for help) within reach, in accordance with the facility's policy and procedure regarding call light use.

This deficient practice had the potential for unmet needs for Patient 3 and Patient 6, as both were unable to call for assistance due to the absence or inaccessibility of the call light. This deficient practice had the potential to result in delayed treatment, potentially negatively impacting the provision of care for both patients. (Refer to A-0398)

11. The facility failed to ensure that two of two sampled rooms (referring to the clean supply room and the medication room that are stocked with intravenous fluids [IV fluids, sterile solutions administered directly into a patient's veins to provide hydration, deliver medications, or supply essential nutrients and electrolytes] and medications) designated for entry by authorized personnel, were secured and not accessible to unauthorized individuals, in accordance with the facility's policy and procedure regarding medication storage areas.

This deficient practice had the potential to compromise the safety and security of medical supplies due to tampering or theft, as well as the sterility (free from germs) of the environment, increasing the risk of contamination, which could negatively impact patient care and safety. (Refer to A-0398)

12. The facility failed to ensure three of three Security Guards (Security Guard 1, 2, and 3) completed their Restraint training annually, in accordance with the facility's policy and procedure regarding restraints (devices that limit a patient's movement).

This deficient practice had the potential for security guards 1, 2, and 3 being unable to safely monitor and assist with patients who have restraints, which may result in injury to patient or the staff. (Refer to A-0398)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on interview and record review, the facility failed to:

1. Ensure one of 30 sampled patient's (Patient 1) physician was notified regarding Patient 1's change of condition (clinically important deviation from a patient's baseline in physical, cognitive [anything related to learning, thinking, and understanding], behavioral or functional domains), in accordance with the facility's policy and procedure regarding physician notification, when Patient 1's vital signs (the basic physiological measurements that reflect the essential functions of the body) indicated increased respiratory rate (38 and 24 breaths per minute; normal respiratory rate is 20) and a low blood pressure (105/53 mmHg [a unit of measurement]; Normal BP is 120/90) on the day of discharge. The facility also failed to re-assess and document Patient 1's latest vital signs prior to discharge, in accordance with the facility's policy and procedure regarding reassessment and documentation.

This deficient practice had the potential to result in delay of immediate interventions needed and may result in worsening of Patient 1's condition including complications such as respiratory distress (a serious lung condition that causes low blood oxygen), severe hypotension (extremely low blood pressure, and/or death.

2. Ensure Patient 1 was placed on a specialty bed (a low-air loss mattress a type of air mattress that helps prevent and treat pressure wounds by constantly circulating air and relieving pressure on the body) as per wound care nurse's recommendations.

This deficient practice resulted in Patient 1 developing pressure injury Stage II (a partial-thickness loss of skin that appears as an open wound, blister [a fluid-filled sac that forms on the skin], or abrasion [a minor injury to the skin that occurs when the surface layers of the skin are broken]).

Findings:

1. During a review of Patient 1's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 7/12/2024, the H&P indicated that Patient 1 was admitted due to shortness of breath (SOB, difficulty breathing), and found to have aspiration pneumonia (a lung infection caused by inhaling things other than air, such as saliva, food particles or stomach contents) and acute respiratory failure (ARF, an inability to maintain adequate oxygenation for tissues). The H&P also indicated that Patient 1 had past medical history (PMH, a record of their health status before their current problem) of stroke with chronic right sided deficit (problems that occur when there is damage to the right side of the brain. Example: weakness on the right side of the body, difficulty with memory, etc.), aphasia (a language disorder that makes it hard for you to read, write, and speak), percutaneous endoscopic gastrostomy (PEG, feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall).

During a review of Patient 1's Vital Signs (VS, basic physiological measurements that reflect the essential functions of the body including heartbeat, breathing rate, temperature, blood pressure, and pain level) flowsheet, dated 7/24/2024, the VS flowsheet indicated that on 7/24/2024:

At 8:00 a.m., Patient 1's respiratory rate (RR) was recorded at 38 breaths per minute (bpm) [a normal respiratory rate for an adult at rest is 12 to 20 bpm], blood pressure (BP) was recorded at 137/77 mmHg (BP is measured in millimeters of mercury, with a typical normal adult range around 120/80 mmHg. The systolic value of 137 indicates slightly elevated pressure, while the diastolic value of 77 falls within the normal range), and heart rate (HR) was documented at 81 beats per minute (bpm) [a normal resting heart rate for adults typically ranges from 60 to 100 bpm].

At 9:21 a.m., Patient 1's RR was recorded at 24 bpm, BP was 125/68 mmHg, and HR was 77 bpm.

At 11:30 a.m., Patient 1's RR was not recorded, BP was 105/53 mmHg, and HR was not recorded.

During a concurrent interview and record review on 10/31/2024 at 11:56 a.m. with the Safety and Quality Coordinator (SQC), Patient 1's medical record was reviewed. The SQC confirmed that Patient 1's medical chart contained no documentation indicating that the physician was notified about Patient 1's abnormally elevated respiratory rate and decreased blood pressure.

During a concurrent interview and record review on 10/31/2024 at 11:41 a.m. with registered nurse (RN 2) Patient 1's VS flowsheet was reviewed. The RN 2 stated "I am not sure why there is only the blood pressure that was documented for Patient 1 on 7/24/2024 at 11:30 a.m." The RN 2 stated that nurses do need to obtain full set of vital signs prior to discharge and any changes in patient's vital signs should be communicated to the physician.

During an interview on 10/31/2024 at 11:56 a.m. with the Director of Oncology and Neuro Departments (Dir 2), after reviewing Patient 1's vital signs (VS) flowsheet dated 7/24/2024, Dir 2 stated, "The patient's respiratory rate of 38 bpm, recorded at 8:00 a.m. on 7/24/2024, as well as the decreased blood pressure recorded at 11:30 a.m. on the same day, should have been communicated to the physician. Both indicate a change from the patient's baseline measurements, and a complete set of VS should have been obtained and recorded by the nurse prior to discharge."

During a review of the facility's policy and procedure (P&P), titled, "Initial Patient Assessment and Re-assessment," dated 3/2024, the P&P indicated, "The assessment of the care or treatment required to meet the needs of the patient will be ongoing throughout the patient's hospital stay, with the assessment process individualized to meet the needs of the patient population. Reassessment shall occur when an intervention has taken place or if there is a change in patient condition or status. IX. Any change in the patient's condition shall require an immediate reassessment with changes in the plan of care."

During a review of the facility's policy and procedure (P&P) titled, "Initial Patient Assessment and Reassessment" dated 3/2024, the P&P indicated that vital signs will be recorded in the patient's electronic health record (EHR) on designated records specified by the nursing unit. Significant variations need to be reported to the charge nurse and physician.

During a review of the facility's policy and procedure (P&P) titled, "Initial Patient Assessment and Reassessment" dated 3/2024, the P&P indicated that a registered nurse (RN) is responsible for collecting and analyzing data about the patient, determining the need for further data collection, identifying the patient's healthcare treatment needs, and planning appropriate care or treatment. The P&P also indicated that all healthcare disciplines involved in the patient's care are required to perform assessments and reassessments in compliance with state licensure laws and relevant regulations. Each discipline must conduct these assessments within its specific scope of practice.

2. During a review of Patient 1's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 7/12/2024, the H&P indicated that Patient 1 was admitted due to shortness of breath (SOB, difficulty in breathing), and found to have aspiration pneumonia ( a lung infection caused by inhaling things other than air, such as saliva, food particles or stomach contents) and acute respiratory failure (ARF, an inability to maintain adequate oxygenation for tissues). The H&P also indicated that Patient 1 had past medical history (PMH, a record of their health status before their current problem) of stroke (clot in the brain) with chronic right sided deficit (problems that occur when there is damage to the right side of the brain. Example: weakness on the right side of the body, difficulty with memory, etc.), aphasia (a language disorder that makes it hard for you to read, write, and speak), percutaneous endoscopic gastrostomy (PEG, feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall).

During a review of Patient 1's medical record (MR) titled, "HAPI (Hospital acquired pressure injury, localized injury to the skin or tissue that occurs during a hospital stay) Prevention Checklist," dated 7/12/2024 at 10:40 p.m., the MR indicated, that on 7/12/2024, Patient 1 had no identified pressure injuries, had middle upper back dry skin tear (traumatic wound that occurs when the skin separates from the underlying layers), redness to sacrum (a triangular bone at the base of the spine)/buttocks area, and both ankles suspected deep tissue injury (DTI, purple or maroon localized area of discolored intact skin or blood?filled blister due to damage of underlying soft tissue from pressure and/or shear [a mechanical force that occurs when tissue layers move in opposite directions).

