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Based on observation, interview, and record review, the facility failed to ensure the facility's policy and procedure was implemented, when education regarding the process for magnetic resonance cholangiopancreatography (MRCP, a non-invasive magnetic resonance imaging [MRI, an imaging procedure] procedure which produces detailed images of the biliary and pancreatic systems) procedure was not provided to one of 30 sample patients (Patient 5).

This failure resulted in a delay in Patient 5's MRCP, and had the potential to cause delay in the provision of care and treatment to Patient 5.

Findings:

On November 4, 2024, at 9:59 a.m., a tour of the Medical/Surgical/Telemetry (MST, unit where patients' heart rates and rhythms are continuously monitored remotely) 2 unit was conducted with the MST Director (MSTD), Scribe 1, and Scribe 2.

An observation was conducted on November 4, 2024, at 9:59 a.m., at Patient 5's room. Patient 5 was observed sitting in bed with a grimace on his face. During a concurrent interview, Patient 5 stated the care is good but he was upset because of the poor communication between the nurses and the physicians. Patient 5 stated, "I was scheduled to have an MRI of the abdomen but now I have to wait three hours because I ate breakfast." Patient 5 stated, "Nobody told me that I shouldn't [eat breakfast]. If I knew then I would not have eaten."

An interview was conducted on November 4, 2024, at 10:28 a.m., with Registered Nurse (RN) 3. RN 3 stated she didn't inform Patient 5 to not eat his breakfast because there was no physician's order for NPO (nothing per orem, nothing by mouth) for the MRI of the abdomen procedure. RN 3 stated the MRI technician informed her the procedure will be delayed because Patient 5 ate breakfast. RN 3 further stated she is not sure if this process is in a policy.

A concurrent interview and record review were conducted on November 5, 2024, at 10:54 a.m., with the MST Director (MSTD). An undated facility document titled, "Decision Support," was reviewed. The document indicated, "...Identified Order: MRI MRCP w/o [without] Contrast...MRI screening and education form to be completed electronically...Patient must be NPO for 4-6 hours prior to the exam..." There was no documented evidence the document was provided to Patient 5.

The MSTD stated the document titled, "Decision Support," is what the nurses provide to the patient prior to a procedure. The MSTD stated there was no documentation the document was provided to Patient 5.

A review of Patient 5's record was conducted on November 5, 2024, at 10:57 a.m., with the MSTD. A facility document titled, "History and Physical," dated November 3, 2024, was reviewed. The document indicated, "...Assessment/Plan...Acute pancreatitis [inflammation of the pancreas]...jaundice [yellowing of the skin]...liver cirrhosis [a condition with scarring of the liver]..."

An undated facility document titled, "Order Information for: MRI MRCP w/o [without] Contrast," was reviewed. The document indicated, "...original order entered and electronically signed by [Name] MRI tech [technician]...11/3/2024 [November 3, 2024] at 15:11 PST [ 3:11 p.m.]...MRI MRCP w/o Contrast..."

A facility policy and procedure titled, "Patient and Family Education," dated, October 2024, was reviewed. The policy indicated, "...To provide the patient, family and/or significant other education/training specific to the patients' needs and abilities and as appropriate to the care, treatment and services provided...Such instructions is presented in ways understandable to the patient, family and/or significant others and includes...The plan of care, treatment and services...Adult...Multidisciplinary personnel will document patient education on an ongoing basis to who was taught, what was taught, patient teaching tools utilized, written information given to the patient..."

Based on observation, interview, and record review, the facility failed to ensure the facility's policies and procedures (P&P) were implemented, for five of 30 sample patients (Patients 1, 2, 3, 6, and 7), when the external urine collection device was not changed every 12 hours in accordance with the facility's P&P.

This failure had the potential to cause infection, delay in patient care, and harm to patients using an external urine collection device.

Findings:

1. A review of Patient 1's record was conducted on November 5, 2024, at 9:36 a.m., with Medical/Surgical/Telemetry (unit where patients' heart rates and rhythms are continuously monitored remotely) Director (MSTD) and Scribe 2. A facility document titled, "History and Physical," dated September 7, 2024, was reviewed. The document indicated, "...Assessment/Plan Diagnoses...UTI [urinary tract infection, an infection affecting the bladder, urethra (a hollow tube which lets the urine pass out of the body), or kidneys]...AKI [acute kidney injury, a condition when the kidney suddenly lose its ability to filter waste from the blood]..."

A facility document titled, "Genitourinary," dated September 7, 2024, was reviewed and indicated an external urinary collection device was applied to Patient 1.

