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Based on interview and record review, the facility failed to ensure the facility's policies and procedures (P&P) were implemented, for six of 46 sample patients (Patients 11, 18, 20, 27, 29 and 43), when the consent to surgery or special procedures were not completed by the physician/s.

These failures had the potential to cause a delay in Patients 11, 18, 20, 27, 29 and 43's surgical procedures, and may cause harm for the patients.

Findings:

1. On December 3, 2024, at 8:30 a.m., a review of Patient 11's record was conducted with Quality Coordinator (QC ) 1. A facility document titled, "History and Physical," dated September 20, 2024, indicated Patient 11 was admitted to the facility on September 20, 2024, for Sepsis (life-threatening medical emergency, bodies overreacts to an infection).

A facility document titled, "Consent to Surgery or Special Procedure" dated October 31, 2024, was reviewed and indicated, "...your doctors have recommended the following operation or procedure: Exploratory laparotomy [a surgical incision (cut) into the abdominal cavity] possible bowel resection possible ostomy...Physician Certification...I, the undersigned physician, hereby certify that I have discussed the procedure described in this consent form with this patient...including...the risks and benefits of the procedure...any adverse reactions...any alternative methods...The potential problems...any research...Physician signature...date...time..."

A facility document titled, "Clinical Note" dated October 31, 2024, was reviewed and indicated, "...plan for emergent exploratory laparotomy possible bowel resection possible ostomy...risks, benefits and alternatives discussed...all questions answered and informed consent was obtained..."

On December 3, 2024, at 8:45 a.m., an interview was conducted with QC 1. The QC 1 stated if the physician does not sign the consent form, they need to include the risks and benefits of the procedure, any adverse reactions, any alternative methods, any potential problems, and any research. The QC 1 stated the documentation in the doctor's note was not completed with all the requirements and the informed consent was incomplete.

2. On December 2, 2024, at 11:06 a.m., a concurrent record review and interview for Patient 18 were conducted with the Critical Care Manager (CCM). A facility document titled, "Consent to Surgery or Special Procedure" dated December 1, 2024, was reviewed and indicated, "...your doctors have recommended the following operation or procedure: Percutaneous tracheostomy [a surgical procedure that creates an opening in the neck for breathing]...Physician Certification...I, the undersigned physician, hereby certify that I have discussed the procedure described in this consent form with this patient...including...the risks and benefits of the procedure...any adverse reactions...any alternative methods...The potential problems...any research...Physician signature...date...time..." The CCM stated the consent should have been signed by the surgeon before the procedure.

On December 3, 2024, at 2:15 p.m., a review of patient 18's record was conducted with QC 1. A facility document titled, "History and Physical," dated November 20, 2024, indicated Patient 18 was admitted to the facility on November 20, 2024, for Nontraumatic subarachnoid hemorrhage (brain bleed that occurs without head trauma).

A facility document titled, "General Surgery Progress Note" dated December 1, 2024, was reviewed and indicated, "...Plan for percutaneous trach today 12/1 [December 1, 2024]...risks, benefits and alternatives discussed...all questions answered...informed consent obtained..."

On December 3, 2024, at 2:15 p.m., an interview was conducted with QC 1. The QC 1 stated if the physician does not sign the consent form, they need to include the risks and benefits of the procedure, any adverse reactions, any alternative methods, any potential problems, any research. The QC 1 stated the documentation in the doctor's note was not completed with all the requirements and the informed consent was incomplete.

3. On December 4, 2024, at 9:23 a.m., a review of patient 20's record was conducted with Quality Coordinator (QC ) 2. A facility document titled, "History and Physical," dated November 25, 2024, indicated Patient 20 was admitted to the facility on November 25, 2024, for cough and confusion.

A facility document titled, "Consent to Surgery or Special Procedure" dated November 26, 2024, was reviewed and indicated, "...your doctors have recommended the following operation or procedure: Lumbar puncture [a medical procedure that involves inserting a needle into the spine]...Physician Certification...I, the undersigned physician, hereby certify that I have discussed the procedure described in this consent form with this patient...including...the risks and benefits of the procedure...any adverse reactions...any alternative methods...The potential problems...any research...Physician signature...date...time..."

A facility document titled, "Bedside Procedure Note" dated November 26, 2024, was reviewed and indicated, "...start date...11/26/24 [November 26, 2024]...after obtaining informed consent..."

On December 4, 2024, at 9:29 a.m., an interview was conducted with Patient Safety Director (PSD). The PSD stated the bed side procedure note does not have the required information for the informed consent. The PSD further stated the informed consent is incomplete.

4. On December 3, 2024, at 10:19 a.m., a review of Patient 27's record was conducted with PSD. A facility document titled, "Progress Note," dated November 12, 2024, indicated, "...[Patient 27]...with right sacroiliac joint [the connection between the spine and the pelvis] instability...discussed treatment with a right sacroiliac joint instrumented stabilization and fusion..."

