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Based on observation, interview, and record review, the facility failed to post a Notice of Patient Rights in an inpatient unit that included the current telephone number and address of the State Agency for patients to file a complaint.

This deficient practice had the potential for patients not to be provided with the contact information of the State Agency in the event a patient needed to file a complaint.

Findings:

During concurrent observation and interview on 4/2/2024 at 10:55 a.m. with the Assistant Director (AD 2) for Nursing Services, the following was observed: In the Cardiac Surgical Intensive Care Unit (a unit that provides the highest level of care for critical patients with heart surgery), there was a notice posted on the wall of the hallway regarding patient rights. The notice did not contain the current contact information of the State Agency for patients to contact to a file a complaint. The AD 2 dialed the phone number posted on the notice and stated number was no longer in service. AD 2 stated Patients and their representatives had the right to file a complaint and patients would not be able to contact the State Agency to file a complaint due to the incorrect contact information.

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibilities," dated 11/05/2020, the P&P indicated the following: Patient Rights ... File a complaint with the State Department of Public Health Services regardless of whether the patient use the hospital's grievance process ...



48186

Based on observation, interview and record review, the facility failed to obtain a physician's order (written instructions a physician has for a patient's treatment) for restraints (purposely limiting or obstructing the freedom of a person's bodily movement) in accordance with the facility's policy and procedure regarding restraints use, for one of 30 sampled patients (Patient 5), when Patient 5 had 4 bedrails up while in bed.

This deficient practice had the potential for the patient (Patient 5) to be unable to readily get out of bed or to have an accident while attempting to get out of bed.

Findings:

During a review of Patient 5's History and Physical (H&P, a physician's formal and complete assessment of the patient and the problem), the H&P indicated Patient 5 was admitted to the facility 3/18/2024 at 1:44 a.m. with a diagnosis of weakness.

During a concurrent observation and interview on 4/2/2024 at 2:38 p.m. with Registered Nurse 3 (RN 3), Patient 5 was observed in bed, laying on his (Patient 5's) back with 4 bedrails up. RN 3 stated that Patient 5 was restrained using bilateral soft wrist restraints (purposely limiting or obstructing the freedom of a person's bodily movement), but this was discontinued, and the patient (Patient 5) no longer requires the use of restraints. RN 3 said that the patient (Patient 5) should not have had all 4 bedrails up as this was considered a restraint.

During a record review on 4/2/2024 at 2:38 p.m., Patient 5's medical record was reviewed and indicated that Patient 5 did not have a physician's order (written instructions a physician has for a patient's treatment) for the use of restraints during the time of observation (4/2/2024). RN 3 stated that the use of restraints required a physician's order. RN 3 acknowledged that if the patient (Patient 5) had 4 bedrails up without an order, the patient could have an accident, while attempting to get out of bed.

During an interview on 4/2/2024 at 12:23 p.m. with Registered Nurse 2 (RN 2), RN 2 stated that the use of 4 bedrails is considered a restraint and that all restraints require a physician's order per policy.

During a review of the facility's policy and procedure (P&P) titled, "Restraints and Seclusion Use Policy: Clinical Manual/General Clinical," dated 4/3/2023, the P&P indicated the following: "Purpose: To provide a policy for the use of violent and non-violent restraints, and death in restraints. Policy: All patients have the right to be free from unnecessary restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. When the use of restraint is necessary, the least restrictive method must be used to ensure a patient's safety. The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner (LP) who is responsible for the care of the patient and authorized to order restraint or seclusion Ill. Definitions: A. Restraint: any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition ..."

During a review of the facility's policy and procedure (P&P) titled, "Falls Prevention Protocol and Interventions Policy: Clinical Manual/General Clinical," dated 12/30/2022, the P&P indicated the following: "Policy: Nurses will assess all patients for potential fall risk. This includes the initial admission and ongoing assessment ... III. Procedure: ... C. ...Three bed rails up at all times, Note: If four bed rails are required the Restraint and Seclusion policy will be implemented ..."




48186

Based on observation, 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 provide an assessment (systematic and continuous process of collecting, analyzing, and interpreting data to evaluate a patient's health) for one of 30 sampled patients (Patient 1), when Patient 1's blood pressure was not taken with vital signs (set of medical measurements [e.g. temperature, heart rate, blood pressure, oxygen status, respirations] that indicate the state of essential functions of the body) check in one of one sampled unit (Unit 1, pre-operative unit [a floor within a hospital where nursing care is provided prior to operative and invasive procedures]).

