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Based on observation, interview, and record review, the hospital failed to meet the Condition of Participation (COP) for Patient Rights when:

1. The hospital failed to follow their policy and procedure (P&P) titled, "Patient's Rights" when the facility did not prominently display Patient Rights signage in the Medical Surgical (MS, general patient population hospitalized for various causes) unit or the Intensive Care Unit (ICU - specialty care unit). Refer to A 116

2. The hospital failed to follow their P&P titled, "Patient's Rights," when the facility did not provide the Notification of Patient's Rights to seven (Patient 8, Patient 25, Patient 26, Patient 28, Patient 4, Patient 5, and Patient 6) of 30 sampled patients during the admission process. Refer to A 117

3. The hospital failed to follow their P&P titled, "Informed Consent [fully understand everything involved including risks, benefits, alternative treatments, and potential side effects] Obtaining & Documenting," to obtain a signed Conditions for Admission (COA, patient agreement for admission to the hospital, treatment and pay for services) for seven out of 30 sampled patients (Patient 8, Patient 4, Patient 5, Patient 6, Patient 25, Patient 26, and Patient 28). Refer to A 131

4. The hospital failed to follow their P&P titled, "Advanced Directive [legal document indicates a person's wishes for medical treatment] --Patient Rights to Self-Determination," to provide Advance Directive information and obtain a signed or declined Advance Directive for eight of 30 sampled patients (Patient 8, Patient 13, Patient 4, Patient 5, Patient 6, Patient 25, Patient 26, and Patient 28). Refer to A 132

5. The hospital failed to follow their P&P titled "Emergency Crash Cart [a wheeled cart containing medicine and equipment for use in life saving emergency] Security and Accountability" to inspect one of three crash carts with defibrillators [a device that sends an electric pulse or shock to restore a normal heartbeat] to ensure proper working order. Refer to A 144

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provisions of patient's rights to be provided care in a safe environment for all patients receiving treatments in this hospital.

Based on observation, interview and record review, the hospital failed to follow their policy and procedure (P&P) titled, "Patient's Rights" when the facility did not prominently display Patient Rights signage in the Medical Surgical Unit (MSU, general patient population hospitalized for various causes) or the Intensive Care Unit (ICU - specialty care unit). This failure had the potential to result in patients, staff and visitors to lack knowledge of patient rights. This failure had the potential to result in all patients, staff and visitors to not be aware of patients' rights.

Findings:

During a tour of the facility on 11/8/22, at 9:30 AM, with the Quality Risk Coordinator (QRC), QRC was unable to show where the facility posted Patient's Rights in the MSU or ICU in the hospital. QRC stated, "These rights should be posted for patients and families to read. MSU unit has a capacity of 38 patients; ICU has a capacity of four beds."

During an interview on 11/8/22, at 2:30 PM, with the Risk Coordinator (RC), RC provided the psychiatric department's P&P titled, "Patient's Rights." RC stated, "Even though the P&P is identified as pertaining to the psychiatric services, this P&P is the hospital-wide policy also."

During a review of the facility's P&P titled, "Patient's Rights," dated 10/21/22, the P&P indicated, "To ensure compliance with regulatory rules and requirements. To ensure that the "Patient's Rights" are prominently displayed ...The nurse will show the patient the location of posted Patient's Rights in the unit hallway ..."

Based on interview and record review, the hospital failed to follow their policy and procedure (P&P) titled, "Patient's Rights," when the facility did not provide the Notification of Patient's Rights to seven (Patient 8, Patient 25, Patient 26, Patient 28, Patient 4, Patient 5, and Patient 6) of 30 sampled patients during the admission process. This failure had the potential to result in Patient 8, Patient 25, Patient 26, and Patient 28, Patient 4, Patient 5, and Patient 6 or patients' guardians/responsible parties/family member, being unaware of their rights.

Findings:

a. During a concurrent interview and record review on 11/8/22, at 9:45 AM, with Physician's Scribe, Patient 8's Electronic Medical Record (EMR) and paper medical chart were reviewed. PS stated, "Patient 8 was admitted on 10/31/22 for a 72-hour involuntary hold" PS was unable to provide documented evidence in either Patient 8's EMR or the paper medical chart of the facility provided the Notification of Patient Rights to Patient 8.

b. During a concurrent interview and record review on 11/8/22, at 1:15 PM, with PS, Patient 25's EMR was reviewed. Patient 25's EMR did not indicate the facility provided the Notification of Patient Rights to Patient 25 or guardian. PS stated, "Not here."

c. During a concurrent interview and record review on 11/8/22, at 1:25 PM, with PS, Patient 26's EMR was reviewed. Patient 26's EMR did not indicate the facility provided the Notification of Patient Rights to Patient 26 or guardian. PS stated, "It's not here either."

d. During a concurrent interview and record review on 11/8/22, at 1:45 PM, with PS, Patient 28's EMR was reviewed. Patient 28's EMR did not indicate the facility provided the Notification of Patient Rights to Patient 28 or guardian. PS stated, "No, not here."

e. During a concurrent interview and record review on 11/8/22, at 3:38 PM, with PS, Patient 4's EMR was reviewed. Patient 4's EMR did not indicate facility provided the Notification of Patient Rights to Patient 4 or guardian. PS reviewed Patient 4's EMR twice and stated, "It's not here."

f. During a concurrent interview and record review on 11/8/22, at 3:48 PM, with PS, Patient 5's EMR was reviewed. Patient 5's EMR did not indicate the facility provided the Notification of Patient Rights to Patient 5 or guardian. PS stated, "It's not here."

g. During a concurrent interview and record review on 11/8/22, at 4 PM, with PS, Patient 6's EMR was reviewed. Patient 6's EMR did not indicate the facility provided the Notification of Patient Rights to Patient 6 or guardian. PS stated, "Nope, It's not here."