A facility document titled, "Consent to Surgery or Special Procedure" dated December 2, 2024, was reviewed and indicated, "...your doctors have recommended the following operation or procedure: Right Sacroiliac Joint Instrumented stabilization and fusion...Physician Certification...I, the undersigned physician, hereby certify that I have discussed the procedure described in this consent form with this patient...including...the risks and benefits of the procedure...any adverse reactions...any alternative methods...The potential problems...any research...Physician signature...date...time..." There was no documented evidence the consent was signed by the physician performing the procedure.

5. On December 3, 2024, at 10:28 a.m., a review of Patient 29's record was conducted with PSD. A facility document titled, "History of Present Illness", dated December 2, 2024, indicated, Patient 29 was admitted on December 2,2024 for acute onset right lower quadrant abdominal pain.

A facility document titled, "Consent to Surgery or Special Procedure" dated December 2, 2024, was reviewed and indicated, "...your doctors have recommended the following operation or procedure: Diagnostic Laparoscopy [a surgical procedure used to examine the organs in the belly (abdomen)], possible bowel resection, possible exploratory laparotomy...Physician Certification...I, the undersigned physician, hereby certify that I have discussed the procedure described in this consent form with this patient...including...the risks and benefits of the procedure...any adverse reactions...any alternative methods...The potential problems...any research...Physician signature...date...time..." There was no documented evidence the consent was signed by the physician performing the procedure.

An interview was conducted on December 3, 2024, at 2:56 p.m., with the PSD. The PSD stated there was no documented evidence informed consent was obtained by the physician performing the procedure for Patient's 27, and 29 prior to the procedurs.

6. On December 3, 2024, at 12:59 p.m., Patient 43's record was reviewed with the Quality Manager (QM). The facility document titled, "History and Physical" dated November 6, 2024, was reviewed, and indicated Patient 43 was admitted to the facility for Atrial fibrillation with rapid ventricular response (a type of irregular heart rhythm) on November 6, 2024.

A facility document titled, "Pulmonary Critical Care Note," dated November 7, 2024, authored by MD 1, was reviewed with the QM. The document indicated, Patient 43 would need an IVC (inferior vena cava-A large vein that empties into the heart) filter (a small metal device that prevents blood clots from traveling from the legs to the lungs or heart) placement.

A facility document titled, "Cardiology Progress Note," dated November 10, 2024, authored by MD 3, was reviewed with the QM. The document indicated, IVC filter pending with no documentation showing discussion of risks and benefits, alternative treatments, or nature of the procedure/operation, or treatment for the pending procedure.

A facility document titled, "Consent to Surgery or Special Procedure" dated November 10, 2024, at 5:43 p.m., was reviewed. The document indicated a signature by Patient 43, and a witness signature. No signature of physician certification was documented indicating, "...risks and benefits of the procedure...adverse reactions that may reasonably be expected to occur ...alternative efficacious [effective] methods of treatment...potential problems that may occur..." were discussed with Patient 43.

A facility document titled, "Cardiac Cath Report", dated November 12, 2024, authored by MD 3, indicated, "...Successful IVC filter placement..."

On December 3, 2024, at 2:15 p.m., a concurrent interview and record review with the QM was conducted. The QM stated, "consent should have been obtained by the physician prior to the procedure...It should have been done and documented..."

A facility P&P titled, "Consent for Procedures," dated October 2022, was reviewed. The document indicated, "A valid consent will be completed prior to any complex procedure or surgery...The informed consent process is the responsibility of the individual performing the procedure...the licensed independent practitioner is responsible for providing the patient ...with the information that is necessary to allow an "informed decision" to be made. The topics that must be addressed, at a minimum are...The nature of the operation or procedure, including other care, treatment or medications ...Potential benefits, risks or side effects of the operation or procedure, including potential problems that might occur...Reasonable alternatives and the relevant risks, benefits, and side effects related to such alternatives..."

Based on interview and record review, the facility failed to provide care in a safe environment, for one (Patient 1) of 46 sampled patients, when the Patient Safety Attendant (PSA) left Patient 1 unsupervised while Patient 1 was on a one to one (1:1) sitter.

This failure led to Patient 1 getting out of restraints and pulling out their IV (Intravenous, with in the vein), and had the potential to lead to Patient 1 harming himself or others.

Findings:

On December 2, 2024, an unannounced complaint validation survey was conducted at the facility.

On December 3, 2024, at 8:35 a.m., a review of Patient 1's record was conducted with Quality Coordinator (QC) 2.

The facility document titled, "Psychiatric Consultation Note" dated October 26, 2024, at 11:40 a.m., indicated, "Reason for consult: Concern for altered mental status/catatonia [a disorder that disrupts a person's awareness of the world around them. People with this condition sometimes react very little or not at all to their surroundings, or might behave in ways that are unusual, unexpected or unsafe to themselves or others.]...On evaluation, the patient was resting in bed with his eyes open; however, he was staring ahead with a blank expression on his face and was nonverbal and unable to be engaged...the patient's mother was present at his bedside and volunteered information...Assessment and Plan...Diagnosis: Altered mental status, likely secondary to catatonia; and/or delirium [a mental state of confusion and disorientation that can develop suddenly over hours or days]...Please note that a 1:1 sitter, group sitter, or virtual sitter may remain indicated in the setting of concern for altered mental status...at this time, there is inadequate evidence to substantiate that the patient meets the criteria for a 5150 involuntary psychiatric hold..."

