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Based on interview and record review, the facility failed to ensure for one of 30 sampled patients (Patient 5), Patient 5 was provided the documents regarding patient's rights in Patient 5's preferred language.

This deficient practice resulted in Patient 5 to not be informed of her rights as a patient in the language the patient understands.

Findings:

During an interview on 2/6/2024 at 2:20 p.m. with Patient 5, Patient 5 stated upon admission, the patient's (Patient 5) family member signed the documents that explained the patient's rights. Patient 5 subsequently said that she did not know these forms came in other languages. Patient 5 stated her preferred language was Spanish and the forms given to her were in English.

During an interview on 2/6/2024 at 2:21 p.m. with Patient 5's family member (FM), Patient 5's FM stated he signed Patient 5's admission papers because Patient 5 was feverish and was not thinking clearly. Patient 5's FM stated his preferred language was Spanish and he was given the form to sign in English.

A review of the "Patient Rights Acknowledgement" form, indicated Patient 5 was notified of patient rights and responsibilities, patient rights to make decisions about medical care and treatment, current vaccination information, financial assistance, advance directives (legal documents that provide instruction for medical care to the facility in the event the patient is not able to communicate his/her wishes). This document showed it had been signed by Patient 5's husband on 2/1/2024 and was written in English language.

During an interview on 2/9/2024 at 2:30 p.m. the Quality Manager stated patient's rights and responsibilities are discussed upon admission to the hospital and patient's rights and responsibilities acknowledgment forms are available in other languages beside English. She confirmed that Spanish forms should have been available at the time of Patient 5's admission and provided to Patient 5 and Patient 5's family member.

A review of the facility's "Administrative Policies and Procedures - Patient Rights & Responsibilities," last revised 6/2022, indicated that patients and their representatives have the right to receive accurate and current information regarding the patient's health status in terms understandable to patients and representatives, so that they can make informed decisions.

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

1. Ensure the physician's order for seizure precaution (safety measures provided for the patient during seizure, uncontrolled electrical activity in the brain causing abnormal muscle movement) was followed for one of 30 sampled patients (Patient 2).

This deficient practice resulted in Patient 2's unsafe care and had the potential for Patient 2 to suffer from physical harm during a seizure.

2. Ensure for one of 30 sampled patients (Patient 4) had been turned and repositioned in accordance with the facility's policy and procedure.

This deficient practice had the potential to result in Patient 4's development, deterioration, and worsening of pressure injury (PI - damage to upper and lower levels of the skin due to pressure of body part on a surface) and had the potential to cause Patient 4 to suffer from pain and wound infection.

Findings:

1. During an observation on 2/6/2024 at 2:15 p.m. with Clinical Supervisor (CS) 1, Patient 2's room door was observed to have a sign which displayed "Seizure Precautions." At this time, Patient 2 was observed sitting on the side of the bed; Patient 2's side rails, footboard, and headboard of the bed were not padded. Patient 2 was not wearing a yellow wrist band that indicated she may be at risk of falling. This observation was validated by the CS 1.

During a concurrent interview on 2/6/2024 at 2:15 p.m. with CS 1, CS 1 stated Patient 2 was on seizure precaution and that the bed rails should be padded to prevent injury to Patient 2 during a seizure. CS 1 stated all other fall risk precautions should be taken.

During a review of the facility's document titled, "Nursing Skill - Initiating Seizure Precautions for Adults," the document indicated that nurses should implement safety precautions to prevent seizure-related injuries ranging from bruising to head injury. Some of the precautions mentioned in this procedure include: Removing hazards in the room or relocate to a safe place; Place padding around headboards, footboards, and side rails as appropriate; Place bed into lowest position with side rails raised; Place signage in patient's room to alert others seizure precautions are in place.

2. During a review of Patient 4's "Admission/Registration" record, dated 1/20/2024, the record indicated Patient 4 was admitted to the facility on 1/20/2024 at 3:57 p.m.

