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Based on interview and record review, the medical record of two of 30 sampled patients (Patient 26 and Patient 29), was lacking the signed consent for treatment, and was not provided a copy of Patient Rights.

This failure could lead to patients not being aware of their rights and other options for treatment.

Findings:

Patient 26 was admitted to the hospital on 12/5/24 with a diagnosis of new onset Diabetes Mellitus (DM, a condition which affects the way the body process blood sugar). Patient 26 was discharged on 12/7/24.

During a concurrent interview and record review, on 12/10/24 at 11:43 a.m., with the Clinical Quality Nurse (CQN), the CQN confirmed Patient 26 was not provided the Condition of Admission (COA, a contract between a patient and a hospital).

Patient 29 was admitted to the hospital on 12/2/24 for Labor Vaginal Delivery (the process of giving birth to a baby through the birth canal). Patient was discharged on 12/5/24.

During a concurrent interview and record review, on 12/10/24 at 1:45 p.m., with the CQN, the CQN confirmed Patient 29 does not have the COA. The CQN stated there was no documentation in the medical record that the COA was provided to Patient 29.

During an interview on 12/10/24 at 11:21 a.m., with the Chief Nursing Officer (CNO), the CNO stated patients should have COA.

During a review of the hospital's policy and procedure (P&P), titled "Patient Rights and Responsibilities", date revised 7/2017, indicated " ...to ensure the Patient Rights and Responsibilities are provided to each patient ...The patient Access staff will provide all patients the Patient Rights and Responsibilities form at time of Admission. All patients should receive the hospital's Notice of Patient Rights and Responsibilities form (ADM-1901) at time of Admission/Registration."

Based on interview and record review, the hospital failed to ensure nursing staff developed individualized care plans (a tool used to provide nursing care to patients) and updated care plans for three of 30 sampled patients (Patients 1, 9, and 18) when, upon admission, no care plans were developed.

These failures had the potential to result in lack of, or delay in providing appropriate care, and monitoring of these patients.

Findings:

1. Patient 1 had been admitted on 12/3/2024 with diagnoses which included: vomiting and right lower abdominal pain.

During a review of Patient 1's hard copy record and subsequent interview, with the director of quality (DOQ) on 12/10/24 at 1:14 p.m., the DOQ stated Patient 1 did not have any care plans developed.

During an interview with the chief nursing officer (CNO) on 12/11/24 at 10 a.m., the CNO stated Patient 1 should have had care plans initiated /developed upon admission.

2. Patient 9 had been admitted on 12/3/2024 with diagnoses which included: chest pain, weakness and numbness in upper and lower extremities.

During a review of Patient 9's hard copy record and subsequent interview, with the director of quality (DOQ) on 12/10/24 at 11:50 a.m., the DOQ stated Patient 9 did not have any care plans developed/initiated.

During an interview with the chief nursing officer (CNO) on 12/11/24 at 10 a.m., the CNO stated Patient 9 should have had care plans initiated upon admission.



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3. Patient 18 was admitted to the hospital on 12/5/24 for Pneumonia (an infection that affects one or both lungs).

During a concurrent interview and record review, on 12/10/24 at 10:49 a.m., with the Nurse Manager (NM), the NM confirmed care plan was not initiated upon admission. The NM stated care plan should be initiated and updated.

During an interview on 12/10/24 at 11:21 a.m., with the Chief Nursing Officer (CNO), the CNO stated should have a care plan upon admission and care plan update for any problem identified.

During a review of the facility's policy and procedure (P&P) titled Interdisciplinary Care Plans, revise/reviewed 12/2018, the P&P indicated, ...

II. POLICY: Inpatients will have a plan of care initiated within eight -8 hours of admission. For each shift worked, the care plan will be reviewed/updated by the RN ...

...Patients receive care and treatment based on an assessment of their needs, the severity of their disease, condition, impairment, or disability.

V. PROCEDURE:

A. Documentation

An interdisciplinary plan of care will be documented for all inpatients in the patient's medical record.

Based on interview and documents review, the hospital failed to follow a physician order to administer a medication during the period of system downtime. This failure had the potential for negative health outcome for the patient.

Findings:

During a concurrent interview and record review, on 12/9/24, at 2:35 PM, with the Nurse Manager (NM) of the Medical Surgical unit, Patient 31's Medication Administration Record (MAR), dated 12/8/24, was reviewed. The MAR indicated, "Thiamine (Vitamin B1) 100 mg oral tablet, give 1 tablet by mouth one time a day at 9:00 AM." The MAR did not show the medication was given on 12/8/24. The NM stated, "The MAR should specify when the medication was administered and the nurse who signed off on it." And the NM also stated she would need to clarify this medication order with the nurse on duty that morning to see if the administration record was documented elsewhere on the chart.

During an interview on 12/11/24 at 11:23 AM with the NM, the NM confirmed that the nurse did not administer the thiamine order on the morning of 12/8/24 as the nurse did not find the medication to be available in the Pyxis (automatic drug dispensing cabinet).

During a review of the facility's policy and procedure (P&P) titled, "Administration of Medication," dated 5/2021, the P&P indicated, "B: Compliance with Medication Orders: 1. Medications shall be prepared and administered in compliance with the orders of the prescriber or practitioner responsible for the patient's care and accepted standards of practice." On page 3, it further indicated, "Observe the patient take the medication. Stay with the patient until he/she has swallowed the medication. . .Properly document the administration or the patient's refusal of the medication."