This deficient practice had the potential for medical care and interventions to be delayed resulting in patient harm for Patient 1. (Refer to A-0395)

2. The facility failed to ensure Registered Nurse (CN) 4 was competent in the hemodialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) emergency termination procedure (safe process of disconnecting a patient from the dialysis machine in case of an emergency) for one of 30 sampled patients (Patient 22)

This deficient practice had the potential to result in inadequate return of blood from the machine to the patient (Patient 22) causing harm or even death during hemodialysis treatment. (Refer to A-0397)


3. The facility failed to notify the physician regarding an increased respiratory rate of one of 30 sampled patients (Patient 1). The physician was not notified of abnormal vital signs (set of medical measurements [e.g. temperature, heart rate, blood pressure, oxygen status, respirations] that indicate the state of essential functions of the body) exhibited by Patient 1 in accordance with physician order (written instructions a physician has for a patient's treatment) and the facility's policy and procedure regarding Nursing scope of services that pertains to appropriate reporting of observed patient abnormalities.

This deficient practice had the potential for a delay in the provision of medical care and treatments provided to the patient (Patient 1) which may result in complications such as acute respiratory distress (a type of lung failure due to fluid build-up in the lungs and low blood oxygen levels). (Refer to A-0398)

4. The facility failed to notify the physician when one of 30 sampled patient's (Patient 1) heart rate was 50 beats per minute (bpm, Normal is 60 to 100 bpm) in accordance with the physician order and the facility's policy and procedure regarding Nursing scope of services that pertains to appropriate reporting of observed patient abnormalities.

This deficient practice had the potential for cardiac (heart) complications such as further decreased heart rate leading to cardiac arrest (when the heart stops beating), thus requiring additional medical interventions, treatment and/or care for Patient 1. (Refer to A-0398)

5. The facility failed to administer one of 30 sampled patient's (Patient 1) medication (Bumex, a diuretic [causing increased urination] medication) in a timely manner per Physician order and in accordance with the facility's policy and procedure regarding medication administration. This deficient practice had the potential for Patient 1 to have a worsening of health condition which may result in lengthened patient recovery time and prolonged hospitalization. (Refer to A-0398)

6. The facility failed to ensure one of one sampled registered nurse (RN 4) 4 followed the facility's policy and procedure (P&P) for putting on (donning) personal protective equipment (PPE, equipment worn to minimize exposure to illness, includes gown, gloves, mask, face shield.) while taking care of one of 30 sampled patients (Patient 17), who was on contact precaution (interventions taken to prevent transmission of infectious agents).

This deficient practice had the potential for the introduction of pathogens (a microorganisms such as bacteria or virus that can cause a disease process) from RN 4 not wearing proper personal protective equipment (PPE) and the potential for risk of transmission of microorganism to other patients in the same unit or hospital setting. (Refer to A-0398)

7. The facility failed to ensure that an assessment, reassessment of pain level including documentation of vital signs monitoring was completed for one of 30 sampled patients (Patient 21) in accordance with the facility's policy and procedure regarding assessment, reassessment, and vital signs monitoring.

This deficient practice had the potential to result in the delay of appropriate treatment or medical intervention for Patient 21 which may lead to serious complications or death. (Refer to A-0398)

8. The facility failed to ensure its Contract Dialysis Company (CDC or Company) followed county masking guidelines of wearing a face mask, over the nose and mouth, in patient care areas for one of 30 sampled patients (Patient 12).

This deficient practice had the potential for the spread of infections such as Covid-19 (coronavirus, a highly contagious respiratory disease that spreads through droplets released when an infected person coughs, sneezes, or talks) and creating an unsafe environment for Patient 12. (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 observation, interview and record review, the facility failed to provide an assessment (systematic and continuous process of collecting, analyzing, and interpreting data to evaluate a patient's health) for one of 30 sampled patients (Patient 1), when Patient 1's blood pressure was not taken with vital signs (set of medical measurements [e.g. temperature, heart rate, blood pressure, oxygen status, respirations] that indicate the state of essential functions of the body) check in one of one sampled unit (Unit 1, pre-operative unit [a floor within a hospital where nursing care is provided prior to operative and invasive procedures]).

This deficient practice had the potential for medical care and interventions to be delayed resulting in patient harm for Patient 1.

Findings:

During a concurrent observation and interview on 4/3/2024 at 10:40 a.m. with Charge Nurse 1 (CN 1), 7 bays (beds located in a room of a hospital) were observed in Unit 1 (pre-operative unit [a floor within a hospital where nursing care is provided prior to operative and invasive procedures]). CN 1 stated that when patients arrived on the unit (Unit 1), they (referring to patients) received an initial assessment (systematic and continuous process of collecting, analyzing, and interpreting data to evaluate a patient's health) that included vital signs (set of medical measurements [e.g. temperature, heart rate, blood pressure, oxygen status, respirations] that indicate the state of essential functions of the body). CN 1 further stated that vital signs should be completed in Unit 1 prior to a scheduled surgical procedure.