During a review of Patient 4's "Default Flowsheet Data," with dates from 1/20/2024 at 12 a.m.-1/25/2024 at 11:59 p.m., the Default Flowsheet Date indicated that on 1/20/2024, Patient 4 had a Stage 3 pressure injury (skin tissue loss where fat may be visible but bone, tendon, or muscle is not exposed) on the right buttock and a Stage 2 pressure injury (one that has progressed to the top layers of the skin but has not affected fatty tissue beneath) on the left buttock.

During a review of Patient 4's "Default Flowsheet Data," with dates from 1/21/2024 at 12 a.m. - 1/25/2024 at 11:59 p.m., the flowsheet indicated that on the following dates and times, Patient 4 was not regularly turned and repositioned at least every 2 hours:

- On 1/22/2024 at 8:00 a.m., Patient 4 was turned and repositioned on the left side.
Patient 4 was turned and repositioned next at 8:00 p.m. (12 hours after) on the right side;
-On 1/23/24 at 6:00 p.m., Patient 4 was turned and repositioned on the right side.
Patient 4 was turned and repositioned next at 8:00 a.m. (12 hours after) on the right side
-On 1/24/2024 at 12:00 p.m. Patient 4 was turned and repositioned on the right side.
On 1/24/2024 at 2:00 p.m. Patient 4 was still on his right side.

During a concurrent interview on 2/6/2024 at 3:10 p.m. with Registered Nurse (RN) 6, RN 6 acknowledged the gaps in documentation of Patient 4's turning and repositioning from 1/22/2024 through 1/24/2024. RN 6 stated, the patients with pressure injury should be turned and repositioned at least every 2 hours.

During a review of the facility's "Department Policies and Procedures - Skin Integrity," last revised 12/2022, the document indicated nurses should consider placing patients on a low air loss mattress under the following circumstances: Patients with stage 3, 4 (deep skin injuries that may expose bone, tendons, or muscle), or Deep Tissue Injury (DTI, purplish coloration of intact skin or blood-filled blister from injury to underlying soft tissue caused by pressure), patients with limited number of turning surfaces to which they can be turned. This document stated the nursing team will position patients at risk of pressure injury at least every 2 hours; any limitation to repositioning the patient will be documented.

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

1. Ensure the patient's acuity level (the measure of nursing intensity or the level of care the patient requires) was included in the nursing patients' assignment schedule in the Neonatal Intensive Care Unit (NICU, units where intensive care is provided for newborn infants who are premature or have health problems) and the Labor and Delivery Unit (L&D, units that provide care to pregnant individuals during labor, childbirth, and the immediate postpartum period) in accordance with the facility's staffing policy.

This deficient practice had the potential to result in an inappropriate nursing patients' assignment which may lead to inadequate nursing care for the patients with high acuity level of care.

2. Ensure for one (1) of 30 sampled patients (Patient 16), the facility's policy on intravenous (IV administered through the vein) therapy guidelines was implemented when, Patient 16's midline catheter (an 8-12 cm catheter inserted in the upper arm with the tip located just below the armpit) access site was not labeled (date of insertion) and initialed by staff who inserted the IV catheter.

This deficient practice had the potential to result in Patient 16's increased risk for intravascular (within the blood vessel) catheter-related infections.

3. Ensure for six (6) of 30 sampled patients (Patients 17, 18, 19, 20, 21, and 1), the facility's policy on intravenous therapy guidelines was implemented when Patients 17, 18, 19, 20, 21 and 1's peripheral (generally placed in the arm or hand) IV (in the vein) access site was not labeled.

This deficient practice had the potential to result in the patients' increased risk for intravascular (within the blood vessel) catheter-related infections.

Findings:

1.a. During a concurrent interview and record review on 2/9/2024 at 1:35 p.m. with Registered Nurse (RN) 14, the "Birthing Center (L&D unit) Assignments sheet," dated 2/9/2024, was reviewed. The Birthing Center (L&D unit) Assignments sheet indicated the RNs' names assigned to a room number where the L&D patients were located. RN 14 confirmed that there was no assigned acuity level for each of the patients on the assignment sheet.