During a review of Patient 1's MR, dated 7/13/2024, the MR indicated Patient 1 was evaluated by the wound care nurse on 7/13/2024 at 1:23 p.m. and ordered a specialty bed with low-air loss mattress (designed to help prevent and treat pressure injuries) for Patient 1.

During a review of Patient 1's medical record (MR), under the entry titled, "Wound Note," dated 7/19/2024, it was documented that the wound care nurse (WCN) reassessed Patient 1 on that date (7/19/2024) and identified a Stage II pressure injury (partial-thickness skin loss with exposed dermis) on the patient's (Patient 1) left hip. The MR also indicated that the WCN documented the need for Patient 1 to be placed on a low air-loss bed to reduce pressure and promote healing and placed a call to the contracted company to order a specialty bed for Patient 1.

During a concurrent interview and record review on 10/31/2024 at 10:00 a.m. with the clinical quality coordinator (CQC), Patient 1's medical record was reviewed. The CQC verified that Patient 1's MR contained no documentation indicating that Patient 1 was placed on a specialty bed at any point during their admission from 7/12/2024 through 7/24/2024.

During an interview on 10/31/2024 at 10:26 a.m. with the Director of Oncology and Neuro Departments (Dir 2), regarding specialty beds, the Dir 2 stated "If we don't have a specialty bed in-house, we should call the rental company to order it. While bed delivery may take a few hours, it should not take days to deliver a specialty bed. The primary nurse was responsible for following up on the status of the specialty mattress order to ensure timely delivery and availability for patient care. If there were delays and the bed is not delivered within the expected timeframe, the primary nurse should escalate the issue to higher management, such as the charge nurse or director."

During a review of the facility's policy and procedure (P&P) titled, "Skin Care Assessment," dated 7/2023, the P&P stated that all licensed nurses are permitted to perform skin assessments, initiate prevention interventions, implement wound treatment orders, and coordinate multidisciplinary efforts to prevent and optimize the management of pressure injuries. The P&P also indicated that specialty beds, such as low-air-loss mattresses, should be ordered through the Wound Care department or by contacting the manufacturer directly when a patient requires placement on a low-air-loss mattress.

During a review of the facility's policy and procedure (P&P) titled, "Initial Patient Assessment and Reassessment," dated 3/2024, the P&P indicated that a registered nurse (RN) is responsible for collecting and analyzing data about the patient, determining the need for further data collection, identifying the patient's healthcare treatment needs, and planning appropriate care or treatment.

Based on interview and record review, the facility failed to:

1. Ensure one of 30 sampled patient's (Patient 12) nursing care plan (plan that provides a framework for evaluating and providing patient care needs related to the nursing process) for chest tube care (a flexible tube that's inserted into the chest cavity to drain fluid, blood, or air) was initiated, in accordance with the facility's policy and procedure regarding care plans.

This deficient practice had the potential to result in delayed provision of care when the patient's (Patient 12) needs and risks are not identified. This deficient practice also had the potential to result in complications such as infection, dislodgement of the tube, etc. which may worsen Patient 12's condition leading to prolonged hospitalization and recovery.

2. Ensure one of 30 sampled patient's (Patient 13) nursing care plan for aspiration precaution (measures to prevent food, liquid, saliva, or foreign objects from entering the lungs) was initiated, in accordance with the facility's policy and procedure regarding care plans.

This deficient practice had the potential to result in delayed provision of care when the patient's (Patient 13) needs and risks are not identified. This deficient practice also had the potential to result in complications such as aspiration pneumonia (a lung infection caused by inhaling things other than air, such as saliva, food particles or stomach contents), etc. which may prolong Patient 13's hospitalization and recovery.

3. Ensure one of 30 sampled patient's (Patient 14) nursing care plan regarding the use of incentive spirometry (a treatment that uses a handheld device to help patients improve lung function by breathing in slowly and deeply), was initiated, in accordance with the facility's policy and procedure regarding care plans.

This deficient practice had the potential to result in delayed provision of care when the patient's (Patient 14) needs and risks are not identified. This deficient practice also had the potential to worsen Patient 14's condition by not addressing the respiratory care needs, which may result in complications such as respiratory distress, etc. And may lead to prolonged recovery for Patient 14.

4. Ensure on of 30 sampled patient's (Patient 15) nursing care plan to address cellulitis (a bacterial infection that affects the skin's deeper layers, including the dermis and subcutaneous fat) such as an infection related care plan, was initiated, in accordance with the facility's policy and procedure regarding care plans.

This deficient practice had the potential to result in delayed provision of care when the patient's (Patient 15) needs and risks are not identified. This deficient practice may also result in worsening infection, etc. and thus prolonging patient 15's hospitalization.

5. Ensure staff follow and implemented the nursing care plan (plan that provides a framework for evaluating and providing patient care needs related to the nursing process) for one of 30 sampled patients (Patient 21), when staff did not monitor the daily weight of Patient 21, in accordance with the facility's policy and procedure regarding care planning.

This deficient practice had the potential for staff not being able to accurately monitor Patient 21's weight changes, which may also impact adjustments in treatment regarding Patient 21's nutritional status.


Findings:

1. During a concurrent interview and record review, on 10/30/2024 at 3:16 p.m. with the Quality Coordinator (QC), Patient 12's electronic medical record (EMR, a digital version of paper charting) indicated that on 10/27/2024, Patient 12 was seen in the emergency department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries) with chief complaint of gunshot wound (GSW) to left shoulder and left chest. A chest tube (a flexible tube that's inserted into the chest cavity to drain fluid, blood, or air) was placed in Patient 12's left chest on 10/27/2024 at 2:25 a.m. Patient 12 was admitted and moved to the intensive care unit (ICU, for critically ill or injured patients that is staffed by specially trained medical personnel) on 10/27/2024 at 6:58 a.m. with a chest tube to his (Patient 12) left chest.

During the same interview on 10/30/2024 at 3:16 p.m. with the Quality Coordinator (QC), the QC stated there was no record in Patient 12's EMR that a care plan (plan that provides a framework for evaluating and providing patient care needs related to the nursing process) for chest tube care, was initiated. QC also said a care plan for chest tube care under impaired gas exchange (a serious condition that occurs when the lungs and heart are unable to provide enough oxygen to the body's tissues) should have been initiated upon admission for Patient 12. QC said it was nursing standard of practice and policy that an individualized care plan must be developed, updated, and reviewed daily according to a patient's individualized care needs.
During a review of the facility's policy and procedure (P&P) titled, "Patient Care Planning," with last revised date of 4/2024, the P&P indicated the following:

Each patient has unique expectations, characteristics, and needs including those dictated by the patient's age and the severity of disease, condition, impairment or disability for which services were sought. In order to provide care, treatment and rehabilitation to each patient effectively and efficiently, a multidisciplinary plan of care will be initiated for every patient admitted to [Name of the Facility]. The Care Plan is documentation of the plan for the patient's care, treatment, and services based on needs identified by the admission assessment, reassessment and results of diagnostic testing. It shall be reviewed every 24 hours and updated as needed to ensure an appropriate plan of care individualized to each patient and their unique needs. The plan should be maintained and revised based on the patient's response.

II. The Care Plan is developed and revised in collaboration with the applicable disciplines of the Health Care Team and the patient/family. Every applicable discipline shall refer to the care plan and provide input relevant to their expertise, as appropriate for the patient's condition and/or needs.
III. The Care Plan shall reflect the patient's unique needs and resources, utilize patient and/or family involvement, and be based on the patient's goals, including the time frames, settings and services required to meet those goals.
IV. Staff shall evaluate the patient's progress, based on the goals established in the Care Plan. The Care Plan problems, goals, and actions shall be modified or closed, as clinically appropriate based on reassessment; patient's need for further care, treatment, and services; or the patient's achievement of goals and shall be closed at time of discharge.