During a concurrent interview and record review on 4/3/2024 at 2:00 p.m. with the Accreditation Specialist 2 (AS 2), Patient 1's medical record was reviewed and AS 2 verified the following information: Patient 1 arrived to the pre-operative unit on 4/21/2022 at 5:20 a.m. and was admitted at 6:18 a.m. Patient 1 was in Unit 1 pre-operatively to receive a Mitral Valve replacement (a type of heart surgery to replace a part of the heart that allows blood to flow through the heart in the right direction). Patient 1's pre-operative vital signs on 4/21/2022 at 6:15 a.m. indicated a temperature (T) of 97 degrees Fahrenheit (F, a unit of measurement), and at 7:04 a.m. a respiratory rate (RR) of 18. The medical record titled, "strip report," dated 4/21/2022 at 7:05 a.m., indicated additional vital signs taken were a heart rate (HR) of 56 and an oxygen saturation (spO2, measures the amount of oxygen in the blood) 97%.

During a concurrent interview and record review on 4/3/2024 at 2:39 p.m. with the Accreditation Specialist 2 (AS 2) and the Executive Director, Office of Licensure, Accreditation & Regulation (EDOLAR), AS 2 and EDOLAR verified Patient 1's blood pressure was not included in the pre-operative vital signs. AS 2 said that a complete set of vital signs should have included a temperature, respiratory rate, heart rate, oxygen saturations and blood pressure. AS 2 stated that per policy, it was the responsibility of the Registered Nurse (RN) to ensure one complete set of vital signs was obtained while Patient 1 was in the pre-operative unit. AS 2 further stated that it was important to obtain vital signs to have a full assessment of the patient status to provide the appropriate care and interventions for the patient.

During a review of the facility's policy and procedure (P&P) titled, "Admission Protocol for Patients Admitted in the Pre-Operative Holding Area: OR (Operating Room, where surgical procedures are performed)/Anesthesia (a medical intervention that prevents patients from feeling pain during procedures such as surgery)," dated 10/25/2021, the P&P indicated the following: "Policy Statement: The role of the Perianesthesia Nurse (works with patient that are undergoing or recovering from anesthesia or sedation) in the preoperative holding area is to provide safe nursing care in accordance with the American Society of Anesthesiologist (ASA), American Society of PeriAnesthesia Nursing (AS PAN) Standards of Practice and Institutional and regulatory requirements ... Purpose: To promote a safe perianesthesia setting by providing guidelines for best practice for the care of the pre-operative patient ... Procedure: ...D. ... Assess and document vital signs on admission and as needed ..."

Based on observation, interview and record review, the facility failed to ensure Registered Nurse (CN) 4 was competent in the hemodialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) emergency termination procedure (safe process of disconnecting a patient from the dialysis machine in case of an emergency) for one of 30 sampled patients (Patient 22)

This deficient practice had the potential to result in inadequate return of blood from the machine to the patient (Patient 22) causing harm or even death during hemodialysis treatment.

Findings:

A review of Patient 22's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 3/18/2024, indicated Patient 22 was admitted for Respiratory Failure (a serious condition that makes it difficult to breathe on your own). Patient 22 also received Hemodialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) on 4/1/2024.

During an interview with Registered Nurse (CN) 4 on 4/2/2024 at 2 p.m., CN 4 stated that in the event that the Dialysis nurse become incapacitated, CN 4 will call for a rapid response team (RRT, a team of healthcare providers summoned to the patient's bedside when a patient demonstrates signs of imminent clinical deterioration) and call the dialysis center located in the facility's 6th floor. CN 4 was not able to verbalize how to turn off the dialysis machine in the event the dialysis nurse was incapacitated.

During a concurrent observation and interview on 4/2/2024 at 2:40 p.m. with the Manager of Dialysis for Contract Company (MDS) and the Facility Dialysis Director (Dir DS), both the MDS and the Dir DS confirmed there was a sign posted in each of the dialysis machines regarding instructions on how to shut off the Hemodialysis machine in case of an emergency. However, both the MDS and the Dir DS were not able to verbalize and confirm if non-dialysis nurses were provided with an in-service on how to safely disconnect a patient from the dialysis machine in case of an emergency.

