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Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Nursing Services as evidenced by:

1.The facility failed to document one of 30 sampled patient ' s (Patient 9) behavioral status while he was being physically restrained (a manual or mechanical device restricting a patient ' s movement, generally used to prevent harm to the patient or others).

This deficient practice has the potential for the patient while under restraint may lead to poor blood circulation, depending on the type of restraint, and inability of the patient to maintain hygiene, due to lack of periodic (occurring repeatedly from time to time) monitoring. (Refer to A-0395)



2.The facility failed to assess, reassess, manage and document seven of 30 sample patients (Patient 2, Patient 10, Patient 18, Patient 19, Patient 20, Patient 22 and Patient 30) pain level per facility policies and procedures.

These deficient practices resulted in patients ' needs for pain relief not being met. (Refer to A-0398).

3. The facility failed to ensure one of 30 sample patients (Patient 2) was administered was administered medications from home by an authorized and licensed hospital personnel according to a doctor ' s order and facility policy and procedure during hospital admission.



This deficient practice resulted in Patient 2 receiving home medication from a family member without a physician order and without clearance from pharmacist (a licensed person who give out prescription medication) to verify the identification of the medication while in the facility. (Refer to A-0405)

The cumulative effect of these deficient practices resulted in the facility ' s inability to provide quality health care in a safe environment.

Based on observation, interview, and record review the facility failed to document and monitor one of 30 sampled patient ' s (Patient 9) behavioral status while he was being physically restrained (a manual or mechanical device restricting a patient ' s movement, generally used to prevent harm to the patient or others).

This deficient practice has the potential for the patient while under restraint may lead to poor blood circulation, depending on the type of restraint, and inability of the patient to maintain hygiene, due to lack of periodic monitoring



Findings:

During a tour on 5/29/2025 at 10:40 a.m., accompanied by RN 2, Patient 9 was observed in bed with soft restraints (band placed around a patient ' s wrist and tethered to the bed to restrict movement) to both wrists. The restraints were secured to the underside of the bed and Patient 9 ' s arms were spread out and apart from the midline (imaginary line runs down the center of the body, that dividing into left and right halves) of his body. Patient 9 was sleeping at this time.



During an interview on 5/29/2025 at 1:40 p.m., RN 2 stated Patient 9 pulled out two IV lines (small tubes placed within veins to infuse fluids) last night (5/28/2025) and was restrained to prevent Patient 9 from pulling out the lines and slowing the delivery of medicine. RN 2 also stated patients with restraints should be monitored to ensure the restraint is not too tight around the wrist and the patient has a chance to use the restroom. RN 2 subsequently stated, after reviewing the ' Flowsheets ' for ' Non-Violent Restraints (Medical Surgical) ' dated 5/29/2025, there was no documentation of monitoring Patient 9 for restraint tightness or offering toileting from 9:00 AM through 1:00 PM on 5/29/2025. During an interview on 5/29/2025 at 1:15 p.m., the Clinical Director of Regulatory Affairs (CDRA) stated, per the hospital ' s policy, if a patient is monitored every two hours while on restraints then the details of monitoring should be recorded in the patient ' s medical record.

During a review of the ' Neurocritical Care Admission Note ' , patient assessment performed by a neurosurgeon - surgeon specializing in surgery on the nervous system, especially the brain and spinal cord, dated 5/3/2025, indicated Patient 9 presented to the hospital after two generalized tonic-clonic seizure (change of the electrical activity in the brain that exhibits loss of consciousness, stiffening of the body, and jerking movements). The treatment plan of this note indicated frequent neuro-checks (assessments of a patient's neurological function such as body movement and ability to speak, typically performed by nurses to monitor and detect changes in a patient's condition) by nursing and antiseizure medications will be administered.

A review of the ' Non-behavioral, non-violent/non-self destructive, restraint order number 780608056, dated 5/29/2025 at 3:26 AM, indicated restraint began on 5/29/2025 at 3:30 a.m., and ended 5/30/2025 at 11:59 p.m. The ' Comments Section ' of this order indicated the restraint order must be renewed every calendar day based upon examination of the patient.

