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Based on document review, observation, and interview, the facility failed to provide safe environment for 1 of 10 patients (Patient #10). See Tags A0115 and A0144.

The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review, observation, and interview, the facility failed to provide care in a safe environment for 1 of 10 patient medical records reviewed. (Patient #10)

Findings include:

1. Review of policy titled "Patient Rights and Responsibilities", Policy Number RE 09, last reviewed 06/2021, indicated patients will be treated in a safe environment.

2. Review of Patient 10's medical record indicated that on 02/08/2024, patient experienced shortness of breath and A4 (Charge Nurse) placed a plastic bag over patient's mouth and nose. A6 (Licensed Practical Nurse) requested A4 to remove the plastic bag; the plastic bag was removed. A6 resumed care of the patient.

3. Observation of incident video on 02/08/2024 indicated that A4 obtained a plastic bag from the nurse's station and placed it over Patient 10's head for approximately 30 seconds.

4. Interview with A1 (Director of Nursing) on 02/28/2024 at approximately 3:40 p.m. confirmed that A4 placed a plastic bag over Patient 10's head on 02/08/2024. A1 indicated that A4 was dismissed from staffing.

Based on document review and interview, nursing services failed to document vital signs according to policy; discharged or transferred a patient without a written order for 9 of 10 patient medical records reviewed. (Patients 2, 3, 4, 5, 6, 7, 8, 9, and 10).

Findings include:

1. Review of policy titled, "Vital Signs", Policy Number CC.28, last reviewed 06/2021, indicated vital signs will be taken a minimum of three times daily.

2. Review of policy titled "Discharge of Patients", Policy Number CC.63, last reviewed 06/2021, indicated all patients require a formal discharge and an order from the physician is required for discharge.

3. Review of patient 2's medical record lacked documentation of vital signs according to policy on 12/14/2023, 12/16/2023, and 12/17/2023; nursing transferred patient to the emergency room on 12/17/2023 without a transfer order.

4. Review of patient 3's medical record lacked documentation of vital signs according to policy on 12/8/2023 and 12/09/2023; nursing transferred patient to the emergency room on 12/09/2023 and discharged patient on 12/10/2023 without a discharge or transfer order.

5. Review of patient 4's medical record lacked documentation of vital signs according to policy on 11/26/2023, 11/28/2023, 11/29/2023, 12/1/2023, 12/05/2023, 12/07/2023, 12/09/2023, 12/11/2023, and 12/12/2023; nursing transferred patient to the emergency room on 12/11/2023 and discharged patient on 12/13/2023 without a discharge or transfer order.

6. Review of patient 5's medical record lacked documentation of vital signs according to policy on 01/03/2024 and 01/06/2024; nursing transferred patient to the emergency room on 01/06/2024 without a transfer order.

7. Review of patient 6's medical record lacked documentation of vital signs according to policy on 01/19/2024, 01/22/2024, 01/25/2024, 01/27/2024, 01/28/2024, and 01/29/2024; nursing transferred patient to emergency room on 01/25/2024 and discharged patient on 01/29/2024 without a discharge or transfer order.

8. Review of patient 7's medical record lacked documentation of vital signs according to policy on 02/11/2024, 02/15/2024, 02/21/2024, 02/24/2024, and 02/25/2024; nursing transferred patient to the emergency room on 02/16/2024 and discharged patient on 02/26/2024 without a discharge or transfer order.

9. Review of patient 8's medical record lacked documentation of vital signs according to policy on 02/01/2024, 02/02/2024, 02/05/2024, 02/06/2024, 02/07/2024, 02/09/2024, 02/10/2024, 02/11/2024, 02/12/2024, 02/14/2024, and 02/16/2024; nursing transferred patient to the emergency room on 02/17/2024 without a transfer order.

10. Review of patient 9's medical record lacked documentation of vital signs according to policy on 01/16/2024, 01/18/2024, 01/19/2024, 01/20/2024, 01/21/2024, 01/22/2024, 01/23/2024, and 01/24/2024; nursing discharged patient on 01/24/2024 without a discharge order.

11. Review of patient 10's medical record lacked documentation of vital signs according to policy on 02/08/2024, 02/13/2024, 02/15/2024, 02/16/2024, 02/20/2024, 02/21/2024, and 02/22/2024; nursing discharged patient on 02/22/2024 without a discharge order.

12. Interview with A2 (Regional Quality Manager) on 02/28/2024 at approximately 5:30 p.m. confirmed patients 2, 3, 4, 5, 6, 7, 8, 9,and 10's medical record lacked documentation of vital signs according to policy and nursing services discharged or transferred patients without written orders.

13. Interview with A1 (Director of Nursing) on 02/28/2024 at approximately 5:30 p.m. confirmed that a discharge or transfer order must be written for patients who are discharged or transferred to the Emergency Room.

Based on document review and interview, the facility failed to ensure that agency staff received orientation of facility in 1 of 1 personnel records (A4) reviewed.

Findings include:

1. Review of policy titled "Employee Orientation", Policy Number HR23, last reviewed 09/2018, indicated the purpose of orientation is to ensure all employees develop skills and competencies to effectively and safely perform their duties and responsibilities. The policy indicated an additional policy addressing orientation specifics for contract, registry, and temporary agency staff.

2. Review of A4's (Registered Nurse) personnel files lacked documentation of facility orientation and competencies related to facility and role.

3. Interview with A1 (Director of Nursing) on 02/28/2024 at approximately 4:45 p.m. confirmed that A4's personnel file lacked documentation of orientation and competencies related to facility and role.

4. Interview with A2 (Regional Quality Manager) on 02/28/2024 at approximately 5:15 p.m. confirmed the policy referenced in the above policy could not be located.