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Based on interview and record review, the facility failed to develop and implement a nursing care plan (a set of goals and actions used in the nursing plan to make certain the patient ' s medical needs are met) for two of 35 sampled patients (Patient 20 and Patient 21), in accordance with the facility's policy and procedures regarding care plan development when:



There was no nursing care plan identifying Patient 20 ' s surgical needs. This deficient practice had the potential to result in Patient 20 ' s treatment and care goals not being met by not identifying Patient 20 ' s risks and needs associated with surgery, such as infection, surgical drain (a tube placed near a surgical wound to remove fluids) complications (unexpected and undesirable results), nutrition imbalance (lack of proportion) and loss of skin integrity (the health of the skin).



There was no nursing care plan identifying Patient 21 ' s surgical needs. This deficient practice had the potential to result in Patient 21 ' s treatment and care goals not being met by not identifying Patient 21 ' s risks and needs associated with surgery, such as loss of skin integrity and imbalanced nutrition.



Findings:

1.

During a record review of Patient 20 ' s "History & Physical" (H&P, [a formal evaluation performed by a physician to gather information about a patient ' s health and problems]), dated 8/2/2024 12:14 a.m., the H&P indicated Patient 20 was admitted for emergent exploratory laparotomy with sigmoid colectomy and diverting loop ileostomy (a surgical procedure that involves opening the belly to examine the organs, removes part or all of the large intestines and brings part of the intestine through a opening in the belly that drains in a bag) following an outpatient colon perforation after a colonoscopy. This led to Patient 20 developing hypotension (low blood pressure of circulating blood against the walls of channels that carry blood throughout the body) and peritonitis (redness and swelling of the belly lining).

During a review of Patient 20 ' s progress noted titled, "Surgical Progress Note", dated 8/7/24 at 9:16 a.m., the progress note indicated, Patient 20 was five day postoperative for a sigmoid colectomy (a surgical procedure that removes part or all of the large intestine that connects to the rectum) with colostomy (a surgical procedure that involves bringing one end of the large intestines through an opening in the abdominal wall to allow stool to pass) and diverting loop ileostomy (a procedure that diverts fecal flow out to the skin to prevent stool from leaking during colon surgery). Patient 20 reported getting full easily and spitting up when eating quickly. Wound care and diet discussed with plan to continue ileostomy care and teaching. A negative pressure dressing (bandage applied to reduce inflammatory drainage and promote healing) is applied with plan to leave as long as possible, but remove if the dressing leak or malfunction.



During an interview on 8/5/24 at 2:38 p.m., with Patient 20, Patient 20 became emotional manifested by crying and verbalization. Patient 20 expressed "happiness that someone cares." Patient 20 verbalized concerns about appropriate ileostomy (a surgical opening [stoma] allowing the small intestines to bring waste [stool] out the body, onto the surface of the skin) care, surgical complications (problems from surgery), wound care and treatment/care following discharge (release).

During a concurrent interview and record review on 8/6/24 at 1:03 p.m., with the Nursing Manager (NM6E) and the Organizational Improvement Department (OID), NM6E stated, there was no care plan on file to address potential problems associated with surgery for Patient 20. NM6E stated, it is important to have a care plan identifying all needs to provide appropriate care specific to the patient and make adjustments based on needs and goals.

During a concurrent interview and record review on 8/6/24 at 1:20 p.m., with NM6E and the OID, the NM6E stated, the registered nurse (RN) is responsible for updating the care plan(s) daily (per shift) and should have identified the missing care plans based on Patient 20 and Patient 21 ' s diagnosis. The NM6E stated once this concern was identified, the appropriate interventions (treatments) should have been incorporated (added) in Patient 20 and Patient 21 ' s plan of care.