A review of the ' Flowsheets ' for ' Non-Violent Restraints (Medical Surgical) ' indicated that restraints were discontinued from Patient 9 at 8:00 a.m. on 5/25/2025. Further review of this ' Flowsheet ' for restraint use indicated Patient 9 was on soft restraints beginning 3:30 a.m. on 5/29/2025, per ' Non-behavioral, non-violent/non-self destructive, restraint order number 7806080556; There was no documentation of monitoring from 9:00 AM through 1:00 PM on 5/29/2025 (a total of 4 hours).

During a record review of the facility ' s policy and procedure titled ' Restraint, HS 1321 ' Policy State ID 14535451 approved 11/2023, this document indicated restraints are used so they do not cause unnecessary physical discomfort, harm, or pain and are removable in the event of an emergency. The ' Observation, Monitoring and Documentation ' part of this policy indicted patients under non-violent restraint are observed and monitored at least every 2 hours for signs of injury, level of consciousness and circulation, sensory and motor function (ability to perform voluntary motion); These assessments are then documented.

Based on interview and record review, the facility failed to assess, reassess, manage and document seven of 30 sample patients (Patient 2, Patient 10, Patient 18, Patient 19, Patient 20, Patient 22 and Patient 30) pain level per facility policies and procedures.

These deficient practices resulted in patients ' needs for pain relief not being met.

Findings:

1. During a review of Patient 2 ' s face sheet (a document summarizing a patient ' s personal and demographic information), dated 8/31/2024, indicated patient arrived at the ED (Emergency Department, a specialized area within a hospital that provides immediate medical care for patients with serious or emergent conditions) at 5:06p.m. and with diagnosis of vomiting and abdominal pain.

During concurrent interview and record review on 5/28/2025, at 12:53 p.m., with Emergency Department Director (ED Dir) 1 of Patient 2 ' s ED triage (process of sorting patient for treatment based on injury or illness) notes, dated 9/1/2024, ED Dir 1 stated on 8/31/2024, at 5:11 p.m., patient ' s (Patient 2) family member reported patient had severe pain with a pain score of 8 (intense pain)out of 10 (tool use to measure pain ,with 0 no pain and a score of 10 being the worse possible pain imaginable).

During concurrent interview and record review on 5/28/2025 at 12:55p.m., of Patient 2 ' s Emergency Department (ED) flowsheet with the ED Dir 1. ED Dir 1 stated Patient 2 was not reassessed for pain until 12 hours after initial report of pain, at 9/1/2024 at 5:15 p.m. from the time Patient 2 was admitted in the ED.

During interview and record review on 5/28/2025 at 12:58p.m. with the ED Dir 1, Patient 2 ' s medication administration record (MAR – a legal document that provides a comprehensive and accurate record of all medications administered to a patient), dated 8/31/2024 was reviewed. ED Dir 1 stated there was no medications ordered for Patient 2 ' s severe (serious) pain and patient did not receive any medication for severe pain reported. ED Dir 1 stated there was no documentation of non-pharmacological interventions for Patient 2 ' s severe pain of 8 out of 10.

Concurrently, during review of facility ' s ED Pain Protocol, dated 3/2025), indicated Pain will be assessed using an approved pain scale and pain medication will be expeditiously administered to patients who present to the ED triage in pain.

Concurrently, during review of facility ' s Pain Assessment and Management policy, dated 8/2023), indicated pain is always subjective and pain assessment included information from the patient or patient ' s proxy and pain ratings obtained with a validated pain measurement tool with the patient ' s developmental and/or cognitive status.

2. During an interview on 5/29/2025 at 1:45 p.m. Registered Nurse (RN 2), RN 2 stated per hospital ' s policy dictates (rule) how pain is evaluated (to judge something) an assessment (collection of data about an individual ' s health status) should be documented in the patient ' s medical record. RN 2 also stated that pain intensity(strength) should be monitored to determine if the pain therapy is effective (successful).



Concurrently, during review of facility ' s Pain Assessment and Management policy, dated 8/2023), indicated patients are screened for pain as part of the patient ' s initial evaluation and on an ongoing basis. And, pain is reassessed following pharmacologic and nonpharmacologic interventions with consideration of peak analgesic effect and documented in the medical record.



