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A. Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #2) clinical records reviewed from Location A, the Hospital failed to follow the physician's order for free water flushes (FWF), to ensure that a Registered Nurse (RN) supervised the nursing care for each patient.

Findings include:

1. On 10/12/2021, the clinical record of Pt. #2 was reviewed. Pt. #2 was admitted on 8/30/2021 with a diagnosis of respiratory failure. The clinical record included a physician's order, dated 10/4/2021, that required 200 ml (milliliters) of FWF through Pt. #2's gastrostomy tube (feeding tube) every six hours. The following was noted:

- On 10/5/2021 at 12:00 PM, 150 ml of FWF was given (50 ml short).
- On 10/5/2021 at 6:00 PM, 150 ml of FWF was given (50 ml short).
- On 10/8/2021 at 12:00 MN, 90 ml of FWF was given (110 ml short).
- On 10/8/2021 at 6:00 PM, 180 ml of FWF was given (20 ml short).

2. On 10/12/2021, the Hospital's job description for Registered Nurses (effective 1/2011) was reviewed and required, "... Utilizes the nursing process to... implement and evaluate the delivery of individual patient care... Primary Responsibilities... 8. Executes the medical treatment plan by implementing physician orders..."

3. On 10/12/2021 at approximately 12:30 PM, and on 10/13/2021 at approximately 10:00 AM, findings were discussed respectively with E #4 (Manager B1 and High Acuity Units) and E #3 (Assistant Director of Patient Care). E #3 stated that the physician's order should have been followed.

B. Based on document review and interview, it was determined that for 2 of 4 patients' (Pt. #2 and Pt. #3) clinical records reviewed from Location A, the Hospital failed to ensure that the gastric residual (fluid remaining in the stomach) for patients with enteral feeding (method of providing nutrition directly into the stomach) was checked, to ensure that a Registered Nurse evaluated the care for each patient.

Findings include:

1. On 10/13/2021, the Hospital's training for registered nurses (undated) included, "... Enteral Feeding. I. Residuals. 1. G-tube (gastrostomy) and NGT (nasogastric tube) residuals checked every shift by the RN..."

2. On 10/12/2021, the clinical record of Pt. #2 was reviewed. Pt. #2 was admitted on 8/30/2021 and had a gastrostomy tube (used to give liquid food directly to the stomach) for continuous daily enteral feeding. The clinical record indicated that gastric residual check was left blank on 10/10/2021 AM shift (7:00 AM through 7:00 PM), 10/11/2021 AM shift, and 10/11/2021 PM shift (7:00 PM through 7:00 AM).

3. On 10/12/2021, the clinical record of Pt. #3 was reviewed. Pt. #3 was admitted on 7/13/2021 with a diagnosis of acute respiratory failure. The clinical record indicated that Pt. #3 had a nasogastric tube (tube that carries food to the stomach) for enteral feeding for 21 hours daily. The clinical record indicated that gastric residual check was left blank on 10/9/2021 PM shift, 10/10/2021 AM shift, 10/10/2021 PM shift, and 10/11/2021 AM shift.

4. On 10/12/2021, the Hospital's job description for registered nurses (effective 1/2011) was reviewed and required, "... Complies with all (Name of the Hospital) hospital and departmental policies..."

5. On 10/13/2021 at approximately 10:30 AM, findings were discussed with E #3 (Assistant Director of Patient Care). E #3 confirmed that the gastric residual was not checked. E #3 stated, "If left blank, it means it was not done."


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C. Based on document review and interview, it was determined that for 2 of 3 patients requiring turning to prevent skin wounds (Pts. #8 & #9) at Location B, the Hospital failed to ensure a registered nurse supervised/completed the documentation of patient turning was completed.

Findings included:

1. The Hospital's policy titled, "Skin Care Prevention and Repositioning of Patients," effective 3/2018, was reviewed. The policy required, "The Braden Scale is completed by the staff RN and is accessed in the EMR [electronic medical record] through the Skin Risk intervention... A score of 18 or below indicates risk... 15 - 18 low risk... 13 - 14 moderate risk... 12 or less high risk... Risk Stratification Interventions for Mitigation of Skin Injury... Moderate risk - Turn and offload patients frequently (every 2 hour)..."

2. On 10/12/2021, Pt. #8's clinical record was reviewed. Pt. #8 was admitted on 8/27/2021 with diagnoses of acute respiratory failure and pontine hemorrhage (stroke). Pt. #8's nursing assessment, dated 8/28/2021, included, Pt. #8 was comatose and activity level was "immobile". Pt. #8's skin risk assessment score was 13 points [moderate risk]. During a three day period from 10/9/2021 to 10/11/2021, Pt. 8's clinical record lacked documentation of 2 hour turning on 10/9/2021 from 12:00 AM to 6:00 AM (6 hours missing).

3. On 10/13/2021, Pt. 9's clinical record was reviewed. Pt. #9 was admitted on 8/24/2021 with diagnoses of acute respiratory failure and a right lower extremity wound. Pt. #9's nursing assessment, dated 8/24/2021, included Pt. #9's skin risk assessment score was 13 points [moderate risk]. During a three day period (10/9/2021, 10/10/2021, and 10/11/2021), Pt. 9's clinical record lacked documentation of 2 hour turning on 10/9/2021 from 8:00 PM to 10/10/2021 at 8:00 AM (12 hours missing); and on 10/10/2021 from 8:00 PM to 10/11/2021 at 8:00 PM [24 hours missing].

4. On 10/13/2021 at 11:43 AM, an interview was conducted with the Chief Nursing Officer (E #10). E #10 stated that she reviewed Pt. #8 & #9's turning schedule and found that an Agency Registered Nurse had been assigned to both patient. E #10 stated that the Agency would be contacted to address the missing turning documentation.