42610

During an interview on 11/8/22, at 2:30 PM, with the Risk Coordinator (RC), RC provided the psychiatric department's P&P titled, "Patient's Rights." RC stated, "Even though the P&P is identified as pertaining to the psychiatric services, this P&P is the hospital-wide policy also."

During a review of the facility's P&P titled, "Patient's Rights," dated 10/21/22, the P&P indicated, "On admission to the Psychiatry Unit and during the patient's hospitalization, the patient will be informed of his/her rights according to Welfare and Institutions Codes ...The admission staff will review..."


18790

Based on interview and record review, the hospital failed to follow their policy and procedure (P&P) titled, "Informed Consent [fully understand everything involved including risks, benefits, alternative treatments, and potential side effects] Obtaining & Documenting," to obtain a signed Conditions for Admission (COA, patient agreement for admission to the hospital, treatment and pay for services) for ten of 30 sampled patients (Patient 8, Patient 4, Patient 5, Patient 6, Patient 25, Patient 26, and Patient 28). This failure resulted in Patient 8, Patient 4, Patient 5, Patient 6, Patient 25, Patient 26, and Patient 28 not consenting to hospital admission and subsequent treatments.

Findings:

a. During a concurrent interview and record review on 11/8/22, at 9:45 AM, with Physician's Scribe (PS), Patient 8's EMR was reviewed. PS stated, there was no consent for admission to hospital in Patient 8's EMR or paper medical chart.

b.During a concurrent interview and record review on 11/8/22, at 3:38 PM, with PS, Patient 4's Electronic Medical Record (EMR) was reviewed. Patient 4's EMR did not indicate the facility obtained a signed COA for Patient 4 or guardian. PS reviewed Patient 4's EMR twice and stated, "It's not here."

c. During a concurrent interview and record review on 11/8/22, at 3:48 PM, with PS, Patient 5's EMR was reviewed. Patient 5's EMR did not indicate the facility obtained a signed COA for Patient 5 or guardian. PS stated, "It's not here."

d. During a concurrent interview and record review on 11/8/22, at 4 PM, with PS, Patient 6's EMR was reviewed. Patient 6's EMR did not indicate the facility obtained a signed COA for Patient 6 or guardian. PS stated, "Nope, It's not here."

e. During a concurrent interview and record review on 11/8/22, at 1:15 PM, with PS, Patient 25's EMR was reviewed. Patient 25's EMR did not indicate the facility obtained a signed COA for Patient 25 or guardian. PS stated, "Not here."

f. During a concurrent interview and record review on 11/8/22, at 1:25 PM, with PS, Patient 26's EMR was reviewed. Patient 26's EMR did not indicate the facility obtained a signed COA for Patient 26 or guardian. PS stated, "It's not here."

g. During a concurrent interview and record review on 11/8/22, at 1:45 PM, with PS, Patient 28's EMR was reviewed. Patient 28's EMR did not indicate the facility obtained a signed COA for Patient 28 or guardian. PS stated, "No, not here."


42610

During an interview on 11/8/22, at 3 PM, with the Administrator, the Administrator stated, "If there was no admission paperwork done upon admission to the facility, there is no patient rights acknowledgement, no advanced directives documented and there is no consent for treatment after admission."

During a review of the facility's policy and procedure (P&P) titled, "Informed Consent Obtaining & Documenting," dated 10/27/22, the P&P indicated, "...a. Procedures which are "simple and common: do not require informed consent, they do however require consent. Patient consent (as distinguished from informed consent) is required for simple and common procedures and is obtained at the time of admission when the when the patient or the patient's legal representative receives and signs the Conditions of Admission before or during each hospital admission or outpatient visit. The performance of a blood count, x-ray, and EKG are examples of "simple and common procedures."


18790

Based on interview and record review, the hospital failed to follow their policy and procedure (P&P) titled, "Advanced Directive [AD-legal document indicates a person's wishes for medical treatment] --Patient Rights to Self-Determination," to provide Advance Directive information and obtain a signed or declined AD for eight of 30 sampled patients (Patient 8, Patient 13, Patient 4, Patient 5, Patient 6, Patient 25, Patient 26, and Patient 28). This failure had the potential for staff to be unaware of Patient 8, Patient 13, Patient 4, Patient 5, Patient 6, Patient 25, Patient 26, and Patient 28 and/or legal representative's wishes for treatment.