During a record review of the ' Medicine History and Physical ' (a comprehensive evaluation of a patient ' s medical history and physical examination) indicated Patient 10 was admitted on 5/26/2025 and presented with acute pain crisis (sudden severe pain that can last few hours, days, or even weeks). It also indicated Patient 10 ' s past medical history (a comprehensive record of a patient ' s medical, personal, and family history, encompassing past illnesses, surgeries, injuries, allergies and more) : sickle cell crisis (event when sickle-shaped red blood cells block blood flow, leading to intense pain and other symptom), multiple strokes (sudden disruption of blood flow to the brain, causing brain tissue damage), AVN (Avascular Necrosis, a condition where bone tissue dies due to a lack of blood supply) The ' Medicine History and Physical ' indicated part of Patient 10 plan was to alleviate (reduce) pain due to sickle cell crisis included the use of several pain medications including Tylenol (medication usually given for reduction of minor pain) given three times per day.



During a review of the ' Flowsheets ' showed that on 5/29/2025 at 10:20 a.m., Patient 10 was experiencing pain to the head and that medication was given. This document did not indicate the pain assessment tool used to determine the severity (seriousness) of pain or actual pain experienced by Patient 10. This document did not indicate any follow up assessment of pain after the medication was given.



During a review of the Medical Administration Record (MAR) indicated Patient 10 also received a 30 mg dose of ketorolac (medication used for the short-term relief of moderately severe pain) on 5/29/2025 at 10:20 a.m.  Patient 10 was also given a 500 mg (milligram-a unit of weight or mass in the metric system) dose of Tylenol (pain medication) on 5/29/2025 at 10:27 AM.



During a review of the ' Pain Assessment and Management Policy, HS 1341 ' , this policy indicated assessment includes pain level determined by an appropriate tool consistent with the patient ' s cognition (mind ability to think, learn, and understand). This policy indicated pain assessment will include the following: location, intensity, quality (description), and duration (how long something last). The ' Pain Assessment and Management policy ' specified that depending on the setting, pain is reassessed following medication administration considering the peak (highest point) pain reduction affect and documented in the patient ' s medical record.



3.A review of Patient 18 ' s face sheet (a document summarizing a patient ' s personal and demographic information), dated 5/27/2025, indicated patient arrived in the Emergency Department (ED, a specialized area within a hospital that provides immediate medical care for patients with serious or emergent conditions) at 7:42 p.m. with a chief complaint of sepsis (body response to infection).

During concurrent interview and record review on 5/29/2025, at 2:17 p.m., with Nurse Informaticist (Nse Info) 1 of Patient 18 ' s Emergency Department (ED) triage notes, Nse Info 1 stated patient was triaged at 7:45 p.m. and complained of mild pain with a pain score of 3 out of 10, and with an acuity (severity of patient illness) of 3, urgent(patients with this condition that requires multiple resources and/or have a moderate risk of deterioration, such as a broken bone, a severe headache, or abdominal pain).

During concurrent interview and record review on 5/29/2025 at 2:20p.m., of Patient 18 ' s nursing flowsheet, dated 5/28/2025, Nse Info 1 stated patient was not reassessed for pain from 1:53 a.m. to 8:15 a.m.

Concurrently, during review of the facility ' s policy for Pain Assessment and Management, dated 8/2023, indicated pain is reassessed following pharmacological interventions, with consideration of peak analgesic effect and documented in the medical record.

4.A review of Patient 19 ' s face sheet (a document summarizing a patient ' s personal and demographic information), dated 5/26/2025, indicated patient was admitted to the facility with a diagnosis of infection in the abdominal wall (a multilayered structure of skin, fascia, and muscles that encloses and protects the abdominal cavity and its organs)On 5/29/2025, at 3:05 p.m., during concurrent interview and record review with Nurse Informaticist (Nse Info) 1, Patient 19 ' s Clinic visit, dated 5/23/2025 was reviewed. Nse Info 1 stated patient was seen by her primary physician who found an abscess (collection of pus (thick milky-white or yellowish fluid) within the body tissue) in the patient ' s abdomen that need to be drained.

