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Based on interview and record review, the facility failed to ensure the facility's policies and procedures were implemented, for six of 30 sample patients (Patients 2, 4, 5, 23, 27, and 29), when:

1. For Patients 2, 4, 5, and 23, individualized care plans were not developed nor implemented (Refer to A 0130);

2. For Patients 2, 4, 27, and 29, the blood transfusion consents were not signed by the physician prior to the surgery (Refer to A 0131); and

3. For Patient 23, the alleged involved staff was not placed on administrative leave while an investigation of an alleged abuse was ongoing (Refer to A0144).

The cumulative effects of these systemic failures resulted in the patients' safety to be put at risk, and had the potential to delay the treatment and care of patients in the facility.

Based on interview and record review, the facility failed to ensure an individualized plan of care was developed and implemented, for four of 30 sample patients (Patients 2, 4, 5, and 23).

These failures had the potential to cause a delay in patient care and harm for the patients.

Findings:

1. A review of Patient 2's record was conducted on October 30, 2024, at 10:55 a.m., with the Director of Risk and Quality (DRQ). A facility document titled, "History and Physical [H&P]," dated October 28, 2024, was reviewed and indicated Patient 2 was admitted to the facility on October 28, 2024, for right hip osteoarthritis (a degenerative disease of the joint) and a right total hip arthroplasty (a surgical procedure that replaces the damaged parts of the hip joint with artificial components).

A facility document titled, "[Facility name] Adult Plan of Care-Flowsheet Summary," dated October 28, 2024, was reviewed and indicated, "...Rehabilitation Goals...transfer training goal...date established...Oct-28-2024 [October 28, 2024]...by discharge...Gait training goal...date established Oct-28-2024...by discharge..."

The facility document titled, "[Facility Name] HIM [Health Information Management] Orders," dated October 28, 2024, at 6:11 a.m., was reviewed and indicated, "...SURG. [surgery] Post Op [operative] Orders for Hip or Knee Replacement...order entered: 10/25/2024 [October 25, 2024]...oxyCodone [a narcotic for pain management]...10 milligrams [unit of measurement] oral every 4 [four] hours, PRN [as needed] for pain level 4-6 [four to six]..."

A facility document titled, "[Facility Name] HIM MAR [Medication Administration Record]," dated October 28, 2024, at 6 p.m., was reviewed and indicated, "...oxyCodone...every 4 hours...10 milligrams...oral...10/29/24 [October 29, 2024] 10:37 a.m..."

There was no documented evidence a care plan for pain management was developed for Patient 2.

An interview was conducted on October 30, 2024, at 11:43 a.m., with the Director of Risk and Quality (DRQ). The DRQ stated she did not have find care plans except for the rehabilitation goals for Patient 2. The DRQ stated there was no care plan for pain developed for Patient 2. The DRQ stated Patient 2 was prescribed and administered pain medications.

2. On October 29, 2024, at 11:45 a.m., Patient 4's record was reviewed with the DRQ. A facility document titled, "H&P," dated October 28, 2024, was reviewed. The document indicated Patient 4 was admitted to the facility on October 28, 2024, for status post [after a procedure] total replacement of right hip.

A facility document titled, "[Name of facility] Adult Plan of Care-Flowsheet Summary" dated October 28, 2024, indicated, "...Personalized Care...Care Plan Problem/Focus of care...Overall progress summary...Education..."

There was no documented evidence interventions were included in Patient 4's care plans. There was no documented evidence Patient 4 or Patient 4's family members were involved in the development of Patient 4's care plan.

On October 30, 2024, at 2:56 p.m., an interview was conducted with the Director of the Intensive Care (DID). The DID stated there were no interventions nor patient or family involvement documented in Patient 4's care plan. The DID stated the nurses should have completed these. The DID stated documentation of plan of care and patient involvement is important to show that the care plan is being implemented. She further stated, "Care plans are meant to fully guide nurses in the care they are giving."

3. Patient 5's record was reviewed on October 30, 2024, at 1:36 p.m., with the DRQ. A facility document titled, "H&P," dated October 29, 2024, was reviewed and indicated Patient 5 was admitted to the facility on October 29, 2024, for septic shock (a life-threatening condition that occurs when a severe infection leads to dangerously low blood pressure) due to urinary tract infection (an infection in the bladder and or the urethra where urine passes out of).

A facility document titled, "[Facility name] Adult Plan of Care-Flowsheet Summary," dated October 28, 2024, was reviewed and indicated, "...Personalized Care...Care Plan Problem/Focus of care...Overall progress summary...Education..."

There was no documented evidence an individualized care plan was developed for Patient 5.