2. During a concurrent interview and record review on 10/30/2024 at 3:30 p.m. with the Quality Coordinator (QC), Patient 13's electronic medical record (EMR, digital version of paper charting) indicated that Patient 13 was admitted on 10/8/2024 for altered mental status (a general term that describes a change in how well the brain is functioning). A medical order (a directive from a health care provider that instructs how to care for a patient) was given by a doctor to place Patient 13 on aspiration precaution (measures to prevent food, liquid, saliva, or foreign objects from entering the lungs) on 10/8/2024 at 9:06 p.m. QC stated there was no record in Patient 13's EMR that a care plan (plan that provides a framework for evaluating and providing patient care needs related to the nursing process) for aspiration precaution, was initiated.

During the same interview on 10/30/2024 at 3:30 p.m. with the Quality Coordinator (QC), the QC said a care plan for aspiration precaution should have been initiated upon admission for Patient 13. QC said it was a nursing standard of practice and policy that care plan must be developed, updated, and reviewed daily according to patient individualized care needs.

During a review of the facility's policy and procedure (P&P) titled, "Patient Care Planning," with last revised date of 4/2024, the P&P indicated the following:

Each patient has unique expectations, characteristics, and needs including those dictated by the patient's age and the severity of disease, condition, impairment or disability for which services were sought. In order to provide care, treatment and rehabilitation to each patient effectively and efficiently, a multidisciplinary plan of care will be initiated for every patient admitted to AVMC The Care Plan is documentation of the plan for the patient's care, treatment, and services based on needs identified by the admission assessment, reassessment and results of diagnostic testing. It shall be reviewed every 24 hours and updated as needed to ensure an appropriate plan of care individualized to each patient and their unique needs. The plan should be maintained and revised based on the patient's response.

II. The Care Plan is developed and revised in collaboration with the applicable disciplines of the Health Care Team and the patient/family. Every applicable discipline shall refer to the care plan and provide input relevant to their expertise, as appropriate for the patient's condition and/or needs.
III. The Care Plan shall reflect the patient's unique needs and resources, utilize patient and/or family involvement, and be based on the patient's goals, including the time frames, settings and services required to meet those goals.
IV. Staff shall evaluate the patient's progress, based on the goals established in the Care Plan. The Care Plan problems, goals, and actions shall be modified or closed, as clinically appropriate based on reassessment; patient's need for further care, treatment, and services; or the patient's achievement of goals and shall be closed at time of discharge.

3. During a concurrent interview and record review on 10/31/2024 at 9:30 a.m. with the Quality Coordinator (QC), Patient 14's electronic medical record (EMR, a digital version of the paper chart) indicated that Patient 14 was admitted on 10/29/2024 for Pneumothorax (a medical condition that occurs when air leaks from the lung and fills the space between the lung and chest wall) from an ATV (All-terrain vehicle) accident. A medical order (a directive from a health care provider that instructs how to care for a patient) was given by a doctor to provide Patient 14 an incentive spirometry (a treatment that uses a handheld device to help patients improve lung function by breathing in slowly and deeply) on 10/29/2024 at 8:19 p.m.

During the same interview on 10/31/2024 at 9:30 a.m. with the Quality Coordinator (QC), QC stated there was no record in Patient 14's EMR that a care plan for incentive spirometry was initiated. QC also stated a care plan for incentive spirometry under impaired gas exchange (a serious condition that occurs when the lungs and heart are unable to provide enough oxygen to the body's tissues) should have been initiated upon admission for Patient 14. QC stated it was nursing standard of practice and policy that care plan must be developed, updated, and reviewed daily according to patient's individualize care needs.

During a review of the facility's policy and procedure (P&P) titled, "Patient Care Planning," with last revised date of 4/2024, the P&P indicated the following:

Each patient has unique expectations, characteristics, and needs including those dictated by the patient's age and the severity of disease, condition, impairment or disability for which services were sought. In order to provide care, treatment and rehabilitation to each patient effectively and efficiently, a multidisciplinary plan of care will be initiated for every patient admitted to AVMC The Care Plan is documentation of the plan for the patient's care, treatment, and services based on needs identified by the admission assessment, reassessment and results of diagnostic testing. It shall be reviewed every 24 hours and updated as needed to ensure an appropriate plan of care individualized to each patient and their unique needs. The plan should be maintained and revised based on the patient's response.

II. The Care Plan is developed and revised in collaboration with the applicable disciplines of the Health Care Team and the patient/family. Every applicable discipline shall refer to the care plan and provide input relevant to their expertise, as appropriate for the patient's condition and/or needs.
III. The Care Plan shall reflect the patient's unique needs and resources, utilize patient and/or family involvement, and be based on the patient's goals, including the time frames, settings and services required to meet those goals.
IV. Staff shall evaluate the patient's progress, based on the goals established in the Care Plan. The Care Plan problems, goals, and actions shall be modified or closed, as clinically appropriate based on reassessment; patient's need for further care, treatment, and services; or the patient's achievement of goals and shall be closed at time of discharge.

4. During a concurrent interview and record review on 10/31/2024 at 11:22 a.m. with the Quality Coordinator (QC), Patient 15's electronic medical record (EMR, digital version of paper chart) indicated that Patient 15 was admitted on 5/5/2024 for cellulitis (a bacterial infection that affects the skin's deeper layers, including the dermis and subcutaneous fat) to his (Patient 15) left lower leg.

During the same interview on 10/31/2024 at 11:22 a.m., QC stated there was no record in Patient 15's EMR that a care plan for infection to address Patient 15's cellulitis issue, was initiated. QC stated that a care plan related to infection prevention and treatment should have been initiated upon admission for Patient 15. QC also said it was nursing standard of practice and policy that care plan must be developed, updated, and reviewed daily according to patient's individualized care needs.

During a review of the facility's policy and procedure (P&P) titled, "Patient Care Planning" with last revised date of 4/2024, the P&P indicated the following:

Each patient has unique expectations, characteristics, and needs including those dictated by the patient's age and the severity of disease, condition, impairment or disability for which services were sought. In order to provide care, treatment and rehabilitation to each patient effectively and efficiently, a multidisciplinary plan of care will be initiated for every patient admitted to AVMC The Care Plan is documentation of the plan for the patient's care, treatment, and services based on needs identified by the admission assessment, reassessment and results of diagnostic testing. It shall be reviewed every 24 hours and updated as needed to ensure an appropriate plan of care individualized to each patient and their unique needs. The plan should be maintained and revised based on the patient's response.

II. The Care Plan is developed and revised in collaboration with the applicable disciplines of the Health Care Team and the patient/family. Every applicable discipline shall refer to the care plan and provide input relevant to their expertise, as appropriate for the patient's condition and/or needs.
III. The Care Plan shall reflect the patient's unique needs and resources, utilize patient and/or family involvement, and be based on the patient's goals, including the time frames, settings and services required to meet those goals.
IV. Staff shall evaluate the patient's progress, based on the goals established in the Care Plan. The Care Plan problems, goals, and actions shall be modified or closed, as clinically appropriate based on reassessment; patient's need for further care, treatment, and services; or the patient's achievement of goals and shall be closed at time of discharge.

5. During a review of Patient 21's "Face Sheet," dated 3/2023, the Face sheet indicated the following: Patient 21 was admitted to the hospital on 3/15/2023 for abdominal pain and was discharged from the hospital on 3/23/2023.

During a review of Patient 21's "History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 3/2023, the "H&P" indicated the following: Patient 21 brought in for abdominal pain. Patient 21 had a history of bowel resection (a surgical procedure that removes a diseased or damaged or blocked part of the small or large intestine).

During a concurrent interview and record review on 10/31/2024 at 10:02 a.m. with Quality Manager (QM) 1, Patient 21's "Physician Orders and Care Plan (plan that provides a framework for evaluating and providing patient care needs related to the nursing process)" dated 3/2023, were reviewed. The Physician Orders indicated on 3/14/2023 there was an order to weigh Patient 21 daily. The Care Plan indicated Patient 21's weight was to be monitored. QM 1 confirmed there was physician order for Patient 21 to be weighed daily and the care plan indicated to monitor Patient 21's weight. QM 1 said staff should follow the physician order and the care plan selected.

During the same interview and record review on 10/31/2024 at 10:02 a.m. with QM 1, Patient 21's "Assessment Flowsheet," dated 3/2023, was reviewed. The Assessment Flowsheet indicated Patient 21's weight was only taken once on 3/15/2023. QM 1 stated the following: Confirmed Patient 21's weight was only recorded one day on 3/15/2023. Staff was not following the care plan and physician order regarding daily weight. Staff was also not following the care plan policy. Staff will be educated.