There was no documented evidence Patient 1's external urine collection device was changed on the following dates and shifts:

- On September 8, 2024, day shift (7 a.m. to 7 p.m.);
- On September 8, 2024, night shift (7 p.m. to 7 a.m.);
- On September 9, 2024, day shift; and
- On September 9, 2024, night shift.

2. On November 4, 2024, at 11:08 a.m., a tour of the MST 2 unit was conducted with the MSTD, Scribe 1, and Scribe 2. An observation was conducted inside Patient 2's room, a urine collection canister was observed to be mounted on the wall. The urine collection canister was observed to not be labeled with a date. During a concurrent interview, Patient 2 stated the canister is connected to a device between his legs where he urinates.

An interview was conducted on November 5, 2024, at 11:40 a.m., with Registered Nurse (RN) 7. RN 7 stated the external urinary catheter including the canister should be changed every shift and when needed. RN 7 was stated she was unable to say when Patient 2's external urinary collection device including the urine collection cannister were changed because it was not labeled with a date.

A review of Patient 2's record was conducted on November 5, 2024, at 9:36 a.m., with the MSTD. A facility document titled, "History and Physical," dated November 1, 2024, was reviewed. The document indicated, "...Assessment/Plan...Bilateral pulmonary embolism (blood clot in the lungs)..."

There was no documented evidence Patient 2's external urine collection device was changed on the following dates and shifts:

- On November 2, 2024, day shift;
- On November 2, 2024, night shift;
- On November 3, 2024, day shift;
- On November 3, 2024, night shift; and
- On November 4, 2024, day shift.

3. On November 4, 2024, at 10:12 a.m., a tour of the MST 1 was conducted with the MSTD, Scribe 1, and Scribe 2. An observation was conducted in Patient 3's room. An external urine collection device was observed attached to a collection canister with suction mounted on the wall which were observed to not be labeled with a date.

An interview was conducted on November 4, 2024, at 10:13 a.m., with RN 3. RN 3 stated the external urine collection device including the collection cannister is changed daily and as needed.

A review of Patient 3's record was conducted on November 5, 2024, at 9:48 a.m., with the MSTD. A facility document titled, "History and Physical," dated November 1, 2024, was reviewed. The document indicated, "...Assessment/Plan...URI [upper respiratory infection]...metabolic encephalopathy [a brain disorder caused by a chemical imbalance in the blood]...seizures..."

A facility document titled, "Genitourinary," dated November 3, 2024, indicated the external urine collection device was applied at 8:10 p.m., on November 3, 2024.

There was no documented evidence Patient 3's external urine collection device was changed during the day and night shifts on November 4, 2024.

4. On November 4, 2024, at 11:17 a.m., an observation was conducted in Patient 6's room. A urine collection canister was observed mounted on the wall. During a concurrent interview, Patient 6's family member stated the urine collection canister is connected to a device in between Patient 6's legs where Patient 6 urinates.

An interview was conducted on November 4, 2024, at 11:20 a.m., with RN 5. RN 5 stated Patient 6 has an external urine collection device. RN 5 stated she is unable to say when Patient 6's external urinary collection device including the urine collection cannister was changed because it was not labeled with a date.

A review of Patient 6's record was conducted on November 5, 2024, at 11:36 a.m., with the MSTD. A facility document titled, "History and Physical," dated, November 2, 2024, was reviewed. The document indicated, "...Assessment/Plan...Encephalopathy..."

There was no documented evidence Patient 6's external urine collection device was changed on the following dates and shifts:

- On November 3, 2024, day shift;
- On November 3, 2024, night shift; and
- On November 4, 2024, day shift.

5. On November 4, 2024, at 10:58 a.m., an observation was conducted in Patient 7's room. A urine collection canister mounted on the wall which was observed to not be labeled with a date.

An interview was conducted on November 4, 2024, at 11 a.m., with RN 4. RN 4 stated Patient 7 has an external urine collection device which should be changed every shift. RN 4 stated she was unable to say when the external urinary collection device including the urine collection cannister was changed because it was not labeled with a date.

A review of Patient 7's record was conducted on November 5, 2024, at 11:34 a.m., with the MSTD. A facility document titled, "History and Physical," dated November 3, 2024, was reviewed and indicated, "...Assessment/Plan...Acute respiratory failure [inefficient breathing]..."

There was no documented evidence Patient 7's external urine collection device was changed on the following dates and shifts:

- On November 2, 2024, day shift;
- On November 2, 2024, night shift;
- On November 3, 2024, day shift;
- On November 3, 2024, night shift; and
- On November 4, 2024, day shift.