An interview was conducted on October 30, 2024, at 1:50 p.m., with the DRQ. The DRQ stated an individualized care plans were not developed for Patient 5. The DRQ further stated the nurse should have developed individualized care plans for Patient 5 once the assessment was completed, as it is the nurse's responsibility to initiate the care plans.



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4. A review of Patient 23's record was conducted on October 30, 2024, at 1:31 p.m., with the Director of Intensive Care Unit (DID). The facility document titled, "H&P," dated October 15, 2024, indicated Patient 23 was admitted to the facility on October 15, 2024, for hip fracture (a break in the bone).

The facility document titled, "KBC Adult Plan of Care-Flowsheet Summary" dated October 16, 2024, indicated, "...Personalized Care...Care Plan Problem/Focus of care...Overall progress summary...Education..." There was no documented evidence interventions were developed in Patient 23's care plan.

On October 30, 2024, at 2:56 p.m., an interview was conducted with the DID. DID stated there were no interventions documented for Patient 23's care plans, which the nurses should have done. DID stated documentation of plan of care and patient involvement is important to show that the care plan is being followed. She further stated, "care plans are meant to fully guide nurses in the care they are giving."

A review of the facility's policy and procedure (P&P) titled, "[Facility Name] Care Plans, Patient," revised February 2024, was conducted. The P&P indicated, "...The patient or patient's representative has the right to participate in the development, implementation and revision of their plan of care to meet their medical and psychological needs. The plan of care is to include at a minimum, the right to: pain management plan...inpatient treatment..."

Based on interview and record review, the facility failed to ensure the facility's policies and procedures (P&P) were implemented, for four of 30 sample patients (Patients 2, 4, 27, and 29), when the blood transfusion (medical procedure that involves transferring blood or blood components into a patient's bloodstream through the vein) consents were not signed by the physician/s.

These failures had the potential to cause a delay in Patients 2, 4, 27, and 29's surgical procedures, and may cause harm for the patients.

Findings:

1. A review of Patient 2's medical record was conducted on October 29, 2024, at 10:55 a.m., with the Director of Risk and Quality (DRQ). A facility document titled, "History and Physical [H&P]," dated October 28, 2024, was reviewed. The document indicated Patient 2 was admitted to the facility on October 28, 2024, for right hip osteoarthritis (a degenerative disease of the joint) and a right total hip arthroplasty (a surgical procedure that replaces the damaged parts of the hip joint with artificial components).

An untitled facility document was reviewed. The document indicated, "...Consent to Blood Transfusion Date...Time...Provider Signature..." There was no documented evidence the physician signed the blood transfusion consent prior to Patient 2's surgical procedure.

On October 29, 2024, at 11:19 a.m., an interview with the Director of the Post Anesthesia (a branch of medicine which specializes in the use of medication to prevent pain during surgery and other procedures) Care Unit (DPACU) and the Charge of the Operating Room (COR) were conducted. The COR stated the Physician did not sign the Consent to Blood Transfusion for Patient 2. She stated the surgeon should have signed the consent prior to the surgical procedure. The COR stated, if the blood would have been required during the surgery, the surgeon would have had to scrub out of the surgery, sign the consent, and then scrub back (scrubbing hands for five minutes, doffing [taking off] then donning [putting on] a sterile surgical gown and sterile gloves) which could delay the surgery and the administration of the blood to the patient.

2. A review of Patient 4's record was conducted on October 29, 2024, at 11:45 a.m., with the DRQ. A facility document titled, "H&P," dated October 28, 2024, was reviewed. The document indicated Patient 4 was admitted to the facility on October 28, 2024, for right hip osteoarthritis and a right total hip arthroplasty.

An untitled facility document was reviewed. The document indicated, "...Consent to Blood Transfusion...Date...Time...Provider Signature..." There was no documented evidence the physician signed the blood transfusion consent prior to Patient 2's surgical procedure.

An interview was conducted on October 29, 2024, at 11:45 a.m., with the DPACU and the COR. The COR stated the physician did not sign the consent to blood transfusion for Patient 4. She stated the surgeon should have signed the consent prior to the surgical procedure. The COR stated, if the blood would have been required during Patient 4's surgery, the surgeon would have had to scrub out of the surgery, sign the consent, and then scrub back in, which would delay the surgery and the administration of the blood to the patient.



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3. A review of Patient 27's record was conducted on October 29, 2024, at 11 a.m., with the DRQ. A facility document titled, "H&P," dated October 28, 2024, was reviewed. The document indicated Patient 27 was admitted to the facility on October 28, 2024, for right total hip replacement.

An untitled facility document was reviewed. The document indicated, "...Consent to Blood Transfusion...Date...Time...Provider Signature..." There was no documented evidence the physician signed the blood transfusion consent prior to Patient 27's surgery.