Findings:

During a concurrent interview and record review on 11/8/22, at 9:45 AM, with Physcian's Scribe (PS), Patient 8's EMR was reviewed. PS stated, Patient 8 was admitted to the Psychiatric Unit [PU-mental health] on 10/31/22 for a 72-hour involuntary hold. PS stated, no advanced directive was found in Patient 8's Electronic Medical Record (EMR) or paper medical chart.

During an interview on 11/8/22, at 10:37 AM, with Admission Staff (AS 1), AS 1 stated, "Psych patients go directly to the psych unit when patients comes in. We [admission staff] don't ask them [patients] for signatures [upon arrival], we let them rest first. If patient comes in at 8 AM, we wait till 12 noon, then I ask them for consents. I scan them all to [EMR]. I don't put a hard copy in their charts."

During an interview on 11/9/22, at 3:02 PM, with PS, PS stated, patients admitted with an involuntary hold do not sign an Advance Directive form.


35645


During a concurrent interview and record review on 11/8/22, at 9:42 AM, with Licensed Vocational Nurse (LVN 1), Patient 13's EMR was reviewed. The EMR did not indicate the facility provided AD information to Patient 13 or guardian. LVN 1 stated, "We don't ask patients about advance directives."

During a concurrent interview and record review on 11/8/22, At 3:38 PM, with PS, Patient 4's EMR was reviewed. The EMR did not indicate the facility provided AD information to Patient 4 or guardian. PS stated, "No advance directives provided."

During a concurrent interview and record review on 11/8/22, At 3:40 PM, with PS, Patient 5's EMR was reviewed. The EMR did not indicate the facility provided AD information to Patient 5 or guardian. PS stated, "No advance directives."

During a concurrent interview and record review on 11/8/22, At 3:40 PM, with PS, Patient 6's EMR was reviewed. The EMR did not indicate the facility provided AD information to Patient 6 or guardian. PS stated, "No advance directives."

During a concurrent interview and record review on 11/8/22, At 1:15 PM, with PS, Patient 25's EMR was reviewed. The EMR did not indicate the facility provided AD information to Patient 25 or guardian. PS stated, "No advance directives."

During a concurrent interview and record review on 11/8/22, At 1:25 PM, with PS, Patient 26's EMR was reviewed. The EMR did not indicate the facility provided AD information to Patient 26 or guardian. PS stated, "No advance directives."

During a concurrent interview and record review on 11/8/22, At 1:15 PM, with PS, Patient 28's EMR was reviewed. The EMR did not indicate the facility provided AD information to Patient 28 or guardian. PS stated, "No advance directives."


18790

During an interview on 11/8/22, at 3 PM, with the Administrator and Chief Administrative Office (CAO), the Administrator stated, "If there was no admission paperwork done on admission to the facility, there is no patient rights acknowledgement, no advanced directives documented and there is no consent for treatment upon admission to the hospital."

During a review of the facility's policy and procedure (P&P) titled "Advance Directives," dated 5/1/21, the P&P indicated, "In the event the patient bypasses the routine admissions process due to nature or severity of illness, and is admitted directly to the patient care units, the responsibility to inquire about advance directives and provide necessary information . . . will rest with the nursing staff. The Admitting Department will notify the nursing staff of the need for advance directive follow-up."

During a review of the facility's P&P titled, "Advanced Directive--Patient Rights to Self-Determination", dated 1/30/22, the P&P indicated, "Purpose: This policy is established to insure that [hospital] healthcare team is aware of the existence of any document which is intended to limit heroic measures or direct the healthcare team as to the person's desire for treatment, to preclude taking action contrary to the desire of the patient...Scope: All hospital employees Policy: Every adult patient or his/her surrogate decision-maker who is admitted will be asked if they have completed an advanced directive. Procedure: A. As part of the hospital admission process, the person who documents patients admission shall provide the patient with information regarding the patient's right to make decisions concerning healthcare which include the right to accept or refuse medical or surgical treatment, even if that treatment is life-sustaining. A pamphlet which describes the rights of the patient shall be distributed to the patient. B. Provide patient with hospital policy information 1. As part of the hospital admission process, the person who documents patient's admission shall provide the patient with information regarding the hospital's policies with respect to the implementation of the patient to make decisions concerning healthcare."

Based on observation, interview and record review, the hospital failed to follow their policy and procedure (P&P) titled, "Emergency Crash Cart [a wheeled cart containing medicine and equipment for use in life saving emergency] Security and Accountability" to inspect the one of three crash carts with defibrillators [a device that sends an electric pulse or shock to restore a normal heartbeat] to ensure proper working order. This failure had the potential for equipment failure and a delay of care during a patient's medical crisis (Code Blue).