The facility document titled, "Hospitalist History & [and] Physical" dated October 26, 2024, at 4:13 p.m., indicated, "...presents to ED [Emergency Department] for behavioral crisis episode...On evaluation, pt [patient] had flat affect while mom and grandma in the room...Once family left, patient able to answer questions...admitted he ate some mushrooms for the first time and symptoms began since then...appears catatonic...psych consulted, recs [recommendations] 1:1 [one to one] sitter or virtual sitter may remain indicated in setting of concern for AMS [altered mental status]..."

The facility document titled, "Order History Data" dated October 28, 2024, indicated, "...Order...Sitter...Sitter-Suicidal...Order Date Time...October 28, 2024, 10:04 [a.m.]..."

An untitled facility document dated October 28, 2024, at 1:33 p.m., indicated, "...Multidisciplinary Team Notes...NN [nurses note]...Patient became erratic and combative. Began screaming, jumped out of bed, pulled out IV. Came outside of the room in hall. Patient body slammed his fiancé. Patient screaming and hit staff members. Code grey [a hospital announcement for a violent patient] called...4-point restraints [straps used to limit a patient's movement] applied on patient...MD [Medical Doctor] informed. Management came to bedside. Received orders for patient to transfer to ICU [Intensive Care Unit]..."

An untitled facility document dated October 28, 2024, at 11 p.m., indicated, "...Multidisciplinary Team Notes...NN [nurses note]...@ [at] 2235 [10:35 p.m.] during MD rounds, pt mother called notified RN [Registered Nurse] and MD regarding patient breaking BUE [bilateral upper extremity] wrist restraints. RN, multiple staff, and MD enter the room to find patient breaking out of restraints...standing on top of hospital bed. Code grey activated. Pt then aggressively demands staff to go to one side of room. MD attempted to deescalate [calm a situation] situation with patient...patient then jumps out of bed. Pt runs towards window and hits shoulder on window. Staff wraps patient to deescalate. Pt then brought to bed and restrained. New IV started per MD at bedside...Pt family at bedside and updated by MD. Pt in hospital bed...sitter at bedside..."

The facility document titled, "Pulmonary Critical Care Note" dated October 29, 2024, at 2:08 a.m., indicated, "...During the evening rounds, I was called by nursing staff and the patient's mother calling for help, given that [patient], was standing on the bed, ripping off his IV lines and yelling at the nursing staff. As we tried to get some how closer to him to calm him down, he kept screaming "back away" in a threatening way. As we were backing off from the bed where he was standing on, he jumped from the bed and went to the back of the room where the windows are. During this time security was called...In 2 [two] attempts he struck the windows without breaking them, when the patient's mother and nursing staff rushed towards him and finally, he was subdued by force. He was taken to the bed and had to be restrained...during all this process, the mother was extremely upset complaining that we did not do anything to help him and that we had allowed him to jump to the window (which did not happen). I attempted to explain to her, that [patient] was very violent and dangerous and "tackle him" could come with dangerous consequences...while trying to explain this, she kept hyperventilating [heavy rapid breathing] and kept speaking with her family over the phone leaving me several times without finishing...she continued to state that her son was "possessed" by some sort of devil-evil spirit and was not himself..."

The facility document titled, "Camera observer- Patient Activity Log- Safety" dated October 28, 2024, indicated, Patient 1 was under camera observation from 11 a.m. until 3 p.m on October 28, 2024.

The facility document titled, "Patient Sitter Observation Form" dated October 28, 2024, did not indicate observations were documented from 3 p.m. to 7 p.m. The document indicated PSA 1 was sitting with the patient from 7 p.m. October 28, 2024, until 6:45 a.m. on October 29, 2024.

On December 3, 2024, at 3 p.m., an interview and review of sitter observation forms was conducted with the PSD. The PSD stated facility orders for a 1:1 sitter show in the computer as "sitter- suicidal" and would follow the suicide prevention plan policy. The PSD stated there should have been sitter documentation between 3 p.m. and 7 p.m. on October 28, 2024. The PSD further stated the sitter should stay with the patient at all times. The PSD stated when the sitter needs to leave the room at any time, they need to call the nurse so the nurse can get someone to sit with the patient until they return. The PSD stated they recall this patient because there was an investigation done. The PSD stated they recall that there was a gap where the sitter stepped out of the room prior to the incident. The PSD stated the patient was able to get out of restraints and pull out his lines after the sitter left the room.

On December 3, 2024, at 3:30 p.m., a concurrent interview and review of facility incident reports was conducted with the PSD. An incident report dated October 28, 2024, at 9: 45 p.m. indicated, "...Sitter left patient alone. Patient broke out of restraints and attempted to jump through window...Sitter left to the bathroom while patient was resting. Mother was in the room and yelled for help...Patient broke out of restraints and was pulling on lines...jumped on the bed...code grey was called...mom was upset the patient was left alone...had a discussion with the sitter [PSA 1] about responsibilities..." The PSD stated it was reported to them that the sitter left the room to use the restroom and did not notify the nurse or get coverage. The PSD stated the sitter should have stayed with the patient and gotten someone to cover for them while they went to the restroom..."