4. A review of Patient 29's record was conducted on October 29, 2024, at 11:15 a.m., with the DRQ. A facility document titled, "H&P," dated October 28, 2024, was reviewed. The document indicated Patient 29 was admitted to the facility on October 28, 2024, for left total hip replacement.

An untitled facility document was reviewed. The document indicated, "...Consent to Blood Transfusion...Date...Time...Provider Signature..." There was no documented evidence the physician signed the blood transfusion consent prior to Patient 29's surgery.

An interview was conducted on October 29, 2024, at 11:35 a.m., with the DRQ. The DRQ stated Patients 27 and 29's blood transfusion consents were not completed and did not have a physician signature. The DRQ further stated the physician must sign the section for the physician informed consent documentation of the facility document titled, "Consent for Blood Transfusion" before the surgery. She stated the staff would need this form signed to get blood from the laboratory. She further stated if the form is not signed by the physician prior to surgery, this will cause delay of the surgery and the administration of blood to the patient.

A review of the P&P titled, "[Facility Name] Consents," dated May 2022, was conducted. The P&P indicated, "...an [authorization for and consent to surgery or special diagnosis or therapeutic procedures] is completed on every patient undergoing surgery, an invasive procedure or blood transfusion...the informed consent is obtained by the physician...if a consent form is filled out incorrectly, a new form must be completed and signed..."

Based on interview and record review, the facility failed to ensure the facility's policy for abuse was implemented, for one of 30 sampled patients (Patient 23), when Registered Nurse (RN) 2, who was allegedly involved in an abuse allegation, was not removed from patient care while the investigation of alleged abuse was ongoing.

This failure had the potential for the patients to be subjected to abuse.

Findings:

On October 24, 2024, at 8:08 p.m., the facility sent a report by facsimile (a telephonic transmission) indicating, "...at approx. [approximately] 0730 [7:30 a.m.] [name of Patient 23's roommate heard his roommate [Patient 23] being slapped by 2 [two] night shift nurses when being cleaned up during the night shift. This nurse [asked if he witnessed this being done and he stated he did not since the curtain was closed, but heard it happening..."

A review of Patient 23's record was conducted on October 25, 2024, at 4 p.m., with the Director of Medical Surgical Unit (DMS). A facility document titled, "Progress Notes," dated October 25, 2024, at 11:28 a.m., authored by RN 1, was reviewed. The document indicated, "...Late Entry: 10/24/24 [October 24, 2024] Approx [approximately] 0800 [8 a.m.] LVN [Licensed Vocational Nurse] [LVN's Name] notified me of report that pt [Patient 23] was "slapped" in the middle of the night by night shift CNA's [Certified Nurses Assistants]. Upon report, I assessed pts [patient's] condition, pt had no physical signs of abuse present. Minor scratches were seen on the pts upper L [left] chest where the tele [telemetry, continuous remote heart monitoring] lead [wires that connect electrodes to a telemetry unit] was present. Bruising on pts upper right arm and left side that was reported to have been caused by pts falls at home. Pt showed nor verbalized any signs or symptoms of distress. Charge nurse [charge nurse's name] notified, pt was moved to another another [sic] room and police were notified..."

A review of a facility document titled, "[Name of Facility] Medical Surgical Telemetry Unit Assignment Sheet," dated October 28, 2024, was conducted. The document indicated, "...[Name of RN 2]...Patient room assignment..."

A review of RN 2's timecard, dated October 23, 2024, through October 28, 2024, was conducted. The document indicated, "...Monday [October 28, 2024]...In 17:56 [5:56 p.m.]...out 0:41 [12:41 a.m.]...in 1:11 [1:11 a.m.]...out 08:06 [8:06 a.m.]..."

On October 25, 2024, at 4:01 p.m., an interview was conducted with the DMS. The DMS stated the LVN came in and reported to her that the roommate of Patient 23 had told her two black people were cleaning Patient 23 up and he heard a slap but could not see who the staff were because the privacy curtain was closed. The DMS stated the local police department was notified, did their investigation, and reported to her that "there was no abuse." The DMS stated she thought the investigation was over because the local police department had come to investigate. The DMS stated she had been told if the investigating police officer said there's no evidence of abuse and patient is safe, the facility did not have to suspend staff allegedly involved or the staff allegedly involved would not be assigned to the alleged abused patient. The DMS stated she did not place any nursing staff on administrative leave after receiving report about the alleged abuse on Patient 23 on October 24, 2024. The DMS further stated she did not interview the night shift staff who was allegedly involved in the abuse. The DMS stated the alleged victim was not able to talk so she did not interview him. The DMS stated she was unable to provide documentation of an investigation which was conducted related to the allegation abuse on Patient 23.