Findings:

During a concurrent observation, interview, and record review on 11/2/22, at 12:45 PM, with Registered Nurse (RN) 3, in the Psychiatric unit, the "Crash Cart Check List," dated 11/22, and the defibrillator tape, dated 11/1/22, were reviewed. The "Crash Cart Check List," indicated, staff last checked the crash cart on 11/1/22. The defibrillator tape indicated, the night shift checked the defibrillator on 11/1/22. RN 3 stated, licensed staff should check the crash cart equipment every shift. RN 3 stated, the crash cart equipment (defibrillator and suction machine) had not been checked during her shift today. RN 3 stated, she checked the defibrillator while plugged into the electrical outlet. RN 3 stated, she did not know what she would do if the defibrillator was needed in an area, such as the hallway, if the defibrillator did not work and no electrical outlet was available.


35645


During a concurrent observation and interview on 11/3/22, at 9 AM, with RN 3, RN 3 demonstrated checking the crash cart. RN 3 stated, "I always check the crash cart when it's plugged in" RN 3 checked the Automatic External Defibrillator (AED) and suction machine with the crash cart plugged in. The AED and suction machine worked. RN 3 unplugged the crash cart and checked the suction machine and AED again. Neither the AED nor the suction machine worked. RN 3 stated, she was not aware the AED and suction machine did not work on battery when unplugged.

During a review of the hospital's P&P titled, "Emergency Crash Cart Security and Accountability," dated 10/13/21, the P&P indicated, "The crash carts will be inspected and defibrillator checked every shift to ensure appropriate top and side contents, to confirm locked status and to verify proper working condition." The P&P did not provide the steps to take to confirm the crash cart was in working order.

Based on interview and record review, the hospital failed to develop, implement, and maintain an effective, ongoing, data-driven Quality Assessment Performance Improvement (QAPI-Proactive approach to identify and improve system issues that cause poor health outcomes.) Program that meets the Condition of Participation (COP) for QAPI when:

1. The hospital failed to have a system in place to monitor, track and trend, review and analyze the Quality Assessment Performance Improvement (QAPI) indicators (data to measure and track clinical performance and outcomes) to improve health outcomes, hospital service and operations. Refer to A 273

2. The hospital failed to have a system in place to use data collected regarding patient care and patient safety to identify opportunities for improvement and develop plan of actions for quality performance improvement (QAPI) and inform hospital staff of hospital's performance improvement activities. Refer to A 283

3. The hospital failed to develop and implement performance improvement projects. Refer to A 297

The cumulative effect of these systemic practices resulted in the hospital's inability to ensure the provision of quality health care in a safe environment for all patients receiving care in this hospital.

Based on interview and record review, the hospital failed to have a system in place to monitor, track and trend, review and analyze the Quality Assessment Performance Improvement (QAPI) indicators (data to measure and track clinical performance and outcomes) to improve health outcomes, hospital service and operations. This failure resulted in the hospital's inability to monitor the effectiveness and safety of services and quality of patient care for all patients served by the hospital.

Findings:

During an interview on 11/8/22, at 10:59 AM, with Chief Nursing Officer (CNO), CNO stated, she was not a member of QAPI. CNO added, "I'm not, we don't have a QAPI team.

During an interview on 11/8/22, at 11:35, with Quality and Risk Management Coordinator (QRMC), QRMC stated, she did not know any quality indicators the hospital was working on or the process of data collection to monitor facility compliance. QRMC was unable to provide a documented QAPI program approved by the governing body. QRMC stated, "[The previous QRMC] did not give me any [QAPI] binder [when she left 10/2022]." QRMC stated, there are no on-going performance improvement projects.

During an interview on 11/8/22, at 11:45 AM, with QRMC, QRMC stated, "I have not done any tracking, or any Performance Improvement [PI] projects [since the former QRMC left in 10/2022]." QRMC stated, the hospital does not have any current QAPI projects.

During an interview on 11/8/22, at 1:32 PM, with Infection Control Preventionist (ICP), ICP stated, "I am not a member of QAPI." ICP was not able to explain how she identified and reported problems to QAPI committee to improve the quality of patient care. ICP stated, "We have issues on documentation of patients with urinary catheters (tubes) and PICC [Peripherally Inserted Central Catheter- provides long-term access to large veins leading directly to the heart]." ICP was unable to provide documented evidence the QAPI Committee had baseline (starting point) data and had taken actions to improve documentation of patients with foley catheter and/or PICC lines.

During an interview on 11/9/22, at 11 AM, with Chief Nursing Officer (CNO), CNO stated, "I know we don't have on-going QAPI projects."

During a review of the Centers for Disease Control (CDC, national health organization) Infection Preventionist Training Course, Module 3, dated 6/10/20, indicated QAPI members included the following: clinical and administrative leadership, infection preventionist, front-line staff from clinical and non-clinical departments, pnarmacy and laboratory.

During an interview on 11/9/22, at 11:15 AM, with QRMC, QRMC stated, the hospital does not have any PI projects right now. QRMC stated, the hospital does not have a QAPI policy and procedure. I have not been able to find a QAPI policy.

Based on interview and record review, the hospital failed to have a system in place to:

1. Use data collected regarding patient care and patient safety to identify opportunities for improvement and develop plan of actions for quality performance improvement (QAPI).

2. Inform hospital staff of hospital's performance improvement activities.

These failures resulted in missed opportunities for improvement in patient health outcomes, patient safety and quality of care for all patients served by the hospital.