During a concurrent interview and record review on 4/5/2024 at 9:15 a.m. with the MDs and the Dir DS, a copy of the facility's documentation of in-service regarding how to turn off the hemodialysis machine in case of an emergency provided for non-dialysis nurses, was requested. However, the facility was not able to provide evidence of any in-service provided to non-dialysis nurses regarding emergencies during hemodialysis. In addition, the Facility did not have a Policy and Procedure (P&P) regarding emergency termination of dialysis by a non-dialysis staff.

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

1.a. Notify the physician regarding an increased respiratory rate for one of 30 sampled patients (Patient 1). The physician was not notified of abnormal vital signs (set of medical measurements [e.g. temperature, heart rate, blood pressure, oxygen status, respirations] that indicate the state of essential functions of the body) exhibited by Patient 1 in accordance with physician order (written instructions a physician has for a patient's treatment) and the facility's policy and procedure regarding Nursing scope of services that pertains to appropriate reporting of observed patient abnormalities.

This deficient practice had the potential for a delay in the provision of medical care and treatments provided to the patient (Patient 1) which may result in complications such as acute respiratory distress (a type of lung failure due to fluid build-up in the lungs and low blood oxygen levels).

1.b. Notify the physician when one of 30 sampled patient's (Patient 1) heart rate was 50 beats per minute (bpm, Normal is 60 to 100 bpm), in accordance with the physician order and the facility's policy and procedure regarding Nursing scope of services that pertains to appropriate reporting of observed patient abnormalities.

This deficient practice had the potential for cardiac (heart) complications such as further decreased heart rate leading to cardiac arrest (when the heart stops beating), thus requiring additional medical interventions, treatment and/or care for Patient 1.

2. Administer one of 30 sampled patient's (Patient 1) medication (Bumex, a diuretic [causing increased urination] medication) in a timely manner per Physician order and in accordance with the facility's policy and procedure regarding medication administration. This deficient practice had the potential for Patient 1 to have a worsening of health condition which may result in lengthened patient recovery time and prolonged hospitalization.

3. Ensure one of one sampled registered nurse (RN 4) 4 followed the facility's policy and procedure (P&P) for putting on (donning) personal protective equipment (PPE, equipment worn to minimize exposure to illness, includes gown, gloves, mask, face shield.) while taking care of one of 30 sampled patients (Patient 17), who was on contact precaution (interventions taken to prevent transmission of infectious agents).

This deficient practice had the potential for the introduction of pathogens (a microorganisms such as bacteria or virus that can cause a disease process) from RN 4 not wearing proper personal protective equipment (PPE) and the potential for risk of transmission of microorganism to other patients in the same unit or hospital setting.

4. Ensure that an assessment, reassessment of pain level including documentation of vital signs monitoring was completed for one of 30 sampled patients (Patient 21) in accordance with the facility's policy and procedure regarding assessment, reassessment, and vital signs monitoring.

This deficient practice had the potential to result in the delay of appropriate treatment or medical intervention for Patient 21 which may lead to serious complications or death.

5. Ensure its Contract Dialysis Company (CDC or Company) followed county masking guidelines of wearing a face mask, over the nose and mouth, in patient care areas for one of 30 sampled patients (Patient 12).

This deficient practice had the potential for the spread of infections such as Covid-19 (coronavirus, a highly contagious respiratory disease that spreads through droplets released when an infected person coughs, sneezes, or talks) and creating an unsafe environment for Patient 12.

Findings:

1.a. During a review of Patient 1's medical record titled "Face Sheet (a document that gives a patient's information at a quick glance)," the Face Sheet indicated Patient 1 was admitted to the facility on 5/8/2022 at 12:57 a.m. with diagnoses of shortness of breath (unable to breath normally) and hyperkalemia (too much potassium in the blood).

During a concurrent interview and record review on 4/4/2024 at 2:19 p.m. with Nurse Professional Development Practitioner 1 (NPD 1), Patient 1's medical record titled "Vital Signs (set of medical measurements [e.g. temperature, heart rate, blood pressure, oxygen status, respirations] that indicate the state of essential functions of the body)," dated 5/18/2022, was reviewed. The vital signs indicated the following: at 7:51 a.m., the respiratory rate was 31; at 11:00 a.m. the respiratory rate was 38; and at 11:09 a.m., the respiratory rate was 39. NPD 1 verified there was a physician order, dated 5/8/2022 at 5:18am, for nursing staff to notify the physician if the respiratory rate was greater than 30.