During an interview on 2/9/2024 at 1:35 p.m. with the Director of the L&D Department (DLD), the DLD stated that the L&D department adheres to the same staffing policy and procedure of the facility, titled "Patient Classification and Interrater Reliability Guidelines." The DLD confirmed that the acuity level of patients and the reason for their admission were not documented on the assignment sheet.

During a review of L&D nursing assignment "Birthing Center Assignments," dated 12/15/2023 through 1/31/2024, for day shift and night shift, the nursing assignments did not include the acuity level assigned to each of the patients. In addition, the nursing assignment did not indicate the licensed credentials of the staff nurses whether they were registered nurses (RN) or licensed vocational nurses (LVN).

During a review of the facility's policy and procedure (P&P) titled, Patient Classification and Interrater Reliability Guidelines," dated September 2023, the P&P indicated the following: To provide guidelines to categorize patients into classifications which reflect acuity and adherence to regulatory standards. Inter-rater reliability is a method to establish the amount of nursing care needed for each category of patient is validated for each unit and for each shift. The method will address the amount of nursing care needed, by patient category and pattern of care delivery. This method is to determine staff resource allocations based on nursing care requirements for each shift and each unit. This method validates the reliability of the patient classification system for each unit and for each shift. PROCEDURE:
- Patient classification will be determined for each patient on each shift and will be updated as the patient's condition warrants. Acuity will be documented on the staff assignment sheets.

1.b. During a concurrent interview and record review on 2/9/2024 at 3:40 p.m. with the Manager of NICU (MNICU), the NICU assignments titled, "Daily Staffing Sheet," dated 12/21/2023 through 1/31/2024, was reviewed. The MNICU stated she started entering patient acuity level on the NICU assignment sheet in December 2023 and that prior to December 2023, patients' acuity was not documented on the Daily Staffing Sheet. The MNICU stated the NICU follows the facility's staffing policy and procedure titled "Patient Classification and Interrater Reliability Guidelines."

In the same interview and record review, the NICU assignment sheets indicated the following dates did not include the patients' acuity level:

On 12/21/2023, day shift (7 a.m. to 7p.m), the space for acuity was left unfilled.
On 12/22/2023, day shift and night shift (7 p.m. to 7a.m) the space for acuity was left unfilled.
On 12/23/2023, day shift and night shift, the space for acuity was left unfilled.
On 12/24/2023, day shift, the space for acuity was left unfilled.
On 12/25/2023, day shift, the space for acuity was left unfilled.
On 12/26/2023, day shift and night shift, the space for acuity was left unfilled.
On 12/27/2023, night shift, the space for acuity was left unfilled.
On 1/1/2024, day shift and night shift, the space for acuity was left unfilled.
On 1/2/2024, night shift, the space for acuity was left unfilled.
On 1/3/2024, day shift and night shift, the space for acuity was left unfilled.
On 1/4/2024, day shift and night shift, the space for acuity was left unfilled.
On 1/5/2024, day shift, the space for acuity was left unfilled.
On 1/6/2024, day shift, the space for acuity was left unfilled.
On 1/7/2024, day shift and night shift, the space for acuity was left unfilled.
On 1/9/2024, day shift, the space for acuity was left unfilled.

Confirmed with MNICU that the Daily Staffing Sheet as listed above did not include each patient's acuity level.

During a review of the facility's policy and procedure (P&P) titled, Patient Classification and Interrater Reliability Guidelines," dated September 2023, the P&P indicated the following: To provide guidelines to categorize patients into classifications which reflect acuity and adherence to regulatory standards. Inter-rater reliability is a method to establish the amount of nursing care needed for each category of patient is validated for each unit and for each shift. The method will address the amount of nursing care needed, by patient category and pattern of care delivery. This method is to determine staff resource allocations based on nursing care requirements for each shift and each unit. This method validates the reliability of the patient classification system for each unit and for each shift. PROCEDURE:
- Patient classification will be determined for each patient on each shift and will be updated as the patient's condition warrants. Acuity will be documented on the staff assignment sheets.