Findings:

1. During an interview on 11/8/22, at 1:32 PM, with Infection Control Preventionist (ICP), ICP stated, "We have issues on documentation of patients with urinary catheter (tubes) and or PICC [Peripherally Inserted Central Catheter - provides long term access to large veins leading to the heart]" ICP was unable to provide documented evidence the QAPI Committee had baseline (starting point) data and had taken actions to improve documentation of patients with urinary catheters and/or PICCs.

During a concurrent interview and record review on 11/8/22, at 2:05 PM, with Hospital Pharmacist (HP), the 2022 Year to Date Medication Events documentation was reviewed. HP stated, the 2022 Year to Date Medication Events indicated, the hospital had nine medication events and 22 medication near miss events [no actual harm caused to patient from giving or not giving medication]. The 2022 Medication Events indicated, the following: by Category "Wrong strength 33%, Omission 11%, Wrong medication 22%, Wrong patient 22%:" By Severity "Event resulted in need for treatment or intervention [temporary patient harm] 11%, Events occurred that reached the patient but did not cause harm 78%, Circumstance has capacity to cause error 11%:" By Location "MedSurg [Medical Surgical]/ICU [Intensive Care Unit] 67%, Psych [Mental Health Unit] 22%: and By near miss events "ICU/MS Nursing 18, Psych Nursing 2, Surgery 2." HP was not able to provide documented evidence the QAPI Committee had taken performance improvement actions to reduce errors and near misses.

During an interview on 11/9/22, at 11 AM, with Chief Nursing Officer (CNO), CNO stated, the hospital did not have any on-going Improvement projects.

2. During an interview on 11/8/22, at 9:20 AM, with Charge Registered Nurse (RN 4), RN 4 stated, "I am the day Charge RN and I have not heard of QAPI. I have not participated in any hospital projects. I do not know of any hospital projects." RN 4 stated, the hospital had not provided information about 2021/22 hospital quality projects.

During an interview on 11/8/22, at 9:30 AM, with RN 5, RN 5 stated, "I do not know of any hospital quality projects. I do not participate in any hospital projects. I have not identified any issues. I have not communicated any issues to the higher ups. They [Administration] have not communicated any issues with us."

During an interview on 11/8/22, at 9:40 AM, with RN 3, RN 3 stated, "I don't know any hospital quality projects. I do not think there's any. I don't know if they are doing that [QAPI projects] here. We [nurses] all are not aware. We [nurses] are not involved at all."

During an interview on 11/8/22, at 9:50 AM, with RN 6, RN 6 stated, "I am still on orientation, I don't remember a discussion about QAPI or hospital quality projects in our orientation class."

During an interview on 11/8/22, at 10 AM, with RN 4, RN 4 stated, "With my 5 years working here, I have not identified any issues or communicated to the top. Maybe this QAPI is only for the top people like managers and higher."

During an interview on 11/8/22, at 10:10 AM, with Ward Clerk (WC), WC stated, "I started here in May 2022. I honestly do not know what the QAPI or quality projects of the hospital are. I am not a part of that. I don't even know if the hospital has projects, so I don't participate at all. Nobody told us about that [QAPI]."

During an interview on 11/9/22, at 11:15 AM, with QRMC, QRMC stated, "We don't have a QAPI policy and procedure." I have not been able to find a QAPI policy.

Based on interview and record review, the hospital failed to develop and implement performance improvement projects. This failure had the potential to result in adverse outcomes to go unnoticed for all patients receiving care in the hospital.

Findings:

During a concurrent interview and record review on 11/8/22, at 11:35, with Quality and Risk Management Coordinator (QRMC), QRMC stated, the hospital does not have any performance improvement projects.

During an interview on 11/8/22, at 1:32 PM, with Infection Control Preventionist (ICP), ICP stated, the hospital has issues on documentation of patients with urinary catheters (tube) and Peripherally Inserted Central Catheter (PICC - provides long-term access to large veins leading directly to the heart). ICP was unable to provide documented evidence of a hospital QAPI project for either urinary catheter or PICC documentation.

During a concurrent interview and record review on 11/9/22, at 11 AM, with Chief Nursing Officer (CNO), CNO stated, "We [the hospital] do not have any on-going QAPI projects."

During a concurrent interview and record review on 11/9/22, at 11:15 AM, with QRMC, QRMC stated, "We don't have PI projects right now." QRMC stated, "We [the hospital] don't have QAPI policy and procedure." I have not been able to find a QAPI policy.

Based on observation, interview, and record review, the hospital did not meet the Condition of Participation (COP) for the Nursing Services as evidenced by:

1. The hospital failed to ensure adequate and competent staff to provide appropriate, urgent, and emergency care for 29 of 29 patients in the Medical/Surgical and Psychiatric units
Refer to A 392.

2. The hospital failed to provide adequate critical level of care for one of 30 sampled patients (Patient 3) Refer to A 392.

3. The hospital failed to follow their policy and procedure (P&P), titled "Physician Orders, Verbal, Telephone," to use telephone orders infrequently for three of 32 sampled patients (Patient 30, Patient 31, and Patient 32). Refer to A 407.