NPD 1 confirmed there was no notification to the physician by nursing staff per the physician order (written instructions a physician has for a patient's treatment). NPD 1 further confirmed per the nursing progress note that the physician was not notified until 5/18/2022 at 11:25 a.m. The nursing progress note indicated: "[Physician] rounding. Discussed plan of care. Pending BiPap delivery to room for patients work of breathing." NPD 1 verified, there was no documentation in the medical record to notify the physician of Patient 1's increased respiratory rate on 5/18/2022 at 7:51 a.m. until 5/18/2022 at 11:25 a.m.

During an interview on 4/4/2024 at 11:15a.m. with the Assistant Nurse Manager 1 (ANM 1) and Assistant Nurse Manager 2 (ANM 2), ANM 2 stated the following: The physician should be notified per the parameters indicated in the physician order. Per policy, the physician orders are what Registered Nursing (RN) staff follow when determining when to notify the physician. ANM 1 said the following: when to notify the physician is based off the assessment of the nurse. If there are out of range vital signs, the Registered Nurse should notify the physician immediately, per the physician order. ANM 1 stated that when the physician is notified of vital signs, per the physician order, this should be documented in the patient's medical record. ANM 1 and ANM 2 acknowledged that if the physician is not notified of vital signs timely, the patient can decompensate (functional deterioration of a structure or system that had been previously working).

During a review of the facility's policy and procedure (P&P) titled, "Nursing Service Department Scope of Service," dated 3/13/2024, the P&P indicated the following: "Nursing Mission: ...committed to leadership and excellence in the delivery of quality, compassionate, value-added, person-centered health care services ... Scope of Service Provided: ... Service is provided within the scope as defined by the California Nurse Practice Act (Section 2723 of the Business and Professions Code): "The practice of nursing means those functions, including basic health care, which help people cope with difficulties in daily living which are associated with their actual or potential health or illness problems or the treatment thereof which require a substantial amount of scientific knowledge or technical skill" and includes: ... Direct and indirect patient care services, including, but not limited to, the administrations of medication and therapeutic agents, necessary to implement a treatment, disease prevention, or rehabilitative regimen ordered by and within the scope of licensure of a physician, dentist, podiatrist, or clinical psychologist as defined by Section 1316.5 of the California Health and Safety Code ..."

A review of the California Nurse Practice Act (The body of California law that mandates the Board to set out the scope of practice and responsibilities for RNs) (Section 2723 of the Business and Professions Code) indicated the following: " ... (4) Observation of signs and symptoms of illness, reactions to treatment, general behavior, or general physical condition, and (A) determination of whether the signs, symptoms, reactions, behavior, or general appearance exhibit abnormal characteristics, and (B) implementation, based on observed abnormalities, of appropriate reporting, or referral, or standardized procedures, or changes in treatment regimen in accordance with standardized procedures, or the initiation of emergency procedures ..."

1.b. During a review of Patient 1's medical record titled, "Face Sheet (a document that gives a patient's information at a quick glance)," the Face Sheet indicated Patient 1 was admitted to the facility on 4/21/2022 at 5:27 a.m. with a diagnosis of mitral valve insufficiency (a heart condition where the heart valve flaps don't close tightly, causing blood to move backward when the valve is closed).

During a concurrent interview and record review on 4/4/2024 at 2:19 p.m. with Nurse Professional Development Practitioner 1 (NPD 1), Patient 1's medical record titled "vital signs (set of medical measurements [e.g. temperature, heart rate, blood pressure, oxygen status, respirations] that indicate the state of essential functions of the body)," dated 4/29/2024, indicated: At 4:00 p.m. Patient 1's heart rate was 50. NPD 1 confirmed there was no notification to the physician by nursing staff per the physician order. NPD verified the physician order, dated 4/21/2022 at 11:25 a.m., indicated to notify the physician for heart rate less than 55. Patient 1's physician order, dated 4/29/2022 at 6:47 p.m., indicated an order to discharge to home. Patient 1 was discharged from the facility on 4/29/2022 at 6:47 p.m.

During an interview on 4/4/2024 at 11:15 a.m. with Assistant Nurse Manager 1 (ANM 1) and Assistant Nurse Manager 2 (ANM 2), ANM 2 stated the following: The physician should be notified per the parameters indicated in the physician order. Per policy, the physician orders are what Registered Nursing (RN) staff follow when determining when to notify the physician. ANM 1 said the following: when to notify the physician is based off the assessment of the RN. If there are out of range vital signs, the Registered Nurse should notify the physician immediately, per the physician order. ANM 1 stated that when the physician is notified of vital signs, per the physician order, this should be documented in the patient's medical record. ANM 1 and ANM 2 acknowledged that if the physician is not notified of vital signs timely, the patient can decompensate (functional deterioration of a structure or system that had been previously working).