During a review of the facility's policy and procedure (P&P) titled, "Staffing Policy Plan," dated September 2023, the P&P indicated, "A staffing plan that will be used to determine the personnel recommended for each shift as outlined in the unit's staffing grid and as necessary to provide the scope of services. The plan shall also establish general guidelines as to the qualifications of staff assigned to provide patient care. Staffing guidelines are to be reviewed annually or more frequently as needed. Staffing guidelines are to be utilized and considered recommendations as acuity will also be utilized as a tool to determine staffing ... Staffing Guidelines: The minimum staffing needed for each skill level (LPN/LVN, RN, CNA, MT, US) is determined by the nurse-patient guidelines and/or patient care acuity needs ..."

2. During a concurrent observation and interview on 2/6/2024 at 2:02 p.m., with Registered Nurse (RN) 1, in Patient 16's room, Patient 16 was observed with a midline catheter on the right arm. Patient 16's midline catheter site at the right arm did not have a label with the date the dressing was changed. RN 1 stated, "It is important that the registered nurse assess the IV sites and ensure that there are labels with dates (date the dressing was changed) as the dressing has to be changed every week or when the dressing is soiled to prevent infection."

During a review of Patient 16's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 1/31/2024, the H&P indicated Patient 16 was found with oxygen saturation at 70 percent (a normal oxygen saturation level is between 95 percent and 100 percent). The H&P also indicated Patient 16's "Problem List," included atypical pneumonia (inflamed or swollen lung tissue due to infection caused by different bacteria) and the plan was for Patient 16 to be admitted for administration of IV (Intravenous, into the vein) antibiotic (medicines that fight infections caused by bacteria).

During a concurrent interview and record review on 2/9/2024 at 2:40 p.m. with the Survey Coordinator and Quality Assurance (SCQA), the SCQA stated an IV guideline was provided for the nursing staff to follow in managing the patient's IV access.

In the same interview and record review, the document provided by the SCQA titled "Inserting a Peripheral IV in Adults," indicated, "A peripheral IV cannula is inserted using an over-the-needle catheter to deliver fluids, aqueous medications, blood products, and parenteral nutrition directly into a patient's peripheral vein. It is the fastest way to deliver fluids and medications throughout the body. Monitor for complications of peripheral IV insertion, including extravasation, phlebitis, thrombosis, hematoma, and infiltration, including redness, swelling, pain, and visual or palpable enlargement of the cannulated blood vessel ...Label dressing with date/time of insertion per facility protocol." (Dynamic Health, EBSCO Information Services, 2024).

3.a. During a concurrent observation and interview on 2/6/2024 at 2:20 p.m. with the Performance Improvement Coordinator (IP coordinator) in Patient 17's room, Patient 17 was observed with an IV site on the left forearm. Patient 17's IV site did not have a label with a date (date the IV catheter was inserted) and the IV dressing was observed peeling off around the edges. There was a medication (Zosyn, an antibiotic) infusing through the IV. IP coordinator stated he will inform the primary nurse to change the dressing and label the dressing.

During a review of Patient 17's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 2/3/2024, the H&P indicated that Patient 17 came into the emergency department for a complaint of epigastric (upper middle area of the abdomen) pain that was radiating to the mid-back with associated nausea (feeling the urge to vomit). The H&P further indicated, "Patient 17 had an abdominal ultrasound (imaging test that uses sound waves to make pictures of organs, tissues, and other structures) which revealed cholelithiasis (the formation of gallstones) and signs of acute cholecystitis (inflammation of the gallbladder. Patient with leukocytosis (increase in the number of white cells in the blood during an infection). Patient admitted for further care."