4. The hospital failed to follow their policy and procedure (P&P) to sign verbal orders within 48 hours for three (Patient 4, Patient 5, and Patient 26) of 30 sampled patients. Refer to A 454.

5. The hospital failed to follow their policy and procedure (P&P) titled "Covid-19 Staff Vaccinations Requirements" for non-vaccinated staff to wear N-95 respirator (provides high level of protection from particles and viruses) while in the hospital for one of sixteen unvaccinated staff. Refer to A 772

These failures resulted in hospital's inability to provide quality, safe, and appropriate critical level of care for one of 30 patients and ensure safe and quality care for all the patients being treated in this hospital.

Based on observation, interview and record review, the hospital failed to ensure a Registered Nurse (RN) was immediately available to provide emergency patient care when:

1. Two of two RNs with Advanced Cardiac Life Support certification (ACLS, additional education specific to provide urgent and emergency treatment for life-threatening conditions), assigned to the Medical-Surgical (MS, general patient population hospitalized for various causes) unit responded to code blue (life threatening medical emergency) situations in the psychiatric unit, leaving one RN, without ACLS, alone on the MS unit. This failure had the potential for all MS patients requiring emergency medical treatment to not have critical care nursing expertise immediately available.

2. Adequate and competent Intensive Care Unit (ICU, specialty care unit) trained RNs, were employed to provide critical care according to hospital's licensure for one of four sampled patients (Patient 3). This failure resulted in the emergency transfer of Patient 3 to another hospital for a higher level of care and had the potential for delayed treatment.

Findings:

1. During an interview on 11/2/22, at 1:08 PM, with the Risk Coordinator (RC), RC stated, today, the hospital had one patient in the MS unit on telemetry (tele, continuous monitoring of heart activity to assess a patient's heart condition). Usually the hospital has five patients utilizing tele. The facility has the MS code blue team respond to any code blue in the psych unit. Most of the registered nurses (RNs) working in MS are ACLS certified (indicates expertise in heart rhythm identification and immediate treatment).

During a concurrent interview and record review, on 11/2/22, at 1:08 PM, with the Risk Coordinator (RC), a list of RNs having ACLS certification, and the RN Staffing Work Schedules for MS unit, dated 10/9/22 through 11/19/22 were reviewed. RC stated, 16 RNs had ACLS certification and 17 RNs did not have ACLS certification.

During a concurrent interview and record review on 11/2/22, at 1:45 PM, with the Chief Administrative Officer (CAO), CAO stated, "There was a code blue for Patient 1 on 10/5/22 on the psych [mental health] unit. The code blue team from MS responded immediately and provided ACLS expertise. ACLS is not required for RNs to work in psych." CAO reviewed the MS RN schedule, dated 10/5/22. CAO stated, after the code blue team left the MS floor, no RN with ACLS certification remained in MS to provide oversight for the MS and tele patients. CAO provided the RN staffing work schedules for two months (dated September 2022 and November 2022) for the psych unit. CAO reviewed the list of RNs with ACLS certification. CAO stated, "There are no RNs scheduled for psych who have ACLS certification for these two months."

2. During an interview on 11/3/22, at 11:18 AM, with Registered Nurse Manager (RNM), RNM stated, "When patient's condition changes and requires a critical level of care, the hospital is not able to provide that higher level of care because we don't have critical care nurses available. ICU is mostly closed. I know we are licensed for ICU level of care, but we are not able to provide that. There was one patient we transferred because he needed higher level of care and we were not able to provide that because there was no ICU nurse available."


42610


During an interview on 11/3/22, at 11:50 AM, with Registered Nurse Manager (RNM), RNM stated, she received a call on 9/11/22 from the facility regarding Patient 3 having chest pain and a high troponin (a lab test that measures current heart tissue injury) level. Patient 3 was placed under the care of Registered Nurse (RN) 8. RN 8 was not an ICU nurse. Later, at approximately 11:00 PM, RNM stated, she received a call from Medical Doctor (MD) 5 and MD 5 ordered for Patient 3 to transfer to the ICU while waiting for a transfer out of the facility to a higher level of care hospital. RNM told MD 5 there were no ICU nurses available to care for the patient. RNM stated, she was concerned about the length of time it would take to arrange for a transfer to another hospital, so Emergency Medical Services (EMS-911) was called.

During a review of Patient 3's Electronic Medical Record (EMR) titled "Progress Note" (PN), dated 9/11/22 at 3:19 PM, the PN indicated, "patient developed chest pain this morning indistinguishable [not able to be identified as different or distinct] from possible panic attack pain was sharp located mid-sternum [chest area] and patient described it as a 9/10 [pain scale-1 equals minor pain and 10 equals the most pain] . . . EKG [electrocardiogram-test to record electrical signal from the heart to check for different heart conditions] was performed at the bedside . . . indicated possible ischemia [heart injury] cardiac enzymes [lab test that measures substances in the blood that may indicate heart injury] were ordered."