An interview was conducted on November 5, 2024, at 9:47 a.m., with the MSTD. The MSTD stated the external urinary catheter should be changed every 12 hours in accordance with the facility's hospital P&P.

A review of the facility P&P titled, "External Urinary Catheter: Female," dated October 2024, was conducted. The P&P indicated, "...During use...Replace device every 12 hours or if soiled with stool or bodily fluids other than urine..."

There was no documented evidence a facility P&P was developed for the male external urinary catheter.

An interview was conducted on November 5, 2024, at 11:40 a.m., with the Quality Director (QD). The QD stated the facility has not developed a policy for the male external urinary catheter. The QD stated the P&P for the female external urinary catheter is currently being followed for the male external urinary catheter.

Based on interview and record review, the facility failed to ensure the facility's policy and procedure (P&P) titled, "Abuse and Neglect: Elder and Dependent Adult Recognition and Reporting 1525," was implemented, for one of 30 sample patients (Patient 16), when Patient 16 was physically hit with a closed fist by Staff 1.

This failure resulted in Patient 16 sustaining superficial scratches and swelling to his left eyebrow.

Findings:

On November 4, at 2:45 p.m., an interview was conducted with the Director of Behavioral Health Services (DBHS). The DBHS stated, on September 18, 2024, at approximately 5:45 a.m., Patient 16 stood up from his wheelchair and hit Staff 1, then Staff 1 hit Patient 16. The DBHS stated the facility has no tolerance for staff hitting patients and Staff 1's employment was terminated.

A facility document titled, "Physician Orders," dated September 13, 2024, was reviewed. The document indicated, "...Per 5150 [an involuntary 72-hour hospitalization of patients who may be a threat to self or others]...He [Patient 16] endorsed suicidal ideation & [and] homicidal ideation with a plan & intent...He stated that prior to leaving his home/work...he grabbed his 380 Beretta [gun] out of his safe & debated whether he wanted to shoot himself in the head or rob another bank...Admitting Diagnosis: Major Depressive Disorder [a mood disorder which causes a persistent feeling of sadness and loss of interest], recurrent, severe, without Psychosis [a condition with impaired reality]..."

A facility document titled, "Behavioral Health (BH) Psychiatric [related to mental illness and its treatment] Evaluation," for Patient 16, dated September 13, 2024, was reviewed. The document indicated, "...review of systems...also includes antisocial personality disorder [a mental health disorder defined by a long term behavior which disregards the rights and well-being of others]...Urine Drug Screen [a test which detects evidence of recent drug use or misuse in a sample of urine] positive for alcohol, cocaine [a highly addictive drug], danger to self danger to others [sic], due to command auditory hallucinations [hearing voices, sounds that don't exist in reality]...also gravely disabled [unable to meet basic needs due to a mental health disorder, substance use disorder, or chronic alcoholism..."

A facility document titled, "Consult-Internal Medicine," dated September 14, 2024, was reviewed. The document indicated, "...Patient [Patient 16] has been feeling very depressed recently, patient feels hopeless, helpless and worthless...Patient also had a severe pain on the right leg...The patient had very poor impulse control..."

A facility document titled, "BH Progress Note-Nurse," dated September 18, 2024, at 5:40 a.m., indicated, "...Patient [Patient 16] was agitated because staff was redirecting his peer who was wheeling him on the wheelchair to go to his own room for medication administration. This patient became upset, got up and start to hit a staff member [Staff 1] who was part of the team redirecting his peer as the staff at the point also thew punches at patient. Patient sustained superficial scratches and a little swelling to his lt [left] eyebrow..."

An untitled and undated facility document was reviewed. The document indicated, "...On 9/18 [September 18, 2024] at 5:40 [a.m.] patient [Patient 16] stated he wasn't going to take any [expletive] shots and I'll [expletive] anyone who comes near me...and took a defensive stance toward Staff 1 then struck out with his fists and hit Staff 1, at this point Staff 1 retaliated and threw approx. [approximately] 5 [five] closed fisted blows at the patient which resulted in the patient's left eye temple [sic] getting cut open...staff tried to redirect Staff 1 away from patient toward the medroom [medication room]..."

A facility document titled, "BH Progress Note-Nurse," dated September 18, 2024, at 6:25 a.m., was reviewed. The document indicated, "...As staff was exiting Patient 16's room with the other male peer, Patient [Patient 16] then proceeded to posture at male medication nurse [Staff 1]. Patient began swinging at staff with closed fists, and both patient and male staff began punching each other. Patient was hit to the left side of his face with a closed fist by male staff twice..."