During a review of the facility's document titled "Inserting a Peripheral IV in Adults," the document indicated, "A peripheral IV cannula is inserted using an over-the-needle catheter to deliver fluids, aqueous medications, blood products, and parenteral nutrition directly into a patient's peripheral vein. It is the fastest way to deliver fluids and medications throughout the body. Monitor for complications of peripheral IV insertion, including extravasation, phlebitis, thrombosis, hematoma, and infiltration, including redness, swelling, pain, and visual or palpable enlargement of the cannulated blood vessel ...Label dressing with date/time of insertion per facility protocol." (Dynamic Health, EBSCO Information Services, 2024).

3.b. During a concurrent observation and interview on 2/6/2024 at 2:40 p.m. with the Clinical Supervisor (CS) 1 and the IP coordinator, in Patient 18's room, Patient 18 was observed with an IV site on the left forearm. Patient 18's IV site did not have a label with a date (date the IV catheter was inserted). CS 1 stated, "It is important that the registered nurse assess the IV sites and assure that there are labels with dates as the IV catheter has to be changed every three days to prevent infection."

During a review of Patient 18's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/2/2024, the H&P indicated that Patient 18 was brought in by ambulance for nausea, vomiting, and abdominal pain. The H&P further indicated an ultrasound revealed a thrombus (a blood clot formed in situ within the vascular system of the body and impeding blood flow) in the femoral veins (a large blood vessel in the thigh). The patient (Patient 18) was on antibiotics.

During a review of the facility's document titled "Inserting a Peripheral IV in Adults," the document indicated, "A peripheral IV cannula is inserted using an over-the-needle catheter to deliver fluids, aqueous medications, blood products, and parenteral nutrition directly into a patient's peripheral vein. It is the fastest way to deliver fluids and medications throughout the body. Monitor for complications of peripheral IV insertion, including extravasation, phlebitis, thrombosis, hematoma, and infiltration, including redness, swelling, pain, and visual or palpable enlargement of the cannulated blood vessel ...Label dressing with date/time of insertion per facility protocol." (Dynamic Health, EBSCO Information Services, 2024).

3.c. During a concurrent observation and interview on 2/6/2024 at 2:56 p.m. with CS 1 and the IP coordinator, in Patient 19's room, Patient 19 was observed with an IV site on the inner left forearm. Patient 19's IV site did not have a label with a date, and the dressing tape was peeling off with one tape dangling from the IV site. CS 1 stated she will inform the primary nurse to assess the IV site, change the dressing, and label the IV site with a date (date the IV catheter was inserted).

During a review of Patient 19's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/4/2024, the H&P indicated Patient 19 presented to the emergency department for symptoms of shortness of breath. The H&P further indicated Patient 19's chest x-ray (a photographic or digital image of the internal composition) revealed pulmonary vascular congestion [obstruction of the normal flux of blood within the blood vessel network of the lung resulting in engorgement of lungs vessels]).

During a review of the facility's document titled "Inserting a Peripheral IV in Adults," the document indicated, "A peripheral IV cannula is inserted using an over-the-needle catheter to deliver fluids, aqueous medications, blood products, and parenteral nutrition directly into a patient's peripheral vein. It is the fastest way to deliver fluids and medications throughout the body. Monitor for complications of peripheral IV insertion, including extravasation, phlebitis, thrombosis, hematoma, and infiltration, including redness, swelling, pain, and visual or palpable enlargement of the cannulated blood vessel ...Label dressing with date/time of insertion per facility protocol." (Dynamic Health, EBSCO Information Services, 2024).


3.d. During a concurrent observation and interview on 2/6/2024 at 2:56 p.m. with charge nurse (Charge) 3, in Patient 20's room, Patient 20 was observed with an IV site on the right hand. Patient 20's IV site did not have a label with a date (date the IV catheter was inserted). Charge 3 stated, "There should always be a label on the IV site with the date ((date the IV catheter was inserted). The facility policy is to assess the IV site every 4 hours to ensure dressing is not soiled and to ensure IV site is changed every 3 days to prevent infection."