During an interview on 10/31/2024 at 10:17 a.m. with Director of Med Surg (Medical Surgical, a unit of the hospital that takes care of patients with a variety of medical and surgical conditions), Telemetry (a unit in the hospital where patients undergo continuous cardiac [heart] monitoring), & Oncology (a medical specialty that focuses on cancer) (DMTO) 1, DMTO 1 stated the following: DMTO 1 confirmed checking the electronic medical record (EMR) of Patient 21. Did not find daily weight monitoring done by the staff. Daily weight monitoring was the responsibility of assigned registered nurse. Will educate the staff. Staff did not follow the care plan policy.

During a review of the facility policy and procedure (P&P) titled, "Patient Care Planning," dated 2024, the P&P indicated, "Each patient has unique expectations, characteristics, and needs including those dictated by the patient's age and the severity of disease, condition, impairment or disability for which services were sought. In order to provide care, treatment and rehabilitation to each patient effectively and efficiently, a multidisciplinary plan of care will be initiated for every patient admitted to [Name of the facility]. The Care Plan is documentation of the plan for the patient's care, treatment, and services based on needs identified by the admission assessment, reassessment and results of diagnostic testing. It shall be reviewed every 24 hours and updated as needed to ensure an appropriate plan of care individualized to each patient and their unique needs. The plan should be maintained and revised based on the patient's response."

Based on interview and record review the facility failed to:

1.a. Ensure that nursing staff re-assessed (a re-evaluation of a patient's health status) and documented the pain level for one of 30 sampled patients (Patient 6) in accordance with the facility's policy and procedure regarding pain re-assessment , after the administration of Morphine (a narcotic pain medication used to relieve moderate to severe pain by acting on the central nervous system to alter the perception of pain) to Patient 6.

1.b. Ensure that nursing staff addressed the pain level for one of 30 sampled patients (Patient 6) in accordance with the facility's policy and procedure on pain management after the patient reported being in pain.

1.c. Ensure that nursing staff assessed and documented the pain level for one of 30 sampled patients (Patient 6) at a minimum each time Patient 6's vital signs (includes temperature, blood pressure, respiratory rate, heart rate, pain level) were obtained and recorded, in accordance with the facility's policy and procedure regarding nursing assessment and vital signs check.

These deficient practices had the potential to result in delayed treatment and worsening of pain, negatively impacting the patient's (Patient 6) comfort and recovery.

2.a. Ensure Patient 1 and/or their designated representative receive the necessary information and resources for safe and effective post-discharge care, when personalized teaching plan to educate Patient 1 and/or designated representative regarding management of G-tube care and medication administration (the process of delivering medication to a patient through a gastrostomy tube [G-tube, a tube that is inserted into the nose or mouth and passed into the stomach or small intestine]) at home, was not developed and provided to Patient 1 and/or designated representative.

2.b. Ensure Patient 1 and/or designated representative were provided with written and verbal discharge instructions for managing enteral feedings (a liquid nutritional formula is delivered through a tube that is inserted into the stomach or small intestine) and aspiration precautions (measures taken to minimize the risk of food, liquid, or other materials entering the lungs) to follow at home.

2.c. Ensure Patient 1 and/or designated representative were provided with discharge instructions and necessary guidance on wound care and treatment (the process of evaluating and treating wounds to promote healing, prevent infection, and reduce complications).

These deficient practices had the potential for Patient 1 and/or designated representative not to receive the necessary education and guidance for managing Patient 1's complex care needs at home, potentially increasing the risk of complications and or hospital readmission due to insufficient discharge preparation.

3. Ensure two of 30 sampled patients (Patient 3 and Patient 6) had their call light device (a device used by the patient to call for help) within reach, in accordance with the facility's policy and procedure regarding call light use.

This deficient practice had the potential for unmet needs for Patient 3 and Patient 6, as both were unable to call for assistance due to the absence or inaccessibility of the call light. This deficient practice had the potential to result in delayed treatment, potentially negatively impacting the provision of care for both patients.

4. Ensure that two of two sampled rooms (referring to the clean supply room and the medication room that were stocked with intravenous fluids [IV fluids, sterile solutions administered directly into a patient's veins to provide hydration, deliver medications, or supply essential nutrients and electrolytes] and medications) designated for entry by authorized personnel, were secured and not accessible to unauthorized individuals, in accordance with the facility's policy and procedure regarding medication storage areas.

This deficient practice had the potential to compromise the safety and security of medical supplies due to tampering or theft, as well as the sterility of the environment, increasing the risk of contamination, which could negatively impact patient care and safety.

5. Ensure three of three Security Guards (Security Guard 1, 2, and 3) completed their Restraint training annually, in accordance with the facility's policy and procedure regarding restraints (devices that limit a patient's movement).

This deficient practice had the potential for security guards 1, 2, and 3 being unable to safely monitor and assist with patients who have restraints, which may result in injury to patient or the staff.

Findings:

1.a. During a review of Patient 6's History and Physical (H&P, comprehensive assessment of a patient that includes taking a detailed medical history from the patient, followed by a physical examination to gather information about their current health condition), dated 10/29/2024, the H&P indicated that Patient 6 complained of generalized weakness and pain and was diagnosed with pancreatitis (sudden inflammation of the pancreas [ an organ that aids in digestion of food] that can cause severe abdominal pain, nausea [the urge to vomit], vomiting, and fever).

During further review of Patient 6's Medical Record titled, "VS (Vital signs, includes temperature, blood pressure, respiratory rate, heart rate, pain level) Flowsheet," dated 10/29/2024, the MR indicated, on 10/29/2024 at 10:19 p.m., Patient 6's pain level was documented as 7 out of 10 (a pain level 7 out of 10 on numeric scale indicated severe pain).

During a review of Patient 6's Medication Administration Record (MAR), dated 10/29/2024, the MAR indicated that on 10/29/2024, at 10:22 p.m., Patient 6 received 2 milligrams (mg, measuring unit) of Morphine (a narcotic pain medication used to relieve moderate to severe pain by acting on the central nervous system to alter the perception of pain).

During a concurrent interview and record review on 10/31/2024 at 4:14 p.m. with the Clinical Quality Coordinator (CQC), Patient 6's "VS Flowsheet," dated 10/29/2024, was reviewed. The flowsheet contained no record of a pain reassessment for Patient 6 after the administration of Morphine on 10/29/2024 at 10:22 p.m. In addition, the medical record indicated that Patient 6's pain level was not assessed or reassessed until a day later, when it was documented 8/10 (severe pain) at 4:10 p.m. on 10/30/2024. The CQC stated that nurses were expected to perform a pain reassessment within an hour after administering pain medication to evaluate its effectiveness and the patient's response.

During a review of the facility's policy and procedure (P&P) titled, "Pain Assessment and Re-Assessment," dated 9/2022, the P&P indicated that patients should be screened for pain alongside routine vital signs according to unit protocols. The policy encourages the appropriate use of analgesics and states that interventions should be made to relieve pain when reported. A reassessment of pain should occur within a clinically appropriate time frame based on the intervention used, with a reassessment required no later than 2 hours after the administration of pain medication.

1.b. During a review of Patient 6's History and Physical (H&P, comprehensive assessment of a patient that includes taking a detailed medical history from the patient, followed by a physical examination to gather information about their current health condition), dated 10/29/2024, the H&P indicated that Patient 6 complained of generalized weakness and pain and was diagnosed with pancreatitis (sudden inflammation of the pancreas [ an organ that aids in digestion of food] that can cause severe abdominal pain, nausea, vomiting, and fever).

During a concurrent interview and record review on 10/31/2024 at 4:14 p.m. with the Clinical Quality Coordinator (CQC), Patient 6's "VS (Vital Signs, includes temperature, blood pressure, respiratory rate, heart rate, pain level) Flowsheet," dated 10/30/2024, was reviewed. The Flowsheet indicated that on 10/30/2024 at 4:10 p.m., Patient 6's pain level was documented as 8 out 10 (severe pain).

During a review of Patient 6's MAR, dated 10/30/2024, the MAR indicated that Patient 6 had a standing order for two different pain medications- Morphine (a narcotic pain medication used to relieve moderate to severe pain by acting on the central nervous system to alter the perception of pain) and Norco (pain medication that combines hydrocodone, an opioid pain reliever, with acetaminophen [Tylenol], a non-opioid analgesic) to be administered for pain as needed. The MR also indicated that no pain medication was recorded to have been administered to Patient 6 on 10/30/2024 for pain level at 8 out 10.