On November 4, 2024, at 4 p.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated, for any physical abuse, they are supposed to separate the staff and the patient to prevent any physical altercation against the patient. RN 1 stated the staff will report the abuse to the person on call, call the psychiatrist, and call the medical physician if there are any injuries. RN 1 stated the staff is supposed to do a verbal de-escalation, use an open seclusion (placing patient in a room alone until they are calm) or offer medications as interventions to assist a patient in a crisis.

A concurrent interview and review of the video recording of the incident was conducted on November 5, 2024, at 9:20 a.m., with the Chief Nurse Officer (CNO) and Quality Director (QD). In the video recording, Patient 16 was observed to be hit three times by Staff 1. CNO stated they teach de-escalation in the facility and that was not done. The CNO stated, "We want to avoid any physical contact with the patient."

A facility P&P titled, "Abuse and Neglect: Elder and Dependent Adult Recognition and Reporting 1525," revised April 2024, was reviewed. The P&P indicated, "...Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect, and exploitation. [Name of Facility] strives to protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff..."

Based on observation, interview, and record review, the facility failed to ensure the facility's policy and procedure was implemented, when education regarding the process for magnetic resonance cholangiopancreatography (MRCP, a non-invasive magnetic resonance imaging [MRI, an imaging procedure] procedure which produces detailed images of the biliary and pancreatic systems) procedure was not provided to one of 30 sample patients (Patient 5).

This failure resulted in a delay in Patient 5's MRCP, and had the potential to cause delay in the provision of care and treatment to Patient 5.

Findings:

On November 4, 2024, at 9:59 a.m., a tour of the Medical/Surgical/Telemetry (MST, unit where patients' heart rates and rhythms are continuously monitored remotely) 2 unit was conducted with the MST Director (MSTD), Scribe 1, and Scribe 2.

An observation was conducted on November 4, 2024, at 9:59 a.m., at Patient 5's room. Patient 5 was observed sitting in bed with a grimace on his face. During a concurrent interview, Patient 5 stated the care is good but he was upset because of the poor communication between the nurses and the physicians. Patient 5 stated, "I was scheduled to have an MRI of the abdomen but now I have to wait three hours because I ate breakfast." Patient 5 stated, "Nobody told me that I shouldn't [eat breakfast]. If I knew then I would not have eaten."

An interview was conducted on November 4, 2024, at 10:28 a.m., with Registered Nurse (RN) 3. RN 3 stated she didn't inform Patient 5 to not eat his breakfast because there was no physician's order for NPO (nothing per orem, nothing by mouth) for the MRI of the abdomen procedure. RN 3 stated the MRI technician informed her the procedure will be delayed because Patient 5 ate breakfast. RN 3 further stated she is not sure if this process is in a policy.

A concurrent interview and record review were conducted on November 5, 2024, at 10:54 a.m., with the MST Director (MSTD). An undated facility document titled, "Decision Support," was reviewed. The document indicated, "...Identified Order: MRI MRCP w/o [without] Contrast...MRI screening and education form to be completed electronically...Patient must be NPO for 4-6 hours prior to the exam..." There was no documented evidence the document was provided to Patient 5.

The MSTD stated the document titled, "Decision Support," is what the nurses provide to the patient prior to a procedure. The MSTD stated there was no documentation the document was provided to Patient 5.

A review of Patient 5's record was conducted on November 5, 2024, at 10:57 a.m., with the MSTD. A facility document titled, "History and Physical," dated November 3, 2024, was reviewed. The document indicated, "...Assessment/Plan...Acute pancreatitis [inflammation of the pancreas]...jaundice [yellowing of the skin]...liver cirrhosis [a condition with scarring of the liver]..."

An undated facility document titled, "Order Information for: MRI MRCP w/o [without] Contrast," was reviewed. The document indicated, "...original order entered and electronically signed by [Name] MRI tech [technician]...11/3/2024 [November 3, 2024] at 15:11 PST [ 3:11 p.m.]...MRI MRCP w/o Contrast..."

A facility policy and procedure titled, "Patient and Family Education," dated, October 2024, was reviewed. The policy indicated, "...To provide the patient, family and/or significant other education/training specific to the patients' needs and abilities and as appropriate to the care, treatment and services provided...Such instructions is presented in ways understandable to the patient, family and/or significant others and includes...The plan of care, treatment and services...Adult...Multidisciplinary personnel will document patient education on an ongoing basis to who was taught, what was taught, patient teaching tools utilized, written information given to the patient..."