On October 29, 2024, at 1:23 p.m., an interview was conducted with the DMS. The DMS stated she finished talking to staff regarding the alleged abuse incident on Patient 23 on October 28, 2024, at 1 a.m. The DMS stated she was unable to provide documentation of an investigation which was conducted related to the allegation abuse on Patient 23. The DMS stated, "[Name of RN 2] came to work on Monday [October 28, 2024]."

On October 30, 2024, at 9:25 a.m., an interview was conducted with the DMS. The DMS stated she interviewed LVN 1 on the night of October 29, 2024. The DMS stated LVN 1 told her she and RN 2 changed Patient 23 at 6 a.m., on October 24, 2024, and both staff were "black" women.

On October 30, 2024, at 9:42 a.m., the Chief Nursing Officer (CNO) was interviewed. The CNO stated no one was placed on administrative leave during the investigation of the alleged abuse on Patient 23. The CNO stated they could not identify the staff involved in the alleged abuse. The CNO stated Patient 23's roommate had reported that there two African nurses who slapped Patient 23 but he did not know who the staff were. The CNO stated she was not aware that two African American female staff took care of Patient 23 on the night of the alleged abuse incident on Patient 23.

On October 30, 2024, at 4:18 p.m., LVN 1 was interviewed. LVN 1 stated Patient 23's roommate told her two African American nurses were changing Patient 23 and he heard a slap but could not see who the staff were because the privacy curtain was closed.

On October 30, 2024, at 4:29 p.m., an interview was conducted with RN 2. RN 2 stated, around 6 a.m. on October 24, 2024, she repositioned and cleaned up Patient 23 with LVN 1. RN 2 denied the slapping incident involving Patient 23 happened.

A review of policy and procedure titled, "Abuse-Prevention Elder and Dependent Adult," revised June 2022, was conducted. The policy indicated, "...[Name of facility] prohibits and takes measures to prevent the mistreatment...and abuse of patients...Patients have the right to be free of mistreatment...abuse...Patients have the right to be free from...physical abuse...All allegations of abuse identifying an associate [staff] as the suspect will be...thoroughly investigated. Further potential abuse will be prevented while the investigation is in progress...Patients will immediately be protected from further potential abuse while incidents are investigated and until abuse has been ruled out...If the accused abuser is an associate, they will immediately be placed on Administrative Leave by the Director or House Supervisor. Assessments and interviews will be done to identify special needs or interventions required for the alleged victim (patient)..."

Based on observation and interview, the facility failed to ensure the facility's policy and procedure (P&P) for medication storage was implemented, when several 10 ml (milliliters, unit of measurement) 0.9% (percent) normal saline (a type of fluid) intravenous (IV, administered through the vein) flushes (a sterile injection of a salt solution that cleans out intravenous (IV) catheters, central lines, or arterial lines) were observed in a clear plastic container on the countertop to the right and left side of the sink in an unlocked storage room.

This failure had the potential to cause a contamination to the normal saline flushes and increased risk of infection for the patients.

Findings:

A tour of the Intensive Care Unit (ICU, unit with patients with life-threatening injuries and illnesses) and the Definitive Observation Unit (DOU, unit for patients with less than critical care needs where close monitoring is provided for patients) was conducted on October 29, 2024, at 10:38 a.m., with the Director of Risk and Quality (DRQ), and the Director of the Intensive Care (DID). The supply room was observed to not be locked. Inside the supply room, several 10 ml 0.9% normal saline intravenous flushes were observed in a clear plastic container on the countertop to the right and left side of the sink.

On October 29, 2024, at 10:44 a.m., an interview with the DID was conducted. The DID stated the nurses were preparing for an IV and left the supplies on the countertop. The DID stated the countertop by the sink is not the best place to store the supplies.

On October 30, 2024, at 2:10 p.m., an interview with the Director of Pharmacy (DOP) was conducted. The DOP stated 0.9% normal saline is considered a medication. The DOP stated the 0.9% normal saline 10 ml syringe flushes should not be stored in the unlocked ICU/DOU storage room. The DOP stated the normal saline syringe flushes should be stored in the locked medication room.

A review of the P&P titled, "[Facility Name] In Transit Management of Medications," dated August 2024, was conducted. The P&P indicated, "...medications will be maintained in a secure manner during transit storage...Placing the medication in an area that is under continuous visual observation of authorized staff...storing the medication in a locked medication storage room..."

A review of the P&P titled, "[Facility Name] Medication Storage," dated August 2024, was conducted. The P&P indicated, "...medication will be stored in such a manner as to prevent moisture, condensation, contamination, mold growth, or spoilage..."