During a review of Patient 3's EMR titled "INITIAL PHYSICAL ASSESSMENT-CRITICAL REPORT FLOWCHART" (CRF), dated 9/11/22, the CRF indicated, at 9:46 AM, Patient 5's troponin level was 106 mg/ml (normal level is 0-0.04 mg/ml-nanograms per milliliter- a unit of measurement). The CRF indicated, at 4:30 PM, Patient 5's troponin level had increased to 109 mg/ml.

During a review of Patient 3's EMR titled "LABORATORY-COMPARATIVE REPORT" (LCR), dated 9/11/22 at 11:20 PM, the LCR indicated, Patient 5's troponin level had increased to 114 mg/ml.

During a review of Patient 3's EMR titled "PN", dated 9/12/22, at 12:00 AM, the PN indicated, ". . . MD 6 came and saw the patient [Patient 3] and told [RNM] to put pt. to ICU, but we [facility] don't have an ICU nurse. Called our manager [RNM] and advised to call 911 for emergency transfer to higher level of care." PN indicated 911 was called at 1:22 AM, and EMS arrived at 1:36 AM and Patient 3 was transferred to a higher level of care at another hospital.

During a concurrent interview and record review on 11/8/22, at 8:40 AM, with Chief Nursing Officer (CNO), the ICU census (list of patients), dated 5/22 through 10/22 was reviewed. CNO stated, "The hospital is licensed for four ICU beds. We don't have enough ICU competent staff to maintain an open ICU. Out of the 44 nurses employed here, only three are competent to work ICU. If ICU were open for admissions and care, I would need ten ICU competent RNs to provide adequate staffing." CNO stated, three of the four patients (Patient 1, Patient 33, Patient 35) listed on the ICU census patients were in ICU for one day. CNO stated, one of four the patients (Patient 34) listed on the ICU census patients was in ICU for five days.

During a concurrent interview and observation on 11/8/22, at 9 AM, with the MS charge nurse (MSCN), the code team assignment for the day shift, dated 11/8/22, was reviewed. MSCN stated, all the RNs on the code team were ACLS certified. MSCN stated, if a code blue happened in psych today, after the code team left MS to respond, the remaining RN in MS was not ACLS qualified. MSCN stated, the MS unit had nine patients, two patients were on telemetry at the moment. MSCN stated, "There is no provision for RN scheduling to ensure the remaining RNs in MS are ACLS qualified if the code blue team leaves."


35645


During a review of the facility's policy and procedure (P&P) titled, "General Rules and Regulations-Intensive Care Unit," dated 7/24/19, the P&P indicated, "NURSING MANAGEMENT . . . 4. Adequate staff will be maintained by the hospital to competently run this unit on a 24-hour basis, seven days a week . . . "

During a review of the facility's policy and procedure (P&P) titled, "Staffing Acuity Team assignments," (undated), the P&P indicated, "Staffing Assignments: Staffing assignments are designed to match patient needs with the qualifications/competence of the staff to allow the assigned staff to function within their scope of practice."

Based on interview and record review, the hospital failed to follow their policy and procedure (P&P), titled "Physician Orders, Verbal, Telephone," to not use telephone orders for the medical doctor's (MD) convenience for three of 32 sampled patients (Patient 30, Patient 31, and Patient 32). This failure had the potential to result in miscommunication and medication errors for Patient 30, Patient 31, and Patient 32.

Findings:

During a concurrent interview and record review, on 11/9/22, at 11:14 AM, with Physician Scribe (PS), Patient 30's Electronic Medical Record (EMR) was reviewed. Patient 30's EMR indicated, the hospital admitted Patient 30 on 10/28/22 and discharged Patient 30 on 10/31/22. PS stated, "If the physician is the individual inputting the orders, the system will indicate this as 'CPOE' (Computerized Physician Order Entry)." PS stated, the only orders inputted by MD 1 for Patient 30 was on the day of discharge. PS stated, she knew MD 1 came to see Patient 30 daily because PS shared an office with MD 1. When asked if MD 1 gave phone or verbal orders to staff to input instead of inputting them himself, PS did not respond verbally but made the "zipping lip" (won't speak) gesture.

During an interview on 11/9/22, at 11:29 AM, with Registered Nurse (RN) 1, RN 1 stated, MD 1 saw his patients daily, and had already been in this morning to see them.

During an interview on 11/9/22, at 11:35 AM, with RN 2, RN 2 stated, MD 1 saw Patient 31 and Patient 32 that morning and put orders in for them.

During a concurrent interview and record review on 11/9/22, at 11:55 AM, with PS, Patient 31's EMR was reviewed. The EMR, dated 11/9/22, indicated, between 8:58 AM and 11:18 AM, the orders were "phone" orders. PS stated, if MD 1 inputted orders himself, the order would indicate "CPOE," instead of "phone" order.

During a concurrent interview and record review, on 11/9/22, at 11:55 AM, with PS, Patient 32's EMR was reviewed. PS stated, on 11/9/22, MD 1 put in "phone" orders. PS stated, MD 1 placed no CPOE orders for Patient 32 on 11/9/22.