During record review of Patient 19 ' s history and physical (H&P – a comprehensive assessment of a patient ' s health, encompassing both a detailed medical history and a physical examination), dated 5/26/2025, indicated the following:

Past medical history of cancer with an abscess with a drain placed on 1/4/2025, with dependance on gastrostomy tube (g-tube – a flexible tube inserted into the stomach through an opening in the abdominal wall), with a complaint of increasing abdominal pain and swelling, and development of carbapenem resistant pseudomonal infection (class of antibiotic use to treat bacteria that are resistant to other drugs).



During concurrent interview and record review on 5/29/2025 at 3:10p.m., with Nse Info 1, of Patient 19 ' s nursing flowsheet, dated 5/27/2025, and medication administration record (MAR – document used to track and record all medications administered to a patient), dated 5/27/2025, and physician orders for medications, Nse Info 1 stated the following:

At 1:32 p.m., patient complained of moderate pain with a pain score of 4 out of 10 and was given Tylenol (pain medication) 650 milligrams (mg).

Patient ' s pain was not reassessed after one hour from receiving Tylenol 650 mg.

From 3:32 p.m. to 5:00 p.m., left the unit for a procedure and pain was not reassessed.

At 5:00 p.m., patient returned to the unit and complained of severe pain with a pain score of 8 out of 10.

At 5:48 p.m., patient was given oxycodone 10 mg for pain score of 8/10.

Patient ' s pain was not reassessed after one hour from receiving oxycodone 10 mg for severe pain.

At 9:42 p.m., patient complained of worsening pain with a pain score of 9/10 and was given oxycodone 20 mg for worsening pain.

At 10:42 p.m., patient reported mild pain with a score of 1/10.

During review of the facility ' s Pain Assessment and Management policy, dated 8/2023, indicated pain assessment included pain ratings obtained with a validated pain measurement tool consistent with the patient ' s developmental and/or cognitive status. Pain is reassessed following pharmacologic and nonpharmacologic interventions and is documented in the medical record.



5.A review of Patient 20 ' s face sheet (a document summarizing a patient ' s personal and demographic information), dated 5/28/2025, indicated patient arrived at the ED at 2:28 a.m. with a rash.

A review of Patient 20 ' s ED (Emergency Department, a specialized area within a hospital that provides immediate medical care for patients with serious or emergent conditions) physician note, dated 5/28/2025, indicated patient had an abscess in the mouth, which began a week ago with blisters (pocket of fluid underneath the skin) that worsened with swelling in the right cheek, more blisters inside the mouth, and difficulty swallowing.

During concurrent interview and record review of the Emergency Department Time line for Patient ' s 20 Emergency Department visit, on 5/30/2025, at 8:28 a.m., with Nurse Informaticist (Nse Info) 1, of Patient 20 ' s ED timeline, dated 5/28/2025. Nse Info 1 stated the following:

During triage, patient complained of severe pain, in the mouth with multiple blisters, with a pain score of 10 out of 10 (worst pain ever), at 2:38 a.m. There was no indication of pain management until 4:12a,.m.

At 4:12 a.m., physician ordered pain medication, morphine (strong pain medication) 4 mg by vein (IV-intravenous-method of administering fluids or medicine directly in the vein).

No reasseement of Patient ' s 20 pain since triage at 2:38a.m. And prior to administering morphine 4 mg IV for pain at 4:30a.m.

Patient was not reassessed for pain within one hour of receiving the second dose of morphine 4 mg IV, to check the effectiveness of the pain medication given.

At 7:35 a.m. and at 8:49 a.m., patient complained of severe pain with a pain score of 10/10, and there was no documentation of pain-relieving interventions or pain medication given.

At 11:30 a.m., patient complained of severe pain with a score of 10/10 and was given pain medication, hydromorphone (pain medication use to treat severe pain)1 mg IV.

Patient was not reassessed for pain within one hour after receiving pain medication hydromorphone, to check the effectiveness of the pain medication given.

At 4:27 p.m., patient was not reassessed for pain, prior to being given Tylenol 1000 mg IV and morphine 2 mg IV.

Patient was not reassessed for pain within one hour of receiving pain Tylenol and morphine medications, to check the effectiveness of the pain medications given.at 8:24 p.m., patient was admitted to intensive care unit.



During review of facility ' s Pain Assessment and Management policy, dated 8/2023, indicated patient is screened for pain as part of the patient ' s initial evaluation and on an ongoing basis. And pain is reassessed following pharmacologic interventions and documented in the medical record.