During an interview on 8/7/24 at 3:00 p.m., with Advance Clinical Nurse Educator (ACNE), ACNE stated, for patients with surgical wounds, evidenced based nursing (EBN, [care plan]) "should definitely include" skin integrity and/or something related to monitoring the surgical site/wound. ACNE stated, it (EBN/care plan) should also include anxiety, pain, body image, respiratory needs, knowledge deficit, infection, nutrition needs, bleeding, bowel management, homeostasis (a state of balance among all body systems needed for the body to survive and function correctly) and venous thromboembolism (VTE, [blood clots in the vein]) prophylaxis. ACNE stated care plans are important for standardized care specific to each patient ' s needs. ACNE stated, one of the care plans to initiate following surgery should always include Registered Nurse (RN) to RN monitoring of the surgical site. ACNE stated the facility has program based EBN for specific types of surgery. Per ACNE, the nurse(s) may select a specific surgery type and the care plans are prepopulated (automatically add) to include plans/goals/treatments to meet the surgery ' s specific plan of care. ACNE stated, care plans guide interventions (action taken to improve a situation). The ACNE stated, the care plans may be modified to meet each patient ' s individual needs and is important to avoid further complications.

During a review of the facility ' s policy and procedure (P&P) titled, "Standard for Patient Plan of Care", dated 11/7/2022, the P&P indicated the purpose of a care plan is to ensure that each patient is provided with individualized goal-directed care (section 1.1), and to provide a means of interdisciplinary communication to ensure continuity in patient care (section 1.2).

During a review of the facility ' s P&P titled, "Standard for Patient Plan of Care", dated 11/7/2022, the P&P (section 2.1) indicated, the patient ' s plan of care should be initiated within 24 hours. The patient ' s care plan will identify priority problems and needs to be addressed. The patient ' s care plan will be complete, current, and individualized for each patient. There will be ongoing documentation and the plan of care shall coordinate with the medical plan of care.

During a review of the facility ' s P&P titled, "Surgical Wound Dressing Application", dated 5/20/2024, the P&P indicated, use of appropriate dressings can promote wound healing. Dressings can help protect surgical wounds, help prevent infection, and help promote homeostasis.



2.

During a record review of Patient 21 ' s H&P, dated 8/2/2024 9:06 p.m., the H&P indicated Patient 21 was admitted for endometrial carcinoma grade I (a type of endometrial [inner lining of the uterus] cancer) requiring surgical interventions including, hysterectomy (a surgical procedure to remove the womb), right salpingo-oophorectomy (a surgical procedure that removes the fallopian tube and ovary), and possible staging procedure (a series of tests and exams that determine the extent of cancer in the body).

During a review of Patient 21 ' s progress note titled, "Operative Report", dated 8/2/24 at 12:00 a.m. the progress note indicated, Patient 21 required a transverse (across/horizontal) incision suprapubically (lower part of the belly, above the genital organs) and five trocar sites (through the belly wall to insert a surgical instrument). The progress note indicates the procedure should be considered at least 100% more difficult than usual secondary to Patient 21 ' s morbid obesity (having too much body fat, which increases the risk of health problems), pelvic (area of the body below the belly between the hip bones) adhesions, and increased size of the uterus (womb) secondary to fibroids (noncancerous growths in the womb).

During a review of Patient 21 ' s progress note titled, "Hospitalist Progress Note", dated 8/6/24 at 10:04 a.m., the progress note indicated, Patient 21 reported complaints of dizziness, likely vertigo (causes a person to feel like they or their surroundings are spinning or moving, even when they aren ' t) and sustained a low blood pressure requiring medication to be held. Patient 21 is morbidly obese with a body mass index (BMI, measurement that compares weight to height. Normally 18.5 to 24.9) of 50. Patient 21 is receiving Tylenol and Oxycodone for pain control. Patient 21 required lysis of adhesions (a surgical procedure involving small incisions [cuts] in the belly to remove scar tissue that can develop after surgery, with infections, or inflammatory conditions).



During an interview on 8/5/24 at 2:15 p.m., with Patient 21, Patient 21 reports working in the healthcare field and expressed concerns about the inability to see the surgical wounds/sites secondary to their locations and Patient 21 ' s body size, limited mobility from surgical associated discomfort, and pain control. Patient 21 reports being kept longer for pain management at the surgical sites.