During an interview on 10/31/2024 at 4:14 p.m. with the Clinical Quality Coordinator (CQC) regarding the facility's pain management policy, the CQC stated that the nurse should have addressed Patient 6's reported pain level of 8 out of 10 by providing necessary relief, but the nurse did not.

During further review of Patient 6's "VS Flowsheet," dated 10/30/2024 through 10/31/2024, the flowsheet indicated that Patient 6 was not assessed or re-assessed for pain until the following day at 6:43 a.m., on 10/31/2024.

During a review of the facility's policy and procedure (P&P) titled, "Pain Assessment and Re-Assessment," dated 9/2022, the P&P indicated that patients should be screened for pain alongside routine vital signs according to unit protocols. The policy encourages the appropriate use of analgesics and states that interventions should be made to relieve pain when reported. A reassessment of pain should occur within a clinically appropriate time frame based on the intervention used, with a reassessment required no later than 2 hours after the administration of pain medication.

During a review of the facility' policy and procedure (P&P) titled, "Patients' Rights and Responsibilities," dated 3/2022, the P&P indicated that that patients have the right to appropriate assessment and management of their pain, access to information about pain and pain relief measures, and the right to participate in pain management decisions.

1.c. During a review of Patient 6's History and Physical (H&P, comprehensive assessment of a patient that includes taking a detailed medical history from the patient, followed by a physical examination to gather information about their current health condition), dated 10/29/2024, the H&P indicated that Patient 6 complained of generalized weakness and pain and was diagnosed with pancreatitis (inflammation of the pancreas, an organ responsible for producing enzymes that aid in digestion and hormones that help regulate blood sugar).

During a review of Patient 6's medical record (MR) titled, "Vital Signs (VS, includes temperature, blood pressure, respiratory rate, heart rate, pain level) Flowsheet," dated 10/29/2024 the MR indicated that from 10/29/2024 at 5/52 p.m. through 10/31/2024 at 6:43 a.m., Patient 6's Pain assessment was only recorded 3 times while VS were recorded with the frequency of every 4 hours.

During an interview on 10/31/2024 at 4:14 p.m. with the Clinical Quality Coordinator (CQC), the CQC stated that nurses were expected to perform a pain assessment along with vital signs and more frequently if needed, in accordance with the facility's policy.

During a review of the facility's policy and procedure (P&P) titled, "Pain Assessment and Re-Assessment," dated 9/2022, the P&P indicated that patients should be screened for pain alongside routine vital signs according to unit protocols. The policy encourages the appropriate use of analgesics and states that interventions should be made to relieve pain when reported. A reassessment of pain should occur within a clinically appropriate time frame based on the intervention used, with a reassessment required no later than 2 hours after the administration of pain medication.

During a review of the facility' policy and procedure (P&P), titled "Patients' Rights and Responsibilities," dated 3/2022, the P&P indicated that that patients have the right to appropriate assessment and management of their pain, access to information about pain and pain relief measures, and the right to participate in pain management decisions.

2.a. During a review of Patient 1's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 7/12/2024, the H&P indicated that Patient 1 was admitted due to shortness of breath (SOB, difficulty breathing), and found to have aspiration pneumonia ( a lung infection caused by inhaling things other than air, such as saliva, food particles or stomach contents) and acute respiratory failure (ARF, an inability to maintain adequate oxygenation for tissues). The H&P also indicated that Patient 1 had past medical history (PMH, a record of their health status before their current problem) of stroke with chronic right sided deficit (problems that occur when there is damage to the right side of the brain. Example: weakness on the right side of the body, difficulty with memory, etc.), aphasia (a language disorder that makes it hard for you to read, write, and speak), percutaneous endoscopic gastrostomy (PEG, feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall).

During a concurrent interview and record review on 10/30/2024 at 4:03 p.m. with the Safety and Quality Coordinator (SQC), Patient 1's medical record was reviewed. The SQC verified, Patient 1's medical chart contained no documentation of teaching provided to Patient 1 or their family representative on safe G-tube care and medication administration.

During a review of Patient 1's Medical Record (MR) titled, "Discharge Summary," dated 7/24/2024, the MR indicated that Patient 1's family wanted to take the patient (Patient 1) home and Patient 1 required 5 days of antibiotic (medication used to treat bacterial infections) administration trough G-tube (gastrostomy tube, is a flexible tube inserted directly into the stomach through a small surgical opening in the abdomen. It is used to provide nutrition, fluids, and medications to patients who cannot take food or medicine by mouth) because of high risk for aspiration (accidental inhalation of food, liquid, or other material into the lungs).

During a concurrent interview and record review on 10/30/2024 at 4:03 p.m. with the Safety and Quality Coordinator (SQC), Patient 1's medical record was reviewed. The SQC verified, Patient 1's medical chart contained no documentation of teaching provided to Patient 1 or their family representative regarding safe G-tube care and medication administration.

During an interview on 10/31/2024 at 11:29 a.m. with Registered Nurse (RN) 2, who discharged Patient 1 on 7/24/2024, RN 2 reviewed Patient 1's discharge instructions and stated, "I don't know if teaching was ever provided to Patient 1's family during the patient's stay in the facility."

During an interview on 10/31/2024 at 11:49 a.m. with the Director of Oncology and Neuro Departments (Dir 2), Dir 2 stated, "A teaching plan and education on G-tube care and management, as well as enteral feeding (a liquid nutritional formula is delivered through a tube that is inserted into the stomach or small intestine) administration, should be conducted and documented during the patient's stay to ensure these needs are met at home after discharge."

During a review of the facility's policy and procedure (P&P) titled, "Admission, Direct Admission, Transfer, and Discharge," dated 9/20/2022, the P&P indicated that discharged patients and/or their families must receive adequate healthcare education to address their immediate health care needs following discharge. The procedure requires the following steps:

1. Provide Discharge Education: The patient must receive comprehensive discharge education to prepare them for self-care or family support after they leave the facility.

During a review of the facility's policy and procedure (P&P) titled, "Patient/Family Teaching Plan," dated July 2022, the P&P indicated that the educational needs of patients and their families must be assessed prior to any teaching and continuously throughout hospitalization. This formal assessment is documented in the multidisciplinary care plan and within the patient teaching area of the electronic chart. Teaching interventions may include, but are not limited to, the following areas:

1. Knowledge of Condition: Educating the patient and/or family about the patient's medical condition.
2. Knowledge of Safe and Effective Use of Medications: Ensuring understanding of prescribed medications, including proper use and potential side effects.
3. Knowledge of Nutrition: Providing guidance on dietary needs as relevant to the patient's condition.
4. Discharge Instructions: Preparing the patient and/or family for post-discharge care, including understanding treatment plans and managing ongoing care.

During a review of the facility's policy and procedure (P&P) titled, "Patient/Family Teaching Plan," dated July 2022, the P&P indicated that patient and family education is closely linked to discharge planning, as discharge involves educating the patient on post-care management and reinforcing the physician's specific discharge instructions. All teaching and discharge planning activities must be documented in the patient's medical record, ensuring a clear and thorough record of the care and education provided.

During a review of the facility's policy and procedure (P&P) titled, "Documentation," dated 8/2024, the P&P indicated, "The teaching method or plan used to educate the patient about their condition and treatment must be documented. This includes the approach taken for patient education, helping to ensure that all necessary information was provided to the patient and/or their family."

2.b. During a review of Patient 1's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 7/12/2024, the H&P indicated that Patient 1 was admitted due to shortness of breath (SOB, difficulty breathing), and found to have aspiration pneumonia (a lung infection caused by inhaling things other than air, such as saliva, food particles or stomach contents) and acute respiratory failure (ARF, an inability to maintain adequate oxygenation for tissues). The H&P also indicated that Patient 1 had past medical history (PMH, a record of their health status before their current problem) of stroke (clot in the brain) with chronic right sided deficit (problems that occur when there is damage to the right side of the brain. Example: weakness on the right side of the body, difficulty with memory, etc.), aphasia (a language disorder that makes it hard for you to read, write, and speak), percutaneous endoscopic gastrostomy (PEG, feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall).