6.A review of Patient 22 ' s face sheet (a document summarizing a patient ' s personal and demographic information), dated 5/22/2025, indicated that patient arrived in the ED (Emergency Department, a specialized area within a hospital that provides immediate medical care for patients with serious or emergent conditions) at 12:00 a.m., with breathing difficulties.

On 5/30/2025, at 10:49 a.m., during concurrent interview with Nse Info 1 and record review of Patient 22 ' s nursing flowsheet, dated 5/22/2025, Nse Info 1 stated Patient 22 was not assessed for pain from 12:00 a.m. to 3:45 a.m., in the ED.

A review of facility ' s Pain Assessment and Management policy, dated 8/2023, indicated that patients are screened for pain and on an ongoing basis, using pain measurement tools consistent with the patient ' s developmental and intellectual capacity.





7.A review of Patient 30 ' s face sheet (a document summarizing a patient ' s personal and demographic information), dated 4/23/2025, indicated patient was admitted to the facility with a chief complaint of debility (a state of physical weakness).

On 5/29/2025, at 12:05 p.m., uring concurrent interview with Emergency Department (ED - a specialized area within a hospital that provides immediate medical care for patients with serious or emergent conditions) Director (ED Dir) 1 and record review of Patient 30 ' s Emergency Department triage notes, dated 4/23/2025. ED Dir 1 stated patient complained of severe pain with a pain score of 8 out 10, at 2:54 p.m.



During interview on 5/29/2025 at 12:08p.m., with Nurse Informaticist ( a nurse combines their clinical expertise and knowledge of information technology) (Nse Info) 1 stated Patient 30 was reassessed for pain, after two hours, on 4/23/25 at 4:56 p.m., and was given pain medication of Tylenol 1000 mg (milligram-a unit of weight or mass in the metric system) by mouth for pain score of 5/10 – which was moderate pain.

Nse Info 1 stated Patient 30 was not reassessed for pain after having received pain medication of Tylenol at 4:56p.m., to check the effectiveness of the pain medication. Nse Info 1 stated patient should have been reassessed for pain within one hour of receiving Tylenol. Nse Info 1 stated there was no documentation that the pain was relieved after receiving Tylenol 1000 mg on 4/23/2025, at 4:56 p.m., per facility ' s policy and procedure for pain management.

Nse Info 1 also stated Patient 30 was only reassessed for pain, since receiving Tylenol, on 4/24/2025, at 3:00 a.m. – more than 12 hours after receiving Tylenol for pain.

A review of facility ' s policy for Pain Assessment and Management, dated 8/2023, indicated the following:

Patients have the right to evidence-based pain treatment and supports a multidisciplinary (people from different disciplines working together) approach to pain assessment and management.

Pain assessment includes information from the patient or proxy (a person authorized to act for another) about provoking (cause) factors, quality/characteristics, region/radiation(spread), relieving factors associated(related) with symptoms and timing.

Pain assessment includes pain ratings obtained with a validated (confirm) pain measurement tool consistent(regularly) with the patient ' s developmental(growing)and/or cognitive (mental process like thinking, learning and remembering) status.

Patients are screened for pain as part of the patient ' s initial evaluation and on an ongoing basis, for pain scores unacceptable to the patient or proxy.

Pain history is obtained when pain in present, upon initial screening or upon the first report of pain, whichever comes first. If initial pain screen was negative, but a later screen is positive and relevant to the visit, the pain assessment/history is to be obtained, at that time.

Pain assessment will include location, intensity, quality, and duration.

Patients should receive prompt, effective pharmacologic/non-pharmacologic and/or procedural management for their pain, if indicated and relevant to the visit.

Pain management plans are individualized and include concerns of the patient, family and/or proxy.

Pain is reassessed with new reports of pain and following procedures/activities that are expected to cause pain.

Pain is reassessed following pharmacologic (treatment with use of drugs) and non-pharmacologic (treatment with non use of drugs) interventions, with consideration of peak analgesic effect and are documented in the medical record.



A review of facility ' s policy for Emergency Department Pain Protocol, dated 3/2025, indicated the following:

The use of evidence-based nurse-initiated pathways to enhance the quality and efficiency (effectiveness)of patient care to expeditiously(fast) administer pain medications to patients who present to the emergency department (ED) triage area in pain.