On December 4, 2024, at 10:05 a.m., a telephone interview was conducted with the Patient Safety Attendant (PSA) 1. The PSA 1 stated, at 10:30 p.m. on October 28, 2024, they left to use the restroom. The PSA 1 stated the nurse was with the physician so they told [Patient 1's] mom they needed to go and asked mom if it was ok if she watched him while they went to the restroom. The PSA 1 stated the patient's mom said she would watch him. The PSA 1 stated they were not gone for more than five minutes but when they came back to the room, the patient was on top of the bed and staff was in the room. The PSA 1 stated the patient had ripped out his IV line. The PSA 1 stated staff got Patient 1 back into bed and checked the restraints. The PSA 1 stated staff were not notified by the mom until after the patient was out of restraints and was on the bed. The PSA 1 further stated it is standard practice to utilize the family to cover and watch the patient if needed. The PSA 1 stated they did not attempt to notify any staff prior to leaving the patient alone with family. The PSA 1 stated she should have stayed with the patient and notified the RN.

On December 4, 2024, at 10:15 a.m., a concurrent interview was conducted with the PSD. The PSD stated it is not a standard practice to use family to cover a sitter.

On December 4, 2024, at 11:05 a.m., an interview was conducted with PSA 2. The PSA 2 stated they have been a sitter at [name of facility] for eight years. The PSA 2 stated when a sitter needs to leave a patient room for any reason, the process is to call the nurse, CNA (certified nurses assistant), or another PSA to have them cover the patient. The PSA 2 stated when assigned as a sitter, the expectation is to stay with the patient at all times, even if family is present in the room. The PSA 2 further stated it is never acceptable, and is not a standard, to leave a patient and have family cover for the sitter.

The facility Policy and Procedure titled, "Suicide Prevention Plan", revised September 2023, was reviewed. The policy indicated "...Suicide risk levels and Observations...Continuous observation (1:1)...at no time is the patient out of visual contact of a staff member...one on one (1:1) observation is constant and uninterrupted...staff is able to immediately intervene should the patient attempt self-harm and/or unsafe behavior is observed..."

Based on observation, interview, and record review, the facility failed to ensure the facility's policies and procedures were implemented, for nine of 46 sample patients (Patients 1, 11, 13, 14, 18, 21, 35, 37, and 46), when:

1. For Patient 11, the lactic acid (test used to indicate a serious life-threatening condition) 5.0 mmol/L (millimoles per liter, unit of measurement) (normal 0.4 mmol/L to 2.0 mmol/L) critical lab was not reported to the physician.

2. For Patients 13 and 21, the patients were not provided oral care every shift as required.

3. For Patients 13 and 14, the patients were not turned every two hours as required.

4. For Patient 18, daily weights were not obtained as required.

5. For Patient 18, trach care was not provided every 4 hours as required.

6. For Patient 35, 37, and 46, when the patient's pain level was not reassessed after medication administration.

7. For Patient 1, the Patient Safety Attendant (sitter) left the patient unsupervised.


These failures had the potential to impact the health, safety, and delay treatment of the patients.

Findings:

1. On December 3, 2024, at 8:30 a.m., a review of Patient 11's record was conducted with Quality Coordinator (QC) 1. A facility document titled, "History and Physical (H&P)," dated November 27, 2024, indicated Patient 11 was admitted for Sepsis (life-threatening medical emergency, body's overreacts to an infection).

A facility document titled, "Lactic Acid Level," was reviewed and indicated, "...Nov. 5, 24 [November 5, 2024] 13:38 [1:38 p.m.]...5.0 P...mmol/L..."

On December 3, 2024, at 8:54 a.m., an interview was conducted with QC 1. The QC 1 stated she was unable to find documentation the physician was notified of the critical lab for lactic acid of 5.0.

A facility document titled, "Critical Value Reporting," dated September 25, 2024, was reviewed and indicated, "...Immediate notification of test results that suggest an urgent or life-threatening condition...to the appropriate health care professional. Delays in reporting...may adversely affect the quality of patient care...Results...Critical lab results...Lactate/lactic acid level...greater than 3.0 mmol/L..."

2 a. On December 3, 2024, at 11:07 a.m., a review of Patient 13's record was conducted with Quality Coordinator (QC) 1. A facility document titled, "H&P," dated September 20, 2024, indicated Patient 13 was admitted for altered mental status.

There was no documented evidence Patient 13 was provided oral care once a shift on the following dates: November 28, 29, and December 1, 2024, am shift (7 a.m. to 7 p.m.) and November 30, 2024, p.m. shift (7 p.m. to 7 a.m.).

On December 3, 2024, at 11:22 a.m., an interview was conducted with QC 1. The QC 1 stated there was no documented evidence oral care was performed on Patient 13 on the ablove listed dates and times. The QC1 stated the nurses did not perform the oral care every shift per the policy.