During a review of the facility's policy and procedure (P&P) titled, "Nursing Service Department Scope of Service," dated 3/13/2024, the P&P indicated the following: "Nursing Mission: ...committed to leadership and excellence in the delivery of quality, compassionate, value-added, person-centered health care services ... Scope of Service Provided: ... Service is provided within the scope as defined by the California Nurse Practice Act (Section 2723 of the Business and Professions Code): "The practice of nursing means those functions, including basic health care, which help people cope with difficulties in daily living which are associated with their actual or potential health or illness problems or the treatment thereof which require a substantial amount of scientific knowledge or technical skill" and includes: ... Direct and indirect patient care services, including, but not limited to, the administrations of medication and therapeutic agents, necessary to implement a treatment, disease prevention, or rehabilitative regimen ordered by and within the scope of licensure of a physician, dentist, podiatrist, or clinical psychologist as defined by Section 1316.5 of the California Health and Safety Code ..."

A review of the California Nurse Practice Act (The body of California law that mandates the Board to set out the scope of practice and responsibilities for RNs) (Section 2723 of the Business and Professions Code) indicated the following: " ... (4) Observation of signs and symptoms of illness, reactions to treatment, general behavior, or general physical condition, and (A) determination of whether the signs, symptoms, reactions, behavior, or general appearance exhibit abnormal characteristics, and (B) implementation, based on observed abnormalities, of appropriate reporting, or referral, or standardized procedures, or changes in treatment regimen in accordance with standardized procedures, or the initiation of emergency procedures ..."

2. During a review of Patient 1's medical record titled "Face Sheet (a document that gives a patient's information at a quick glance)," the Face Sheet indicated Patient 1 was admitted to the facility on 5/8/2022 at 12:57 a.m. with diagnoses of shortness of breath (unable to breath normally) and hyperkalemia (too much potassium in the blood).

During a concurrent interview and record review on 4/4/2024 at 2:19 p.m. with Nurse Professional Development Practitioner 1 (NPD 1), Patient 1's medical record was reviewed and indicated a physician order (written instructions a physician has for a patient's treatment) for bumetanide (Bumex, a diuretic [causing increased urination] medication) 2 milligrams (mg, a unit of measurement) injection, intravenous (IV) push (a medication or fluid substance delivered directly into the bloodstream quickly) to start 5/18/2022 at 10:00 a.m. NPD verified the medication was given on 5/19/2022 at 1:19 p.m.

During an interview on 4/4/2024 at 11:15 a.m. with Assistant Nurse Manager 1 (ANM 1) and Assistant Nurse Manager 2 (ANM 2), ANM 1 and ANM 2, stated the following: Per policy, Registered Nurses (RNs) have one hour before and one hour after a medication is due, to administer the medication to the patient. It is important to give medications timely to ensure patients get the care required for their diagnosis. If a medication is not given on time, there is a delay in patient care and treatment provided and this can negatively affect the patient.

During a review of the facility's policy and procedure (P&P) titled, " Medication Administration and Documentation, Procedure: Medication Management," dated 2/8/2024, the P&P indicated the following: "Policy: ...medications are safely administered ... E. Prior to medication ... 2. Prior to the medication administration, the individual administering the medication does the following: a. verifies: ... Medication is being administered at the proper time ..."

3. During a review of Patient 17's History and Physical (H&P, a formal and complete assessment of the patient and the problem), the H&P indicated that Patient 17 was admitted on 3/19/2024 due to a mechanical trip (an external force or object caused the fall) and fall (an unplanned descent to the floor with or without injury) at home. The H&P also indicated that Patient 17 tested positive for Extended-spectrum beta-lactamases (ESBL, a bacteria that cannot be killed by many of the antibiotics that doctors use to treat infections) therefore Patient 17 required contact isolation (interventions that are implemented before going into a patient's room and after leaving a patient's room to stop germs from spreading to others).

During a concurrent observation and interview on 4/4/2024 at 11:15 a.m. in 8 North East (medical surgical unit, a unit that serves the general population hospitalized for various causes such as surgery, testing observation, etc.) with Registered Nurse (RN) 4, RN 4 stated all Personal Protective Equipment (PPE, equipment worn to minimize exposure to illness, includes gown, gloves, mask, face shield.) must be worn and removed when entering and/or leaving a contact isolation room. RN 4 stated that she (RN 4) was in a hurry when entering the room to check if the patient (Patient 17) had four side rails up while lying in bed. RN 4 did not wear appropriate PPE when she (RN 4) entered Patient 17's room.

