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Based on interview and record review, the facility failed to implement its policies and procedures when:
1. One of 30 sampled patients (Patient 1) was not given pain medications after reporting pain; and,
2. One staff member did not perform proper hand hygiene after exiting an Isolation Room.

These failures had the potential to result in unrelieved pain and unnecessary suffering to Patient 1, and poor hand hygiene increased the risk of transmitting harmful microorganisms to patients which may lead to serious infections and even death.

Findings:

1. During an interview on 8/7/24 at 4:10 p.m., Nurse C stated a patient's pain level was assessed at least every shift, and pain scales were often used to determine the pain level. Nurse C stated pain scales used numbers from 0 to 10, with 0 meaning no pain, and 10 meaning the worst possible pain. Nurse C stated pain medications were given depending on the patient's pain level, and the pain level was reassessed about an hour after giving oral pain medications, and about 30 minutes after giving intravenous (IV) pain medications. Nurse C stated the goal was to keep the patient's pain at at an acceptable level and to maintain comfort.

During a concurrent interview and record review with Nurse Manager D on 8/8/24 at 10:39 a.m., Patient 1's, "Pain Flowsheet," was reviewed. Patient 1's, "Pain Flowsheet," indicated a pain level of, "5" at 1540 (3:40 p.m.) on 7/4/24, and pain levels of, "6" on 7/5/24 at 0610 (6:10 a.m.), 1200 (12 p.m.), and 1710 (5:10 p.m.). Patient 1's, "Pain Flowsheet," indicated an, "Acceptable Comfort Level: 3." Nurse Manager D confirmed there was no documentation that Patient 1 received any pain medication, or any other interventions, for his reported pain on 7/4/24 and 7/5/24.

A review of the facility policy titled, "Pain Management," dated, "6/8/2022," indicated, "Patients have the right to pain management. It is the policy of the hospital to do the following: ... C. Assess the patient's response to care, treatment, and service implemented to address pain. D. Treat the patient's pain or refer the patient for treatment... C. INTERVENTIONS: 1. Initiate intervention whenever patient's current pain score exceeds their goal... 3. Use adjunctive interventions when appropriate that may include: positioning, relaxation, massage, guided imagery, humor, music, and application of heat/cold..."


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2. During an observation and concurrent interview on 8/5/24 at 2:40 p.m., Nurse Aide A exited a patient room which had a sign on the door indicating, "Enhanced Droplet Precautions" (required for patients diagnosed with or suspected of having infectious microorganisms transmitted by both the Droplet and Contact routes), wearing a N95 respirator (personal protective equipment (PPE) that is used to protect the wearer from potentially infectious particles). Nurse Aide A removed her N95 respirator, threw the respirator in the trash, and sat down at the nurses' station to make a phone call. Nurse Aide A did not perform hand hygiene. When queried, Nurse Aide A verified she did not perform hand hygiene after touching the respirator. Nurse Aide A stated she should have performed hand hygiene after removing the respirator and verified she had received training on hand hygiene. When asked the reason hand hygiene should be performed after removing PPE, Nurse Aide A stated, "Germs."

During an interview on 8/8/24 at 11 a.m., Nurse Manager B stated it was her expectation staff perform hand hygiene after removing a N95 respirator and before making a phone call. When asked the reason hand hygiene should be performed after removing PPE, Nurse Manager B stated, "Infection control."

Review of hospital policy, "[Hospital Name] Specific Hand Hygiene Policy," last revised 4/25/23, indicated, "Purpose: To provide evidence-based guidelines for effective and safe hand hygiene in the healthcare setting and: . . . To reduce the transmission of pathogenic microorganisms and the incidence of healthcare associated infections caused by these organisms . . . Hand hygiene will be performed before or after the following activities: . . . After removing PPE . . . ."