2 b. On December 4, 2024, at 9:54 a.m., a review of patient 21's record was conducted with Quality Coordinator (QC) 2. A facility document titled, "History and Physical," dated November 30, 2024, was reviewed. The document indicated Patient 21 was admitted to the facility for confusion, agitation, and disorientation (state of mental confusion).

There was no documented evidence Patient 21 was provided oral care once a shift on the following dates: December 1, 2, and 3, 2024, am shift (7 a.m. to 7 p.m.).

On December 4, 2024, at 10:08 a.m., an interview was conducted with QC 2. The QC 2 stated there is no documentation of the oral care being completed. The QC2 stated oral care should be completed once per shift. The QC 2 further stated the nurses did not perform the oral care every shift per the policy.

Review of facility policy and procedure, "[Name of facility] Standards of Care, Practice Guidelines and Assessment of the Adult Patient (Excluding Maternal/child)," dated September 12, 2024, was conducted. The document indicated, "...assist with/offer oral hygiene q [every] shift and PRN [as needed]..."

3 a. On December 3, 2024, at 11:07 a.m., a review of Patient 13's record was conducted with Quality Coordinator (QC) 1. A facility document titled, "History and Physical [H&P]," dated September 20, 2024, indicated Patient 13 was admitted for altered mental status.

There was no documented evidence Patient 13 was turned every two hours on the following dates and times:
November 29, 2024, at 4 a.m. and 6 a.m.; and
November 30, 2024, at 12 a.m., 2 a.m., 4 a.m., and 6 a.m.

On December 3, 2024, at 11:20 a.m., an interview was conducted with QC 1. The QC 1 stated there is no documentation that Patient 13 was turned consistently every two hours. The QC1 stated there is no documentation indicating why Patient 13 was not turned.

3 b. On December 3, 2024, at 1 p.m., a review of Patient 14's record was conducted with QC 1. A facility document titled, "H&P," dated November 26, 2024, was reviewed. The document indicated Patient 14 was admitted to the facility for Chronic (longer than 6 months) kidney disease and elevated (greater than 100) heart rate.

There was no documented evidence Patient 14 was turned every two hours on the following dates and times:
November 27, 2024, at 6 a.m.; and
November 29, 2024, at 2 a.m., 4 a.m. and 6 a.m.

On December 2, 2024, at 1:12 p.m., an interview was conducted with the QC 1. The QC 1 stated there is no documentation that patient 14 was turned consistently every two hours. The QC 1 stated there is no documentation indicating why Patient 14 was not turned.

Review of facility policy and procedure, "[Name of facility] Standards of Care, practice Guidelines and Assessment of the Adult Patient (Excluding Maternal/child)," dated September 12, 2024. The document indicated, "...if patient unable to repositioned...patient turning needs will be individualized. Patient must be turned at least every 2 hours as condition allows, maintaining proper body alignment..."

4. On December 3, 2024, at 2:15 p.m., a review of Patient 18's record was conducted with QC 1. A facility document titled, "H&P," dated November 20, 2024, indicated Patient 18 was admitted to the facility on November 20, 2024, for Nontraumatic subarachnoid hemorrhage (brain bleed that occurs without head trauma).

A facility document titled, "daily weights," dated October 21, 2024, was reviewed and indicated, "...Weight, Obtain...Frequency: Daily..."

There was no documented evidence Patient 18's daily weight was taken on the following dates: November 22, 2024, through November 25, 2024, and November 30, 2024, through December 2, 2024.

A facility document titled, "Physician Orders," dated, November 22, 2024, was reviewed and indicated, "...NUR.PHY...Tube feeding...Adult...routine...11/22/24 [December 22, 2024.]...pivot 1.5 cal. liter [unit of measurement]...NPO [nothing by mouth]...55 ML/HR [milliliter/hour, unit of measurement] (1320 ml)...free water...300...Q4H [every 4 hours]..."

On December 3, 2024, at 2:35 p.m., an interview was conducted with QC 1. The QC 1 stated she was unable to find weights taken for Patient 18 on the dates above. The QC 1 stated according to the policy and procedure for patients with continuous tube feeding the weight should be taken daily. The QC 1 further stated, there should be daily weights taken for Patient 18. The QC 1 further stated the RNs (Registered Nurse) did not follow the facility's policy for the dates.

A review of facility P&P titled, "[Name of Facility] Standards of Care, Practice Guidelines and Assessment for the Adult Patient (Excluding Maternal/Child)", dated September 12, 2024, was conducted. The P&P indicated, "...Nutrition...if on enteral nutrition (tube feeding)...weight Daily..."

5. On December 3, 2024, at 2:15 p.m., a review of Patient 18's record was conducted with QC 1. A facility document titled, "History and Physical," dated November 20, 2024, indicated Patient 18 was admitted to the facility on November 20, 2024, for Nontraumatic subarachnoid hemorrhage.