During an interview with the accreditation specialist (AS 2), who was present and witnessed the time RN 4 entered the room without PPE, AS 2 stated that RN 4 should have never entered that contact isolation room (Patient 17's room) without proper protective gear. AS 2 said the expectation is for the staff to remember to wear their PPE prior to entering an isolation room regardless of whether this person is in a rush or not.

During a review of the facility's policy and procedure (P&P) titled, " Isolation, Standard Precautions Policy: Epidemiology/Infection Prevention," dated 1/17/2024, the P&P indicated, " Standard Precautions are used for all patient care activities to protect healthcare personnel (HCP) from infection and to prevent the spread of infection from patient to patient. All healthcare personnel, including medical staff, will routinely use personal protective equipment (PPE)." The P&P also indicated to wear a gown, apron, or other PPE attire, that is appropriate to the task, to protect skin and prevent soiling of clothing during procedures and other patient-care activities when contact with blood, body fluids, secretions, or excretions is anticipated.

4. During a review of Patient 21's facility document titled "patient care timeline," dated 3/31/2024, the document indicated the following:

On 3/31/2024 at 8:40 p.m., Patient 21 arrived at the emergency department (ED, responsible for the provision of medical care to patients arriving at the hospital in need of immediate care) with complaints of chest pain and shortness of breath.

At 8:46 p.m., Patient 21's Vital signs (set of medical measurements [e.g. temperature, heart rate, blood pressure, oxygen status, respirations] that indicate the state of essential functions of the body) were: temperature 98.3 degrees Fahrenheit (F), heart rate 71 (Normal), respiratory rate 18 (Normal), blood pressure 135/62, Oxygen saturation (measures the amount of oxygen in the blood) 98% on room air; No documentation if Patient 21 was having chest pain or if assessed to be having chest pain

At 8:50 p.m., Patient 21 was determined to have an emergency severity index 2 (ESI 2, a prioritization tool used in the Emergency Department to classify patients from most urgent to least urgent. ESI 2 indicates high risk situation).

At 9:10 p.m., Patient 21 was placed on cardiac monitoring (device used to record the electrical activity of the heart)

At 9:27 p.m., Patient 21 was administered Toradol (Ketorolac, used for short-term treatment of moderate to severe pain in adults) 15 milligrams (mg, a unit of measurement)Intravenous (through the vein). No baseline pain scale was documented prior to Toradol administration.

At 9:30 p.m., Patient 21 had a documented pain level of 7 (Pain scale is 0- 10 with 10 as severe). No documented pain re-assessment after 1 hour of Toradol administration. No vital signs documented as well.

At 10:38 p.m., Patient 21 was given Morphine (medication prescribed for severe pain) 4 mg IVP (intravenous push, administered through the vein)

At 11:16 p.m., Patient 21's Pain Assessment included:
Sedation Level: slightly drowsy easily arousable
Pain location: Chest
Pain interventions: Medication; Rest
Pain rating: 3 (Pain Scale 1 to 10).
Pain quality: discomfort.
Pain onset: Gradual
Pain Duration: Continuous
Another pain site: No

At 11:28 p.m., Patient 21 was admitted as inpatient

During a concurrent interview and record review on 4/4/2024 at 4:30 p.m. with the Accreditation Specialist(AS2) and the Associate Director of the Emergency Department (AD3), Patient 21's medical record was reviewed. Both AS2 and AD3 confirmed that there were no succeeding vital signs recorded for patient 21 after the initial vital signs taken on 3/31/2024 at 8:40 p.m. until 4/1/2024 at 12:50 a.m. AD3 stated that since Patient 21 had an ESI level of 2, vital signs should have been reassessed every 2 hours and documented. AD3 also said that there was no medical screening examination documented by the physician. In addition, AD3 confirmed there was no pain assessment documented prior to and after pain medication administration. AD3 stated that pain assessment should have been done and documented within an hour after Toradol administration. AD3 said that vital signs should have been checked along with pain assessment.

A review of Patient 21's facility document titled, "Patient Care Timeline," dated 4/1/2024, indicated the following:

On 4/1/2024, a transthoracic echocardiogram (a test that uses ultrasound [sound waves] to create images of the heart) was ordered at 7:19 a.m. and was completed at 10:45 a.m.
At 10:52 a.m., the transthoracic echocardiogram preliminary result was communicated to MD in ED
At 11:00 a.m., Patient 21 complained of chest pain of 8 (out of the pain scale of 0-10); Nitroglycerin (medication used to treat Chest pain) Infusion was started
At 11:11 a.m., Patient 21 was evaluated by the Cardiothoracic surgery team (a team that specializes in surgery of the heart)

A review of Patient 21's facility document titled, "transthoracic echocardiogram report" study, dated 4/1/2024 indicated Patient 21 had Aortic dissection from the Aorta root to the abdominal Aorta and very severe aortic valve regurgitation (blood flowing back into the aorta).