During a review of the hospital's P&P, titled "Physician Orders, Verbal, Telephone," dated 12/31/21, the P&P indicated, "Verbal and telephone orders are allowed; however in an effort to reduce errors, the use of these types of orders is discouraged. . . It is the policy of this institution never to allow verbal or telephone orders for the purposes of medical staff practitioners' convenience only."

Based on interview and record review, the hospital failed to follow their policy and procedure (P&P) for medical doctors (MD) to sign verbal orders within 48 hours for three (Patient 4, Patient 26, and Patient 5) of 30 sampled patients. These failures had the potential to result in medication errors and adverse outcomes for Patient 4, Patient 26, and Patient 5.

Findings:

During a concurrent interview and record review on 11/8/22, at 3:38 PM, with Physician Scribe (PS), Patient 4's Electronic Medical Record (EMR) was reviewed. Patient 4's EMR indicated, on 9/29/22, at 11:14 AM, Medical Doctor (MD 2) placed a phone/verbal order for Ativan (sedative-promoting calm or inducing sleep)1 milligram (mg-unit of measure). PS stated, the physician had not signed the verbal order for Ativan within 48 hours.

During a concurrent interview and record review on 11/8/22, at 1:25 PM, with PS, Patient 26's EMR was reviewed. Patient 26's EMR indicated: on 10/4/22, at 8 PM, MD 3 placed a phone order for Colace (stool softener), 100 mg as needed, and Tylenol (pain and fever medication), 325 mg PO (By mouth) every four hours as needed. Patient 26's EMR indicated: on 10/4/22, at 10:29 PM, MD 2 placed a phone order for a potassium (an electrolyte) blood level. PS stated, "These phone orders did not have a timely signature by the physician. These phone orders are supposed to be signed by the ordering physician within 48 hours."

During a concurrent interview and record review on 11/8/22, at 3:40 PM, with PS, Patient 5's EMR was reviewed. Patient 5's EMR indicated, on 10/31/22, at 6:41 PM, MD 2 placed a telephone order for Ativan 2 mg to be given every four hours orally as needed; Gabapentin (medication used to treat epilepsy and nerve pain), 400 mg, orally as needed every six hours; Folic acid (treat or prevent anemia) 1 mg orally daily; Magnesium (an electrolyte) daily. PS stated the physician's telephone orders were not signed by the ordering physician. PS stated, "I know all phone orders are not signed."
Patient 5's EMR indicated on 11/1/22, at 7:16 AM, MD 3 gave a phone order of Fluconazole 50 mcg (mcg-unit of measure) nasal spray, one spray daily. PS stated, the physician had not signed the verbal order for Ativan within 48 hours. PS stated, "There's no physician's signature for these orders."
Patient 5's EMR indicated, on 11/1/22, at 10:25 AM, MD 2 placed a telephone order for Nicotine (for smoking cessation) 21 mg patch, one time. Patient 5's EMR indicated, on 11/3/22, at 10:36 AM, MD 2 placed a telephone order of Vistaril (medication for allergy, nausea, and vomiting), 50 mg orally. PS stated, "There's no MD signature for these physician's orders."

During a review of the hospital's policy and procedure (P & P), titled, "Physician Orders, Verbal, Telephone," dated 12/31/21, the P & P indicated, "POLICY Verbal and telephone orders are allowed, however in an effort to reduce errors, the use of these types of orders is discouraged . . . PROCEDURE . . . Physicians must sign all telephone orders within 48 hours."

Based on interview and record review, the hospital failed to follow their policy and procedure (P&P) titled "Covid-19 Staff Vaccinations Requirements" for non-vaccinated staff to wear N-95 respirator (provides high level of protection from particles and viruses) while in the hospital for one of sixteen unvaccinated staff (Housekeeper Supervisor [HS]). This failure resulted in HS wearing a surgical mask (a loose fitting mask worn over the nose, mouth, and chin) while in the hospital and the potential to spread COCID-19.

Findings:

During a concurrent interview and record review on 11/8/22, at 1 PM, with the Infection Control Manager (ICM), the list of hospital staff who refused the Covid 19 boosters was reviewed. ICM stated, "Many staff refused boosters after receiving the two vaccinations, 16 out of 85 staff. We [hospital] couldn't force them to take the boosters. We [infection control education staff] taught them about six foot spacing, hand washing and wearing a surgical mask while at work. If they were with a patient, to wear the N95 mask."

During an interview on 11/8/22, at 2 PM, with ICM and the Housekeeper Supervisor (HS), HS stated, "I am wearing a surgical mask. No one has told me to wear an N95 mask."

During a concurrent interview and record review on 11/8/22, at 2:30 PM, with the Infection Preventionist Coordinator (IPC), IPC reviewed the facility P&P titled, "Covid-19 Staff Vaccinations Requirements", dated 3/10/22. The P&P indicated, "All staff is required to be vaccinated and boosted unless otherwise exempt for medical or religious beliefs...Staff who are not vaccinated or booster eligible need to wear a N95 at all times while in the hospital." IPC stated, the P&P indicated, unvaccinated staff are to wear an N95 while in the hospital. IPC stated, we instruct staff to wear an N95 while caring for patients.