During a concurrent interview and record review on 8/6/24 at 1:15 p.m., with the Nursing Manager (NM6E) and the Organizational Improvement Department (OID), NM6E stated, there was no care plan on file to address potential problems associated with surgery for Patient 21. NM6E stated, it is important to have a care plan identifying all needs to provide appropriate care specific to the patient and make adjustments based on needs and goals.

During a review of the facility ' s policy and procedure (P&P) titled, "Standard for Patient Plan of Care", dated 11/7/2022, the P&P indicated the purpose of a care plan is to ensure that each patient is provided with individualized goal-directed care (section 1.1), and to provide a means of interdisciplinary communication to ensure continuity in patient care (section 1.2).

During a review of the facility ' s P&P titled, "Standard for Patient Plan of Care", dated 11/7/2022, the P&P (section 2.1) indicated, the patient ' s plan of care should be initiated within 24 hours. The patient ' s care plan will identify priority problems and needs to be addressed. The patient ' s care plan will be complete, current, and individualized for each patient. There will be ongoing documentation and the plan of care shall coordinate with the medical plan of care.

During a review of the facility ' s P&P titled, "Surgical Wound Dressing Application", dated 5/20/2024, the P&P indicated, use of appropriate dressings can promote wound healing. Dressings can help protect surgical wounds, help prevent infection, and help promote homeostasis.

Based on observation, interview, and record review, the facility failed to obtain a written informed consent (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) for one of 35 sampled patients (Patient 29), when Patient 29 did not have written informed consent for procedures during a "Code STEMI (an emergency protocol that treat patients with ST-elevation myocardial infarction, a life-threatening heart attack that occurs when plaque in an artery blocks blood flow to the heart)," including catheterization (a procedure when a long, flexible tube called a catheter is inserted into a blood vessel in the arm, groin, upper thigh, or neck, to the heart, and used to diagnose and treat many heart problems); angiogram (a scan that shows blood flow through arteries or vein, or through the heart, using x-rays), computed tomography angiography ([CTA]a medical test that uses X-rays and a computer to create detailed images of blood vessels and blood flow in the body) or magnetic resonance angiography ([MRA]a test to create images of blood vessels and blood flow in the body), coronary angioplasty (a minimally invasive surgery that uses a catheter with a small balloon to open the artery and mesh stent to keep it open and prevent it from reclosing).



This deficient practice had the potential to violate Patient 29's rights to be informed and to choose the type of care or treatment to be received, or alternatives the patient or responsible party preferred.

Findings:

During a review of Patient 29 ' s history and physical ([H&P] a formal and complete assessment of the patient and the problem), dated 8/3/2024, the H&P indicated the patient was admitted on 8/2/2024 from the emergency department (ED) for chest pain and troponin level (a blood test to measures the levels of troponin T and troponin I proteins in the blood, which are released when the heart muscle is damaged, the normal range is 0-0.04 nanograms per milliliter per ng/ml) of 447 ng/ml. An electrocardiogram (EKG is a non-invasive test that measures the electrical activity of the heart) was performed and due to concerns for STEMI, a Code STEMI was called. Catheterization showed multi-vessel coronary artery disease (heart condition that occurs when the coronary arteries that supply blood and oxygen to the heart become narrowed or blocked).

During an interview with Patient 29 on 8/5/2024 at 2:05 p.m., in Patient 29 ' s room, Patient 29 stated that she came to the ED with her daughter on 8/2/2024 due to chest discomfort. Patient 29 further stated in the ED, the facility performed an EKG within 10 minutes and found out she needed to do procedures for a STEMI immediately and they sent her to the Cath Lab (a hospital or clinic examination room that uses diagnostic imaging equipment to perform tests and procedures on the heart and cardiovascular system). Patient 29 stated she was awake and alert at that time and her daughter accompanied her.

During a concurrent record review and interview with the Clinic System Analyst (CSA) on 8/6/2024 at 1:00 p.m., CSA stated no consent was found for any procedure completed during the Code STEMI. CSA stated Patient 29 was sent to the Cath Lab straight from the ED.

During an interview with the Patient Access Director (PAD) on 8/7/2024 at 3:40 p.m., in conference A, the PAD stated that the consent of admission is a general consent for treatment, and it does not include the consent for actual specific procedure and treatment that was performed during the hospitalization course. If a patient has a procedure performed, then another informed consent for that particular procedure should obtain from patient.