A review of Patient 21's Medical Record titled, "Operating report," dated 4/1/2024 indicated, Patient 21 was emergently transferred to the OR (Operating Room, where surgical procedures are performed) for Emergency repair of Aortic Dissection (a serious condition in which a tear occurs in the inner layer of the body's main artery [a blood vessels that carries oxygenated blood to other parts of the body]) at 12:40 p.m. on 4/1/2024.

A review of a Facility Document titled "Documentation patient care process in the emergency department" dated 10/12/2023 indicated Patient "reassessment is done based on prioritization of the change in condition, interventions, and treatment provided and pain management, the patient reports pain, and response to intervention will be documented using the one to ten scale" and "assessment after pain interventions will be documented within 60 minutes of the intervention... insufficient pain relief and or adverse effects are documented and reported to the physician immediately... vital signs are monitored ..."

5. During a review of Patient 12's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 3/23/2024 at 11:47 p.m., the H&P indicated the following: Patient 1 was admitted from an outside hospital for alcoholic cirrhosis of liver (alcohol-related scarring of the liver) with ascites (buildup of fluid in the abdomen) and acute kidney failure (a rapid decline in kidney function).

During an observation on 4/2/2024 at 2:41 p.m., in the Dialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) Unit, the following was observed: Patient 12 was undergoing hemodialysis (a treatment to filter waste and water from the blood) in the Unit. The Biomedical Technician (BMT) was observed near Patient 12 in the patient care area. The BMT wore a facemask that was positioned under BMT's nose. BMT repositioned the face mask to cover the nose and mouth. Then, BMT sat down in the nurse's station in the Dialysis Unit and started talking on the cellular phone with the face mask under his nose.

During an interview on 4/2/2024 at 2:41 p.m., with the Clinical Nurse Manager for the Contracted Dialysis Service (CNMCDS), CNMCDS stated hemodialysis was provided to hospitalized patients by a Contracted Dialysis Service (CDS) in the Dialysis Unit or at the bedside.

During an interview on 4/2/2024 at 2:55 p.m., the BMT stated he (BMT) placed the mask under his nose because he was talking on the phone and declined to answer any further questions.

During an interview on 4/2/2024 at 2:56 p.m., the CNMCDS stated that all staff in patient care areas were required to wear a facemask, covering the bridge of the nose and mouth, to protect oneself and patients from the potential spread of Covid-19.

During an interview, on 4/2/2024 at 3:22 p.m., the Executive Director of the Office for Licensing, Accreditation, and Regulatory (EDOLAR) stated the facility followed current county guidelines, and face masks were required in patient care areas to prevent the potential spread of infections.

During a review of the facility's policy and procedure titled, "Isolation, Standard Precautions Policy: Epidemiology / Infection Prevention," dated 1/17/2024, the P&P indicated the following: Standard precautions is a system of infection control which assumes all blood, body fluids, secretions and excretions from all patients are a potentially infectious. Standard precautions are applied to prevent health care personnel occupational exposures from all patients and from contaminated medical equipment ...Assume that every person is potentially infected or colonized with an organism that could be transmitted in the healthcare setting and apply the following infection control practices during delivery of health care ...Universal Pandemic Precautions (UPP) ...Because COVID-19 can be transmitted from patients who do not have symptoms ...Face mask must be worn at all times ...

During a review of a document titled, "Masking Guidelines Relaxed," dated 3/12/2024, the document indicated the following: With Covid-19 cases continuing to decline ...the Hospital is relaxing some of its masking requirements. These new standards ...follow recent county guidance while ensuring we continue to protect our most vulnerable patients from healthcare workers who may potentially be infected with COVID-19, flu, or RSV (Respiratory Syncytial Virus, a respiratory virus that affects the lungs and breathing passages). The following guidelines are now in effect ... All Hospital team members ... well-fitted mask will be required in all areas where patients are provided care.

During a review of a service agreement between the Hospital and the Contracted Dialysis Company (CDC or Company) titled, "Hospital Services Agreement," dated 3/1/2022, the service agreement indicated "All Company Staff shall comply with the policies and procedures of the Hospital in effect of the date hereof that relate to the provision of the Services, to the extent not inconsistent with applicable laws or regulations, the express terms of this Agreement, and/or Company's own policies and procedures ..."