During a review of Patient 20's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/4/2024, the H&P indicated Patient 20 presented to the emergency room with a complaint of chills, cough, yellow sputum, intermittent vomiting, and diarrhea (loose, watery stool that occurs more frequently than usual) for one week. H&P further indicated Patient 20 had an elevated white blood count (elevated WBC can be a sign and symptom of an infection), patient was started on antibiotics and admitted for further management."

During a review of the facility's document titled "Inserting a Peripheral IV in Adults," the document indicated, "A peripheral IV cannula is inserted using an over-the-needle catheter to deliver fluids, aqueous medications, blood products, and parenteral nutrition directly into a patient's peripheral vein. It is the fastest way to deliver fluids and medications throughout the body. Monitor for complications of peripheral IV insertion, including extravasation, phlebitis, thrombosis, hematoma, and infiltration, including redness, swelling, pain, and visual or palpable enlargement of the cannulated blood vessel ...Label dressing with date/time of insertion per facility protocol." (Dynamic Health, EBSCO Information Services, 2024).

3.e. During a concurrent observation and interview on 2/6/2024 at 4:00 p.m. with Charge 3, in Patient 21's room, Patient 21 was observed with an IV site on the right forearm and the left forearm.

In the same observation and interview, Patient 21's IV site on the right forearm had a smeared writing in black ink that was not legible. Patient 21's IV site on the left forearm did not have a label with a date (date the IV catheter was inserted). Charge 3 stated, "the IV site label should not be written with a marker over the tape. There is a labeling sticker that comes with the IV kit, or there are IV label stickers."

During a review of Patient 21's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/3/2024, the H&P indicated Patient 21 presented to the emergency department for erratic behavior. The H&P further indicated Patient 21 was positive for leukocytes (an increase in the number of white cells in the blood during an infection), and Patient 21's chest x-ray indicated a pulmonary edema (a condition caused by too much fluid in the lungs). Patient 21 would be on IV Rocephin (antibiotic medication).

During a concurrent interview and record review on 2/9/2024 at 2:40 p.m. with the Survey Coordinator and Quality Assurance (SCQA), the SCQA stated an IV guideline was provided for the nursing staff to follow in managing the patient's IV access.

In the same interview and record review, the document provided by the SCQA titled "Inserting a Peripheral IV in Adults," indicated, "A peripheral IV cannula is inserted using an over-the-needle catheter to deliver fluids, aqueous medications, blood products, and parenteral nutrition directly into a patient's peripheral vein. It is the fastest way to deliver fluids and medications throughout the body. Monitor for complications of peripheral IV insertion, including extravasation, phlebitis, thrombosis, hematoma, and infiltration, including redness, swelling, pain, and visual or palpable enlargement of the cannulated blood vessel ...Label dressing with date/time of insertion per facility protocol" (Dynamic Health, EBSCO Information Services, 2024).

3.f. During an observation on 2/6/2024 at 2:10 p.m., with the Quality Manager, Patient 1 was observed to have an IV inserted into the left wrist. Patient 1's IV site was covered with semi-transparent plastic tape and was not marked with the date the IV was inserted. This observation was validated by the Quality Manager.
During an interview on 2/6/2024 at 2:10 p.m. with the Quality Manager, the Quality Manager stated the date of the patient's (Patient 1) IV insertion was documented in the patient's electronic record.
A review of Patient 1's electronic medical record on 2/6/2024 at 3:00 p.m. did not indicate any IV insertion documentation. This was confirmed by the Quality Manager during an interview.
During a review of the facility's document titled, "Nursing Skill - Inserting a Peripheral IV In Adults," the document specified "the IV site should be covered with sterile transparent dressing that maintains a view of the insertion site and its surround area; IV insertion is to be documented in the patient's plan of care and medical record including date/time."