During an interview with the Accreditations Manager (AM) on 8/8/2024 at 3:00 p.m., in conference room A, the AM stated the facility was not able to locate and provide documentation of Patient 29 ' s procedure consents during the Code STEMI, and the written informed consents were not in Patient 29 ' s medical record.

During a review of the facility ' s policy and procedure (P&P) titled "Consent to Treat-admin – TMMC", effective date 6/13/2023, the P&P indicated, "A written consent, signed by the patient or legally authorized representative, must be prepared before any invasive, special diagnostic, or therapeutic procedure is performed except in emergency situations as outlined on page one."

Based on interview and record review, the facility failed to properly execute an informed consent for one of 35 sampled patients (Patient 1), when Patient 1 ' s signed informed consent (permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits) for "left ring finger cyst (a small pocket of tissue often filled with fluid or pus) removal, right little finger cyst removal" was not performed, and a "left ring and right little digit trigger finger release (a surgical procedure that helps make it easier to bend or straighten a finger that is stuck in a bent position)" was completed. Thus, Patient 1 ' s surgical procedure performed was inconsistent with the signed informed consent.

This deficient practice resulted in Patient 1 undergoing a procedure in which he (Patient 1) did not have the information needed to make a voluntary and informed decision, which has the potential to result in physical or psychological harm to the patient (Patient 1).

Findings:

During a concurrent interview and record review on 8/6/2024 at 10:08 a.m. with the Operating Room Manager (ORM), Patient 1 ' s Electronic Medical Record ([EMR], digital version of paper chart), was reviewed. The EMR indicated the informed consent Patient 1 signed was for "left ring finger cyst (a small pocket of tissue often filled with fluid or pus) removal, right little finger cyst removal."



The ORM further stated Patient 1 was scheduled for an outpatient surgical procedure of a ganglion cyst (lumps that most often appear along the tendons [a cord of strong, flexible tissue that connects the muscles to the bones] or joints of wrists or hands) removal on 3/4/2023. The informed consent was signed by Patient 1 for "left ring finger cyst removal, right little finger cyst removal," the Surgeon instead did a "left ring and right little digit trigger finger release" surgery. The inconsistency of the consent vs procedure was found out after surgery when Surgeon 1 talked with Patient 1. Patient 1 pointed out that the cysts were still present, and Patient 1 was sent back to have the correct surgical procedure on the same day.



The ORM added that the safety measure in place to prevent wrong procedure was the calling of "Time-out (a brief pause by the surgical team before an incision [cut to the skin] to confirm the correct patient, procedure, and site)" prior to start of surgery, the surgical team must verify correct patient, correct procedure, and correct site. The ORM stated the fall out in the Time Out process of Patient 1 may be due to "Time Out Fatigue," it is when the surgical team are agreeing to the verification elements but not actively listening.



During a review of Patient 1 ' s Post Operative (medical record that documents a patient ' s recovery after a procedure) Nursing record dated 3/4/2023 at 3:28 p.m., indicated "...that what he (Patient 1) consented is the cyst removal, but [MD 1] is also insisting that it wasn ' t. [MD 1] was about to step out of the unit when I (RN) talked to him (MD 1) and showed him (MD 1) the consent that the patient (Patient 1) signed which specifically stated left ring finger cyst..."



During a review of the facility ' s policy and procedure (P&P) titled, "Consent to Treat," effective date 6/13/2023, indicated the following:



Health care decision making is based on a collaborative relationship between the patient, physician, and/or other health care professionals who are primarily responsible for the patient's care. The process of collaborative interaction between the patient and the health care professional promotes mutual understanding and ensures that the patient's decisions result from this collaborative effort.



The physician who directs the patient's care and treatment is responsible for securing the patient's informed consent to that care and treatment. Other members of the health care team (all health care personnel involved in treating and caring for the patient) should explain the care, treatments, and interventions they are providing. All members of the health care team should provide the patient with information to enhance decision-making capacity and to reasonably ensure the ability to make a voluntary and informed decision.