During a review of Patient 1's medical record (MR) titled, "Emergency Documentation," dated 7/12/2024, the MR indicated that Patient 1 was transported to the facility by ambulance from a congregate health living facility (a residential care facility that provides medical and personal care for individuals with chronic illnesses, disabilities, or complex medical needs) where he resided prior their admission to the hospital on 7/12/2024.

During a review of Patient 1's MR titled "Discharge Summary," dated 7/24/2024, the MR indicated that Patient 1 was at high risk for re-aspiration (Re-aspiration refers to the repeated inhalation of food, liquid, saliva, or other foreign material into the lungs, which can lead to serious complications like pneumonia or respiratory distress. Patients at high risk for re-aspiration require careful monitoring and specific care measures to prevent further aspiration events.), though the family wanted to take the patient home.

During a concurrent interview and record review on 10/30/2024 at 4:03 p.m. with safety and quality coordinator (SQC) Patient 1's MR titled "Discharge Instructions," dated 7/24/2024, was reviewed. The MR indicated that Patient 1's discharge instructions contained no record of information regarding enteral feeding and aspiration precautions instructions when the documents were printed and provided to Patient 1 on 7/24/2024 at 11:30 a.m. The SQC verified that Patient 1's medical record lacked the documentation of relevant discharge post-care instructions for enteral feeding administration and aspiration precautions to follow at home.

During an interview on 10/31/2024 at 11:20 a.m. with Registered Nurse (RN 2) regarding the discharge instructions provided to Patient 1 on 7/24/2024, RN 2 reviewed the instructions and stated, "I recall that this patient left the facility at noon on 7/24/2024, but when I called the designated family member regarding the discharge, they did not answer. I did not include written instructions on enteral feeding and aspiration precautions, and I can't recall why. I thought the patient was being discharged back to a skilled nursing facility, not to home, but this is also undocumented, and I don't remember why."

During a review of the facility's policy and procedure (P&P) titled "Admission Direct Admission, Transfer, and Discharge" (dated 9/20/2022) the P&P indicated that discharged patients and/or their families must receive adequate healthcare education to address their immediate health care needs following discharge. The procedure requires the following steps:

1.Provide Discharge Education: The patient must receive comprehensive discharge education to prepare them for self-care or family support after they leave the facility.

2. Confirm Understanding and Obtain Signatures: Staff must ensure that the patient or their designated representative understands the discharge instructions. Additionally, they must obtain signatures on all relevant discharge forms to confirm comprehension and consent.

2.c. During a review of Patient 1's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 7/12/2024, the H&P indicated that Patient 1 was admitted due to shortness of breath (SOB, difficulty breathing), and found to have aspiration pneumonia (a lung infection caused by inhaling things other than air, such as saliva, food particles or stomach contents) and acute respiratory failure (ARF, an inability to maintain adequate oxygenation for tissues). The H&P also indicated that Patient 1 had past medical history (PMH, a record of their health status before their current problem) of stroke (clot in the brain) with chronic right sided deficit (problems that occur when there is damage to the right side of the brain. Example: weakness on the right side of the body, difficulty with memory, etc.), aphasia (a language disorder that makes it hard for you to read, write, and speak), percutaneous endoscopic gastrostomy (PEG, feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall).

During further review of Patient 1's Medical Record (MR) titled, "Discharge Summary," dated 7/24/2024, the MR indicated that Patient 1 had multiple skin issues, including but not limited to, pressure injuries (partial-thickness skin loss with exposed dermis) that were acquired and treated during Patient 1's stay at the facility from 7/12/2024 through 7/24/2024. The MR also contained wound care follow up orders for each identified pressure injury/skin issue.

During a concurrent interview and record review on 10/30/2024 at 4:03 p.m. with safety and quality coordinator (SQC) Patient 1's MR titled, "Discharge Instructions," dated 7/24/2024, was reviewed. The MR indicated that Patient 1's discharge instructions printed and provided to Patient 1 on 7/24/2024 at 11:30 a.m. contained no record of Patient 1's skin wound descriptions and instructions for treatment and care.

During an interview on 10/31/2024 at 11:20 a.m. with Registered Nurse (RN 2) regarding the discharge instructions provided to Patient 1 on 7/24/2024, RN 2 reviewed the instructions and stated they could not recall specific details about the absence of wound care documentation for Patient 1. RN 2 stated, "Typically, if I have orders for wound care instructions, I include them in the patient's discharge instructions. They should be included. I can't recall why this isn't documented. I also can't remember if any teaching was provided to Patient 1's family member, but I know that if it isn't documented, it wasn't done."

During an interview on 10/31/2024 at 4:07 p.m. with the Wound Care Nurse (WCN), the WCN stated, "The family should be informed of treatment orders before discharge to ensure that treatment and related measures are reinforced and continued after discharge."

During a review of the facility's policy and procedure (P&P) titled, "Admission, Direct Admission, Transfer, and Discharge," dated 9/20/2022, the P&P indicated that discharged patients and/or their families must receive adequate healthcare education to address their immediate health care needs following discharge. The procedure requires the following steps:

1.Provide Discharge Education: The patient must receive comprehensive discharge education to prepare them for self-care or family support after they leave the facility.

3.a. During a concurrent observation and interview on 10/29/2024 at 3:14 p.m. with Charge Nurse (CN 2) in the Emergency Department (ED, specialized area of the hospital where patients receive urgent care for acute medical conditions or injuries), Patient 3 was observed in the room, asleep in bed. The call light (a device used by the patient to call for help) was coiled and attached to the wall behind Patient 3's gurney. CN 2 stated, "The call light probably should be with the patient, but perhaps the patient was not alert enough to use it."

During a review of Patient 3's medical record (MR) titled, "Emergency Documentation," dated 10/29/2024, it was indicated that Patient 3 was seen in the Emergency Department (ED, a specialized medical facility that provides immediate care for patients with sudden onset illnesses or injuries) on 10/29/2024 due to left foot pain.

During an interview on 10/31/2024 at 2:55 p.m. with Registered Nurse (RN 1) regarding Patient 3's call light, which was observed not within the patient's reach, RN 1 stated, "I remember the patient (Patient 3); he (Patient 3) was discharged the same day. The radiology technician brought the patient back after a procedure and did not provide a call light." RN 1 also stated that a call light should have been provided to Patient 3 and should have been placed within the patient's reach.

During a review of the facility's policy and procedure (P&P) titled, "Fall (an unplanned descent to the floor or another lower level with or without injury to patient) Prevention and Reduction," dated 7/2023, the P&P indicated that an environment risk assessment shall be performed with basic interventions initiated for all patients to enhance patient safety. The P&P specified that the call light should be kept within patient's reach.

3.b. During an observation on 10/29/2024 at 2:15 p.m. in the Emergency Department (ED, a specialized medical facility that provides immediate care for patients with sudden onset illnesses or injuries) in the area called "Green Area," housing patients with less severe condition (not immediately life-threatening), Patient 6 was observed alone in the room without a call light. When asked how they would call for assistance if needed, Patient 6 responded, "I would yell out, 'Nurse!'"

During an interview on 10/29/2024 at 1:50 p.m. with the Chief Nursing Officer (CNO), when asked about the lack of call lights in the Green Area of the ED, the CNO stated, "We do not have call lights in this area. We will actually be closing this area next month and relocating to a new section in the ED that has built-in call lights. I'm not sure how long we've been without call lights in the Green Area, but currently, they are not available there. The new West ED will have call lights installed." The CNO also added that patients should be provided with call lights so they can call for help if needed.

During a review of Patient 6's History and Physical (H&P, comprehensive assessment of a patient that includes taking a detailed medical history from the patient, followed by a physical examination to gather information about their current health condition), dated 10/29/2024, the H&P indicated that Patient 6 complained of generalized weakness and pain was diagnosed with pancreatitis (inflammation of the pancreas, an organ responsible for producing enzymes that aid in digestion and hormones that help regulate blood sugar).

During a review of the facility's policy and procedure (P&P) titled, "Fall Prevention and Reduction," dated 7/2023, the P&P indicated that an environment risk assessment shall be performed with basic interventions initiated for all patients to enhance patient safety. The P&P specified that the call light should be kept within patient's reach.