A facility document titled, "Bedside procedure Note," dated December 1, 2024, was reviewed and indicated, "...Start date...12/1/2024 [December 1, 2024.]...Bedside Procedure Note...Procedure performed...Percutaneous tracheostomy [a surgical opening in the neck to allow breathing]...Successful placement of 8 cuffed...tracheostomy..."

There was no documented evidence Patient 18's post operative trach care was completed every 4 hours on the following dates: December 1, 2024, 10:50 p.m. to December 2, 2024, 2:50 p.m.

On December 3, 2024, at 2:40 p.m., an interview was conducted with QC 1. The QC 1 stated the trach care for Patient 18 was not completed every four (4) hours for the first 24 hours per policy. The QC 1 stated the staff did not follow the policy for trach care.

A review of facility P&P titled, "[Name of Facility] Tracheostomy Care," dated February 23, 2022, was conducted. The P&P indicated, "...Meticulous cleaning and maintenance of this airway must be individualized...and be performed minimally every twelve hours by nursing...Patients with less than twenty-four hours post-op [post operative] tracheostomy will receive trach care every four hours by nursing..."

6 a. On December 3, 2024, at 8:38 a.m., a review of Patient 35's record with the Quality Manager (QM) was conducted.

A review of the facility document titled, "History and Physical", dated October 14, 2024, at 9:41 a.m., indicated Patient 35 was admitted to the facility on October 13, 2024, at 12:51 p.m. for cellulitis (a bacterial infection of the skin and subcutaneous tissue) of the right lower extremity (leg). The document further indicated Patient 35 had a medical history of Hypertension (high blood pressure) and diabetes (a chronic disease that occurs when the body can't produce or use insulin properly, resulting in high levels of blood sugar).

A review of an untitled facility document, dated October 13, 2024, at 10:54 p.m., indicated a medication order for " ...Hydromorphone HCL [Dilaudid] ...1 milligram [mg- unit of measurement] ...intravenous [IV - in the vein] now ...", was placed by MD 1.

A review of an untitled facility document, dated October 13, 2024, at 11:05 p.m., indicated, "...1 mg Dilaudid was administered to Patient 35 for pain level of 10 out of 10 using a numeric rating scale [NRS; from 0 to 10, where 0 means no pain and 10 means the worst possible pain]." The document further indicated pain reassessment should be completed within 30 minutes. The document did not indicate reassessment after administration.

On December 3, 2024, at 8:38 a.m. a concurrent interview and record review with the QM was conducted. The QM stated, " ...pain reassessment should have been done, according to P&P, within 60 minutes after administration..."

6 b. On December 3, 2024, a review of Patient 37's record with the QM was conducted.

A review of the facility document titled, "History and Physical", dated October 14, 2024, at 7:04 p.m. indicated, Patient 37 was admitted to the facility on October 13, 2024, at 5:27 p.m. for headache, dizziness (a common health problem that can feel like a range of sensations such as feeling weak), and elevated blood glucose levels. The document further indicated Patient 37 had a medical history of diabetes.

A review of the facility document titled, "Medications Data", dated October 13, 2024, at 7:31 p.m. indicated an order was placed by MD 2. Document indicated an order for, " ...Ketorolac Tromethamine (Toradol) ...15 mg ...IV ..."

A review of an untitled facility document, dated October 13, 2024, at 8:36 p.m., indicated, medication was administered to Patient 37 for pain of 4 out of 10. The document further indicated pain reassessment should be completed within 30 minutes. The document did not indicate reassessment after administration.

On December 3, 2024, at 9:15 a.m. a concurrent interview and record review with the QM was conducted. The QM stated, " ...pain reassessment should have been done, according to P&P, within 60 minutes after pain medication administration..."

6 c. On December 3, 2024, a review of Patient 46's record with the QM was conducted.

A review of the facility document titled, "History & Physical", dated December 2, 2024, at 9:52 a.m., indicated, Patient 46 was admitted to the facility on December 2, 2024, at 3:05 a.m., for flank pain (pain in one side of the body between the upper abdomen and the back). The document further indicated Patient 46 had a medical history of nephrolithiasis (kidney stones).

A review of the facility document titled, "Order History Data", dated December 2, 2024, at 3:07 a.m., indicated an order placed by MD 3 for " ...Hydrocodone Bitart/Acetaminophen (medication used for pain) ...1 tablet ...q4h (every four hours) PRN (as needed) ...po (by mouth) ...PRN reason ...Pain scale 7-10 ..." The document further indicated medication was administered on December 2, 2024, at 3:28 a.m. for pain scale of 9 out of 10. The document further indicated pain reassessment should be completed within 30 minutes. There was no documented evidence Patient 46's pain was reassessed after administration.

On December 3, 2024, at 2 p.m. a concurrent interview and record review with the QM was conducted. The QM stated, " ...pain reassessment should have been done, according to P&P, within 60 minutes after administration..."

A review of the facility P&P document titled, "Pain Assessment and Reassessment", dated October 28, 2020, indicated, " ...Reassessments will be done after any intervention/reassessment within 60 minutes after IV/IM (intramuscular), PO, or Non-pharmalogical intervention ...pain ...reassessment should be documented on the Pain Assessment and Reassessment Screens in Meditech ..."