Pain will be assessed using approved pain scale.

Patients should receive only one dose of medication based on the protocol for pain.

First line goal is acetaminophen (medication use to treat minor pain)650 milligrams (mg) by mouth, for pain, if requested and/or used by patient, before without issue, once.

Ibuprofen (use to treat mild to moderate pain) 400 to 600 mg by mouth, for pain, if requested and/or used by patient before without issue, once.

Registered Nurse (RN) will document all interventions (treatment) for pain control.

Providers will co-sign the order initiated by the RN, per protocol.

Based on interview and record review, the facility failed to ensure one of 30 sample patients (Patient 2) was administered medications from home by an authorized and licensed hospital personnel according to a doctor ' s order and facility policy and procedure.



This deficient practice resulted in Patient 2 receiving home medication from a family member without a physician order and without clearance from pharmacist (a licensed person who give out prescription medication) to verify the identification of the medication while in the facility.

Findings:

A review of Patient 2 ' s face sheet (a document summarizing a patient ' s personal and demographic information), dated 8/31/2024, indicated patient arrived in the Emergency Department (ED) at 5:06 p.m., with patient ' s family member who lived with the patient, with a complaint of problems with the gastrostomy tube (G-tube – a flexible tube inserted into the stomach through an opening in the stomach wall to provide nutrition, fluids and/or medications directly into the stomach).

On 5/28/2025, at 12:53 p.m., durrng concurrent interview with Emergency Department (ED - a specialized area within a hospital that provides immediate medical care for patients with serious or emergent conditions) Director (ED Dir)1 and record review of Patient 2 ' s ED nursing notes, dated 9/1/2024 was reviewed. ED Dir 1 stated Registered Nurse (RN) 3 assisted Patient 2 ' s family member who crushed patient ' s medications, mixed the medications with warm water, and administered the medications by patient ' s G-tube.ED Dir 1 stated Patient 2 had no physician orders for patient ' s family member to administer patient ' s home medications, in the facility. RN 3 did not send Patient 2 ' s home medications to the pharmacy for verification of medication ' s identification, prior to administration, per facility ' s policy and procedure. RN 3 did not document the two medications levetiracetam (treat seizures) and pantoprazole (treat increase stomach acid) given to Patient 2 by Patient 2 ' s family member – including the name of the medication, the dose of the medication, and expiration date of the medication.



During concurrent interview and record review on 5/28/25 at 1:00p.m., with ED Dir, a review of Patient 2 ' s medication administration record, dated 9/1/2024 was conducted. ED Dir 1 stated RN 3 did not give two medications, levetiracetam (treat seizures) 500 milligrams and pantoprazole (treat increase stomach acid) 40 milligrams, because Patient 2 ' s family member already gave the two medications.

A review of facility ' s policy for Medications – Use of Patient ' s Personal, dated 5/2025, indicated the following:

The physician writes an order in the patient ' s medical record indicating that the patient ' s personal supply of medical be used.

Medications brought in by the patient to the hospital are to be immediately delivered to the pharmacy to make a positive identification of the medication by verifying the product ' s physical shape, size, color, and manufacturer ' s imprinted identification number.

If the patient ' s personal supply of medication is used, the pharmacy shall repackage the medication to allow it to be distributed in unit dose form.



A review of facility ' s policy for Medication Administration, dated 11/2024, indicated the following:

Before a medication can be administered, an order must be written by a person lawfully authorized to prescribe.

Requirements of medication administration include identifying the following critical steps: right patient, right drug, right dose, right route, and right time.

Before administration, the individual administering the medication must verify the medication selected hasn ' t expired.

The nurse must observe the patient taking the medication.

Medications are not to be administered to personnel or visitors, except for patient ' s immediate family with approval of the unit director or charge nurse, after an order has been written by the physician on a prescription and dispensed by the pharmacy – this is to be a one-time order only.

Non-Formulary – medications brought into the hospital by the patient may be used if the medication was not available from the pharmacy, if the pharmacist made a positive identification of the drug and re-labeled it in the pharmacy department, if the physician wrote an order authorizing use of the patient ' s personal supply, and the pharmacy department stored the medications brought in from home by the patient, until the patient is discharged.