4. During a concurrent observation and interview on 10/29/2024 at 2:51 p.m. with Risk Management (RM), a door to a clean supply room, labeled "Authorized Personnel Only," was observed to be held open by a trashcan, allowing unrestricted access to anyone in the Emergency Department (ED). The RM stated that the door must be locked because the supply room contained intravenous fluids (IV [through the vein], sterile 'free from germs] solutions administered directly into a patient's veins to provide hydration, deliver medications, or supply essential nutrients and electrolytes) and other medical supplies, which should only be accessible to authorized personnel, such as licensed personnel and supply staff.

During an interview on 10/29/2024 at 2:53 p.m. with the Emergency Department Manager (EDM), the EDM stated that the lock on the supply room door was not functioning, but an order had been submitted to repair it. The EDM also stated that the clean supply rooms should always be locked as a safety precaution.

During an observation on 10/29/2024 at 3:14 p.m. in the Emergency Department area known as the "Blue Zone (which houses critically ill patients)," it was observed that the medication room behind the nurses' station had no locked doors. The area contained shelves stocked with IV fluids and bins with patient medications. Medications were observed in three different bins, accessible to anyone in the Emergency Department.

During an interview on 11/1/2024 at 12:41 p.m. with the Director of Pharmacy (PD) regarding the storage of IV fluids and medications on the nursing units, the PD stated, "IV fluids are considered medications but are treated slightly differently from other medications. They do need to be stored in areas accessible only to authorized licensed personnel." The PD further explained, "Most of our medications are kept in the dispenser, which is accessed via badge and restricted to licensed pharmacists, pharmacy technicians, and other licensed personnel. In the Blue Zone, the nursing station doesn't have doors, but it was assumed that only authorized personnel would enter the area."

During a review of the facility's policy and procedure (P&P) titled, "Security and Inspection of Medication Storage Areas," dated 3/2022, the P&P indicated that medication rooms and patient bins (used for medication storage) to be locked at all times. Access to locked medication rooms is to be granted only to authorized licensed personnel. Additionally, non-licensed personnel performing tasks such as housekeeping or repairs in these areas must be monitored by licensed personnel.

5. During a concurrent interview and record review on 11/01/2024 at 11:26 a.m. with the Manager of Human Resource Operation (MHRO) 1 and Manager of Education (ME) 1, the "Restraint Training" for Security Guards (1,2, and 3), was reviewed. The "Restraint Training" for all 3 Security Guards indicated their annual training was completed on 9/19/2023. ME 1 stated the following: Confirmed all 3 security guards Restraint Training have expired and they have to take it annually. It is important for security guards to get their restraint training to be updated with the restraint process.

During an interview on 11/01/2024 at 12:45 p.m. with the Director of Security and Safety (DSS) 1, DSS 1 stated the following: DSS 1 was aware of the 3 security guards who have expired restraint training. It is important for the security guards to have restraint training annually. DSS 1 takes full responsibility with security guards restraint training, the security guards will be on the restraint training next

Based on observation, interview and record review, the facility failed to ensure two of two sampled medical shut off valves (medical shut-off valve panel 1 and medical shut-off valve panel 2) remained accessible to facility staff, in accordance with the facility's policy and procedure regarding Environment of Care Program and Management Plans.
This deficient practice had the potential to delay the facility's response to quickly shut off the gas supply in an emergency situation, that may prevent hazards like gas leaks, fires, or asphyxiation (a life-threatening condition when the body does not get enough oxygen) to patient, staff and visitors in the event of a disaster or fire.

Findings:

During a concurrent observation and interview on 10/29/2024 at 3:33 p.m. with the assistant clinical manager (ACM), it was observed that two (2) medical gas shutoff valve panels were blocked and not easily accessible to staff. The medical gas shutoff valve panel 1 (Panel 1) located between gurney one and gurney two was blocked by a visitor chair, while the medical gas shutoff valve panel 2 (Panel 2) next to trauma room (where patients that have critical injuries are treated) was blocked by a workstation on wheels. The ACM stated that staff should not have left items that blocked access to the medical gas shutoff valve panel. Access to the mechanical shutoff valves must remain clear and unobstructed so that it can be shut off quickly in the event of a disaster or fire.

During a concurrent interview and record review on 11/1/2024 at 3:10 p.m. with the facility safety officer (FSO), the facility's policy and procedure (P&P) titled, "Environment of Care Program and Management Plans," last revised date 01/2024, was reviewed. The P&P indicated that main supply valve and the area shutoff valves of piped medical gas systems should be accessible and clearly labeled. The FSO stated that access to medical gas shutoff valve panel should be always clear and unobstructed, there shouldn't be any items blocking access to the shut off valve. FSO further said easy access to medical gas valves was important in emergency situations because it allows for immediate action to stop the flow of gas, which can reduce the risk of fire.

Based on interview and record review, the facility failed to ensure the Condition of Participation for Discharge Planning was met as evidenced by:

1. The facility failed to actively engage one of thirty (30) sampled patients (Patient 1) and/or patient's family/ representative(s) in the development of a discharge plan for Patient 1 as well as failed to document the discharge plan evaluation within 24 hours after patient's (Patient 1) admission to the facility in accordance with the facility's policy and procedure regarding the discharge process (the transition of a patient from the hospital to another level of care such as home).

This deficient practice had the potential for Patient 1 and Patient 1's representatives to not fully understand the discharge care needs of Patient 1 which can impact patient outcomes such as compliance with treatment regimen and reduction of unplanned readmission. This deficient practice can also result in the violation of Patient 1's rights when the patient (Patient 1) and/or Patient 1's representative were not included in Patient 1's discharge planning. (Refer to A-0808)

2. The facility failed to ensure that appropriate referrals (wound care services, physical therapy services) were arranged and coordinated with contracted services prior to discharge for one of 30 sampled patients (Patient 1), in accordance with the facility's policy and procedure regarding discharge planning (the process of preparing a patient to leave the hospital and transition to the next level of care).

This deficient practice had the potential for Patient 1's condition to worsen post-discharge due to lack of aftercare (the care and support that patients receive after hospitalization). This deficient practice may also result in readmission or poor quality of life and/or death. (Refer to A-0813)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care.

Based on interview and record review the facility failed to actively engage one of thirty (30) sampled patients (Patient 1) and/or patient's family/ representative(s) in the development of a discharge plan for Patient 1 as well as failed to document the discharge plan evaluation within 24 hours after patient's (Patient 1) admission to the facility in accordance with the facility's policy and procedure regarding the discharge process (the transition of a patient from the hospital to another level of care such as home).

This deficient practice had the potential for Patient 1 and Patient 1's representatives to not fully understand the discharge care needs of Patient 1 which can impact patient outcomes such as compliance with treatment regimen and reduction of unplanned readmission. This deficient practice can also result in the violation of Patient 1's rights when the patient (Patient 1) and/or Patient 1's representative were not included in Patient 1's discharge planning.

Findings:

During a review of Patient 1's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 7/12/2024, the H&P indicated that Patient 1 was admitted due to shortness of breath (SOB, difficulty breathing), and found to have aspiration pneumonia (a lung infection caused by inhaling things other than air, such as saliva, food particles or stomach contents) and acute respiratory failure (ARF, an inability to maintain adequate oxygenation for tissues).

During a review of Patient 1's H&P, dated 7/12/2024, the H&P also indicated that Patient 1 had past medical history (PMH, a record of their health status before their current problem) of stroke (clot in the brain) with chronic right sided deficit (problems that occur when there is damage to the right side of the brain. Example: weakness on the right side of the body, difficulty with memory, etc.), aphasia (a language disorder that makes it hard for you to read, write, and speak), percutaneous endoscopic gastrostomy (PEG, feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall).

During a review of Patient 1's medical record (MR) titled, "Emergency Documentation," dated 7/12/2024, the MR indicated that Patient 1 was transported to the facility by ambulance from a congregate health living facility (a residential care facility that provides medical and personal care for individuals with chronic illnesses, disabilities, or complex medical needs) where he resided prior their admission to the hospital on 7/12/2024.During a review of Patient 1's MR titled. "Discharge Summary," dated 7/24/2024, the MR indicated that Patient 1 was at high risk for re-aspiration (Re-aspiration refers to the repeated inhalation of food, liquid, saliva, or other foreign material into the lungs, which can lead to serious complications like pneumonia (lung infection) or respiratory distress (a serious lung condition that causes low blood oxygen). Patients at high risk for re-aspiration require careful monitoring and specific care measures to prevent further aspiration events)., though the family wanted to take the patient home. The MR also indicated that Patient 1 required tube feeding, home health services, in-home physical therapy, supplemental oxygen, durable medical equipment (DME, medical equipment that can be used repeatedly and is intended to be used in a patient's home for a medical purpose), including a hospital bed.