7. On December 3, 2024, at 8:35 a.m., a review of Patient 1's record was conducted with Quality Coordinator (QC) 2.

The facility document titled, "Psychiatric Consultation Note" dated October 26, 2024, at 11:40 a.m. indicated, "Reason for consult: Concern for altered mental status/catatonia [a disorder that disrupts a person's awareness of the world around them. People with this condition sometimes react very little or not at all to their surroundings, or might behave in ways that are unusual, unexpected or unsafe to themselves or others.]...On evaluation, the patient was resting in bed with his eyes open; however, he was staring ahead with a blank expression on his face and was nonverbal and unable to be engaged...the patient's mother was present at his bedside and volunteered information...Assessment and Plan...Diagnosis: Altered mental status, likely secondary to catatonia; and/or delirium [a mental state of confusion and disorientation that can develop suddenly over hours or days]...Please note that a 1:1 sitter, group sitter, or virtual sitter may remain indicated in the setting of concern for altered mental status...at this time, there is inadequate evidence to substantiate that the patient meets the criteria for a 5150 involuntary psychiatric hold..."

The facility document titled, "Hospitalist History & [and] Physical" dated October 26, 2024, at 4:13 p.m. indicated, "...presents to ED [Emergency Department] for behavioral crisis episode...On evaluation, pt [patient] had flat affect while mom and grandma in the room...Once family left, patient able to answer questions...admitted he ate some mushrooms for the first time and symptoms began since then...appears catatonic...psych consulted, recs [recommendations] 1:1 [one to one] sitter or virtual sitter may remain indicated in setting of concern for AMS [altered mental status]...pt does not meet criteria for 5150 involuntary psych hold at this time..."

The facility document titled, "Order History Data" dated October 28, 2024, indicated, "...Order...Sitter...Sitter-Suicidal...Order Date Time...October 28, 2024, 10:04 [a.m.]..."

An untitled facility document dated October 28, 2024, at 1:33 p.m. indicated, "...Multidisciplinary Team Notes...NN [nurses note]...Patient became erratic and combative. Began screaming, jumped out of bed, pulled out IV. Came outside of the room in hall. Patient body slammed his fiancé. Patient screaming and hit staff members. Code grey [a hospital announcement for a violent patient] called...4-point restraints [straps used to limit a patient's movement] applied on patient...MD [Medical Doctor] informed. Management came to bedside. Received orders for patient to transfer to ICU [Intensive Care Unit]..."

An untitled facility document dated October 28, 2024, at 11 p.m. indicated, "...Multidisciplinary Team Notes...NN [nurses note]...@ [at] 2235 [10:35 p.m.] during MD rounds, pt mother called notified RN [Registered Nurse] and MD regarding patient breaking BUE [bilateral upper extremity] wrist restraints. RN, multiple staff, and MD enter the room to find patient breaking out of restraints...standing on top of hospital bed. Code grey activated. Pt then aggressively demands staff to go to one side of room. MD attempted to deescalate [calm a situation] situation with patient...patient then jumps out of bed. Pt runs towards window and hits shoulder on window. Staff wraps patient to deescalate. Pt then brought to bed and restrained. New IV started per MD at bedside...Pt family at bedside and updated by MD. Pt in hospital bed...sitter at bedside..."

The facility document titled, "Pulmonary Critical Care Note" dated October 29, 2024, at 2:08 a.m. indicated, "...During the evening rounds, I was called by nursing staff and the patient's mother calling for help, given that [patient], was standing on the bed, ripping off his IV lines and yelling at the nursing staff. As we tried to get some how closer to him to calm him down, he kept screaming "back away" in a threatening way. As we were backing off from the bed where he was standing on, he jumped from the bed and went to the back of the room where the windows are. During this time security was called...In 2 [two] attempts he struck the windows without breaking them, when the patient's mother and nursing staff rushed towards him and finally, he was subdued by force. He was taken to the bed and had to be restrained...during all this process, the mother was extremely upset complaining that we did not do anything to help him and that we had allowed him to jump to the window (which did not happened). I attempted to explain to her, that [patient] was very violent and dangerous and "tackle him" could come with dangerous consequences...while trying to explain this, she kept hyperventilating [heavy rapid breathing] and kept speaking with her family over the phone leaving me several times without finishing...she continued to state that her son was "possessed" by some sort of devil-evil spirit and was not himself..."

The facility document titled, "Camera observer- Patient Activity Log- Safety" dated October 28, 2024, indicated, Patient 1 was under camera observation from 11 a.m. until 3 p.m on October 28, 2024.

The facility document titled, "Patient Sitter Observation Form" dated October 28, 2024, did not indicate observation was documented from 3 p.m. to 7 p.m. The document indicated PSA 1 was sitting with the patient from 7 p.m. October 28, 2024, until 6:45 a.m. on October 29, 2024.

On December 3, 2024, at 3 p.m., an interview and review of sitter observation forms was conducted with the PSD. The PSD stated facility orders for a 1:1 sitter show in the computer as "sitter- suicidal" and would follow the suicide prevention plan policy. The PSD stated there should have been sitter documentation between 3 p.m. and 7 p.m. on October 28, 2024. The PSD further stated the sitter should stay with the patient at all times. The PSD stated when the sitter needs to leave the room at any time, they need to call the nurse so the nurse can get someone to sit with the patient until they return. The PSD stated they recall this patient because there was an investigation done. The PSD stated they recall that there was a gap where the sitter stepped out of the room prior to the incident. The PSD stated the patient was able to get out of restraints and pull out his lines after the sitter left the room.

On December 3, 2024, at 3:30 p.m., a concurrent interview and review of facility incident reports was conducted with the PSD. An incident report dated October 28, 2024, at 9: 45 p.m. indicated, "...Sitter left patient alone. Patient broke out of restraints and attempted to jump through window...Sitter left to the bathroom while patient was resting. Mother was in the room and yelled for help...Patient broke out of restraints and was pulling on lines...jumped on the bed...code grey was called...mom was upset the patient was left alone...had a discussion with the sitter [PSA 1] about responsibilities..." The PSD stated it was reported to them that the sitter left the room to use the restroom and did not notify the nurse or get coverage. The PSD stated the sitter should have stayed with the patient and gotten someone to cover for them while they went to the restroom.

On December 4, 2024, at 10:05 a.m., a telephone interview was conducted with the Patient Safety Attendant (PSA) 1. The PSA 1 stated, at 10:30 p.m. on October 28, 2024, they left to use the restroom. The PSA 1 stated the nurse was with the physician so they told [Patient 1's] mom they needed to go and asked mom if it was ok if she watched him while they went to the restroom. The PSA 1 stated the patient's mom said she would watch him. The PSA 1 stated they were not gone for more than five minutes but when they came back to the room, the patient was on top of the bed and staff was in the room. The PSA 1 stated the patient had ripped out his IV line. The PSA 1 stated staff got Patient 1 back into bed and checked the restraints. The PSA 1 stated staff were not notified by the mom until after the patient was out of restraints and was on the bed. The PSA 1 further stated it is standard practice to utilize the family to cover and watch the patient if needed. The PSA 1 stated they did not attempt to notify any staff prior to leaving the patient alone with family. The PSA 1 stated she should have stayed with the patient and notified the RN.

On December 4, 2024, at 10:15 a.m., a concurrent interview was conducted with the PSD. The PSD stated it is not a standard practice to use family to cover a sitter.

On December 4, 2024, at 11:05 a.m., an interview was conducted with PSA 2. The PSA 2 stated they have been a sitter at [name of facility] for eight years. The PSA 2 stated when a sitter needs to leave a patient room for any reason, the process is to call the nurse, CNA (certified nurses assistant), or another PSA to have them cover the patient. The PSA 2 stated when assigned as a sitter, the expectation is to stay with the patient at all times, even if family is present in the room. The PSA 2 further stated it is never acceptable, and is not a standard, to leave a patient and have family cover for the sitter.

The facility Policy and Procedure titled, "Suicide Prevention Plan", revised September 2023, was reviewed. The policy indicated "...Suicide risk levels and Observations...Continuous observation (1:1)...at no time is the patient out of visual contact of a staff member...one on one (1:1) observation is constant and uninterrupted...staff is able to immediately intervene should the patient attempt self-harm and/or unsafe behavior is observed..."

Based on interview and record review, the facility failed to ensure a physical therapy order was followed for one of 46 patients (Patient 12).

These failures had the potential to cause a delay in patients 12's care and physical rehabilitation.

Findings:

On December 3, 2024, at 10:08 a.m., a review of Patient 12's record was conducted with Quality Coordinator (QC) 1. A facility document titled, "History and Physical," dated November 28, 2024, indicated Patient 12 was admitted for syncopal episode (brief loss of consciousness) versus a stroke (blood is blocked to part of the brain).

A facility document titled, "Medical Doctor [MD] Order," dated November 25, 2024, was reviewed. The document indicated, "...PTEVAL- PT [Physical Therapy] Evaluation & [and]Therapy...order...routine...11/25/24 [November 25, 2024]...reason for visit...stroke..."

A facility document titled, "PT [Physical Therapy] Evaluation," dated November 26, 2024, was reviewed. The document indicated, "...PT therapy indicated...Y [yes]...frequency...7x/wk [seven times a week]...duration...2 [two]...Problems/Impressions...patient presents w/ [with] decreased strength, balance..."

There was no documented evidence Patient 12 was provided Physical Therapy on November 27, 2024.

On December 3, 2024, at 10:29 a.m, an interview with QC 1 was conducted. The QC 1 stated that based on the PT evaluation and treatment plan the patient was not seen on November 27, 2024. The QC 1 stated there was no documentation of any treatment on that date. The QC 1 further stated the patient should have had PT one time each day.

A review of the facility Policy and Procedure, titled, "[facility name] Physical Therapy standards of practice," dated September 22, 2021 was conducted. The document indicated, "...the therapist shall implement the physical therapy program according to the treatment plan..."