During a concurrent interview and record review on 10/31/2024 at 9:35 a.m. with the Clinical Quality Coordinator (CQC), Patient 1's medical record was reviewed for discharge planning documentation. The record indicated that no case management notes were recorded in Patient 1's chart from 7/12/2024 through 7/22/2024, which the CQC confirmed. Additionally, the medical record contained a note titled "Case Management (CM)" dated 7/22/2024, showing that a case manager documented their first contact with Patient 1's family representative on 7/22/2024, only two days before Patient 1's discharge from the facility with an anticipation to discharge Patient 1 the following day, on 7/23/2024.

During an interview on 10/31/2024 at 12:00 p.m. regarding the discharge planning process (the process of transitioning a patient from one level of care to another), with the Director of Case Management Services (DCM), the DCM stated that discharge planning begins within 24 hours of a patient's admission and involves case managers, nurses, and other healthcare team members. The DCM stated that nurses conduct the initial assessment, while case managers complete a discharge planning screening within this timeframe, documenting all steps in the patient's medical record.

During the same interview on 10/31/2024 at 12:00 p.m. regarding discharge planning with the DCM, the DCM stated, "Case manager discharge planning practices include communicating with the patient or family to assess living arrangements, such as stairs in the home, and identifying post-discharge needs, including home health services, durable medical equipment (DMEs), and other necessary support. Service coordination is based on patient requirements. For example, if enteral feeding is needed, vendors are contacted. Hands-on training should be provided to the patient and family by the nurse, with documentation to ensure continuity of care. Either the case manager or primary nurse can determine if additional education is necessary, depending on the patient's discharge destination."

During a review of the facility's policy and procedure (P&P) titled, "Patient/Family Teaching Plan," dated 7/2022, the P&P indicated that patient discharge needs are initially assessed on admission. the patient/family will be informed of various resources in the community if needed. Case Managers shall coordinate discharge arrangement and teaching for medical equipment. Any teaching or discharge planning shall be documented in the medical record.

During a review of the facility's policy and procedure (P&P) titled "Discharge Planning," dated 9/2024, the P&P indicated that the facility provides Discharge Planning for all patients according to federal and state regulatory requirements. Patients requiring complex discharge planning are referred to the Case Management department, which arranges necessary services and care based on available resources and authorizations. The P&P indicated that discharge planning should begin at the time of admission. Additionally, case managers from local medical groups are involved in the discharge planning process and are required to document in the facility's electronic health record. The case manager (CM) is responsible for periodically reassessing patients with complex or high-risk discharge needs and must document these assessments in the patient's medical record.

Based on interview and record review, the facility failed to ensure that appropriate referrals (wound care services, physical therapy services) were arranged and coordinated with contracted services prior to discharge for one of 30 sampled patients (Patient 1), in accordance with the facility's policy and procedure regarding discharge planning (the process of preparing a patient to leave the hospital and transition to the next level of care).

This deficient practice had the potential for Patient 1's condition to worsen post-discharge due to lack of aftercare (the care and support that patients receive after hospitalization). This deficient practice may also result in readmission or poor quality of life and/or death.

Findings:

During a review of Patient 1's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 7/12/2024, the H&P indicated that Patient 1 was admitted due to shortness of breath (SOB, difficulty breathing), and found to have aspiration pneumonia ( a lung infection caused by inhaling things other than air, such as saliva, food particles or stomach contents) and acute respiratory failure (ARF, an inability to maintain adequate oxygenation for tissues).

During a review of Patient 1's H&P, dated 7/12/2024, the H&P also indicated that Patient 1 had past medical history (PMH, a record of their health status before their current problem) of stroke (clot in the brain) with chronic right sided deficit (problems that occur when there is damage to the right side of the brain. Example: weakness on the right side of the body, difficulty with memory, etc.), aphasia (a language disorder that makes it hard for you to read, write, and speak), percutaneous endoscopic gastrostomy (PEG, feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall).

During a review of Patient 1's Medical Record (MR) titled, "Discharge Summary," dated 7/24/2024, the MR indicated that Patient 1 was at high risk for re-aspiration (Re-aspiration refers to the repeated inhalation of food, liquid, saliva, or other foreign material into the lungs, which can lead to serious complications like pneumonia or respiratory distress. Patients at high risk for re-aspiration required careful monitoring and specific care measures to prevent further aspiration events), though the family wanted to take the patient home. The MR also indicated that Patient 1 required tube feeding (a method to supply nutrients and fluids to the body if someone cannot safely chew or swallow), home health services, in-home physical therapy, supplemental oxygen, durable medical equipment (DME, medical equipment that can be used repeatedly and is intended to be used in a patient's home for a medical purpose), including a hospital bed.

During an interview on 10/31/2024 at 11:26 a.m. with Registered Nurse (RN 2) regarding the facility's discharge process, RN 2 stated, "The case manager (CM) is responsible for relaying information about home health services, durable medical equipment (DMEs), and transportation arrangements." RN 2 further explained that, typically, the CM would call the nurse to inform them about any DMEs, and other arrangements. "Sometimes it's documented in the patient's chart and sometimes it's not," RN 2 added. "I'm not sure if I typically document this information after receiving a call from the CM."

During the same interview on 10/31/2024 at 11:26 a.m. with Registered Nurse (RN 2) regarding Patient 1's discharge instructions dated 7/24/2024, RN 2 reviewed the discharge instructions and stated, "Based on what is documented, arrangements were made for blood glucose (sugar) monitoring, an enteral feeding pump, and a transfer aid for Patient 1. However, nursing and physical therapy are noted as 'none arranged,' and I cannot recall if I received a call from the CM about those services. I also don't remember for certain if all the DMEs and services were arranged or which ones, as it's not documented."

During a review of Patent 1's MR titled "Case Management notes" dated 7/22/2024, the MR indicated that the CM made first contact with Patient 1's family member on 7/22/2024 and documented and Patient 1 required front wheel walker (FWW, a type of mobility aid designed to help individuals with limited strength, balance, or mobility maintain stability while walking), blood sugar control, and that a family member requested a hospital bed for Patient 1. The MR contained no other record of arrangements made for enteral feeding (a liquid nutritional formula is delivered through a tube that is inserted into the stomach or small intestine) and pump, home health services and in home physical therapy.

During a review of Patient 1's MR titled, Case Management," dated 7/23/2024 at 4:43 p.m., the MR indicated Patient 1's discharge was delayed because a hospital bed had not yet been delivered. Patient 1's MR contained no additional notes recorded by the CM on any other days during Patient 1's hospital stay. The MR contained no recorded confirmation of delivery of the hospital bed and arrangement for home health services in Patient 1's medical record either.

During an interview on 10/31/2024 at 12:00 p.m. regarding discharge planning with the Director of Case Management (DCM), the DCM stated, "Case manager discharge planning practices include communicating with the patient or family to assess living arrangements, identifying post-discharge needs and home health services, durable medical equipment (DMEs), and other necessary support. Service coordination is based on patient requirements. For home health services, discharge orders should specify the services provided (such as nursing visits or wound care) and contact information for the home health agency should be included in the CM's documentation, along with delivery schedules for necessary items. DMEs, such as oxygen or a hospital bed, require specific instructions, including the oxygen levels needed. For supplemental oxygen at home, the oxygen company should be contacted, and this includes providing insurance information, diagnosis, and contact details, as well as determining whether items will be delivered to the hospital or directly to the home. For example, if enteral feeding is needed, vendors are contacted. Enteral feeding also requires an order and input from the dietitian, with the case manager responsible for including this information in the chart for prescription purposes. All steps must be documented in the patient's medical record to ensure continuity of care."

During a review of the facility's policy and procedure (P&P) titled, "Discharge Planning," dated 9/2024, the P&P indicated that the facility provides Discharge Planning for all patients according to federal and state regulatory requirements. Patients requiring complex discharge planning are referred to the Case Management department, which arranges necessary services and care based on available resources and authorizations. The P&P indicated that discharge planning should begin at the time of admission. Additionally, case managers from local medical groups are involved in the discharge planning process and are required to document in the facility's electronic health record. The case manager (CM) is responsible for periodically reassessing patients with complex or high-risk discharge needs and must document these assessments in the patient's medical record.