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Based on observation, interview and record review, the facility failed to ensure sharp objects were properly disposed off for one of 64 patients (Patient 1). This failure had the potential to result an injury or infection of blood borne pathogens to patient,visitor, and staff .

Findings:

During an observation on January 22, 2024, at 10:00 AM, in patient room 214B, a sharp uncapped needle with syringe attached was observed to be resting on the windowsill next to the patient's bed.

During an interview on January 22,2024, at 10:01 AM, with Patient 1, Patient 1 stated, "The nurse last night was using that to fix my JP Drain (Jackson-Pratt (JP) drain a surgical suction drain that gently draws fluid from a wound to help you recover after surgery), she must have left it there."

During concurrent observation and interview on January 22, 2024, at 10:10 AM, with the Chief Nursing Officer (CNO), in room 214B, an uncapped needle with syringe attached was observed to be resting on the windowsill next to the patient's bed. The CNO stated, "an open needle should not ever be left at a patient's bedside, it could injure a patient or anybody else who touches it, it is also an infection control risk." The CNO further stated, "This is not standard nursing practice and does not follow our facility policy on sharp disposal."

During a review of the facility's policy and procedure (P&P) titled, (Standard Precautions: Infection prevention and control Manual), Dated August 2021, indicated, "III Contaminated Sharps (Needles, scalpel Blades, Lancets, etc. ...Needles/Sharps are discarded in a biohazard labeled, impervious, puncture resistant container. A needle/sharp container is located in each patient room, medication rooms and in patient therapeutic departments. All used sharps must be disposed of immediately after use to minimize risk of injury to patients and healthcare workers."

Based on interview and record review, the facility failed to ensure an adequate number of licensed registered nurses (RN) were available to meet patient needs when RN 1 was assigned to care for a total of 5 patients, along with three (3) high-acuity telemetry (heart monitoring). This failure resulted in delays in medication administration for one of 30 sampled patients (Patient 15), which had the potential to result in further delay of care and decreased therapeutic outcomes.

Findings:

During a review of Patient 15's "History and Physical" (H&P) dated January 22, 2024, the "H&P" indicated, Patient 15 was admitted to the hospital after falling at home and hitting his head. Patient 15 had a past medical history of Hypertension (high blood pressure), Myelofibrosis (an uncommon type of bone marrow cancer that disrupts the body's normal production of blood cells and Thrombocytopenia (a condition causing a low blood platelet count. Platelets are colorless blood cells that help blood clot).

During an interview on January 23, 2024, at 10:45AM, with Registry Nurse 1 (RNR1), RNR1 stated, "I have not yet given the morning medications. I did not give the medications earlier because I was trying to prioritize my patients based on acuity. Based on my resources available, I was focusing on other patients." RNR1 further stated, the normal timeframe for medication administration is plus or minus one hour. To deviate from the order, the best practice is to clarify with the physician first. "I haven't had time to call the doctor yet."

During an interview on January 23, 2024, at 2:00 PM, with the MS/T Clinical Supervisor (MSTCS), the MSTCS stated, "we have to call and let the physician know if we want to hold medications. It is a physician order so it should be given as ordered or else confirmed with the physician. Holding or delaying administration of a medication like Protonix because it is 'not critical' is still not an excuse not to call the doctor for permission."

During a concurrent interview and record review on January 23, 2024, at 3:30 PM, with the MS/T Director, (MSTD), the policy and procedure (P&P) titled, "Medication Administration" dated April 2023, was reviewed. The P&P indicated, "Prior to administration, the 6 R's must be verified: ...C. Right Time: 30-60 minutes before or after the scheduled medication time." The MSTD stated, "These medications were given out of the administration window. This is not standard of practice."

During a concurrent interview and record review on January 24, 2024, at 4:00 PM, with the Chief Nursing Officer (CNO), the document "MS/T Patient Care Assignment Sheet" dated January 23, 2024, was reviewed. The "MS/T Patient Care Assignment Sheet" indicated that 5 patients were assigned to Registry Nurse 1 (RNR1) during the day shift (7:00 AM - 7:30 PM) of January 23, 2024. The CNO stated "RNR1 is out of ratio with 3 Telemetry patients and 2 Medical-Surgical (general hospital unit) patients ."

During an interview on January 25, 2024, at 9:00 AM, with the CNO, the CNO stated, the House Supervisor got 4 call-offs during the night and realized at 7:15 AM, on January 23, 2024, that they would be over ratio on the Medical-Surgical / Telemetry (MS/T) unit. One nurse was asked to stay over to assist but did not take an assigned patient load. This did not count towards the nursing ratio because she did not take an assignment and was only assisting until and she left at 11:00 AM. The CNO stated, the hospital attempted to bring in an additional RN but was unsuccessful. The CNO further stated, they remained out of ratio for the duration of the shift.

During a concurrent interview and record review on January 25, 2024 at 10:00 AM, with the CNO, Patient 15's "Medication Administration Record" (MAR) dated January 23, 2024, was reviewed. The "MAR" indicated medications Colace (a stool softener) and Protonix (to reduce stomach acid) were scheduled to be administered at 9:00 AM and were not given until 10:48 AM, on January 23, 2024. The CNO further stated, the nurse who was over ratio (RNR1) was delayed in administering morning medications (protonix and colace) by an hour and 45 minutes.

During a review of the facility's policy and procedure (P&P) titled "Organizational Plan for Providing Patient Care" dated August, 2022, the "P&P" indicated, "Mandated staffing ratio (on MS/T) is 4:1 patient-to-nurse ratio, with the ability to staff 5:1 for a patient case load that encompasses only the 'Medical-Surgical' patient status, with no telemetry monitoring."

During a review of the facility's policy and procedure (P&P) titled "Medication Administration Times" dated April, 2021, the "P&P" indicated, "Medications are to be scheduled and administered according to the hospital-wide routine schedule. Any exceptions to the schedule must be communicated to the pharmacy either via a written physician order or the nursing Medication Administration Record."

Based on observation, interview, and record review, the facility failed to ensure nursing staff followed the facility's policy and procedure (P&P) appropriately when staff did not label IV tubing (tubes used to administer medications into the veins) and peripheral IV sites (a small tube inserted into a vein used to deliver medications and fluids) for nine of 64 patients (Patient 1, Patient 2, Patient 3, Patient 7, Patient 8, Patient 9, Patient 10, Patient, 41 and Patient 42). This failure had the potential to result in longer than the intended use of peripheral IV's and IV tubing placing vulnerable patients at risk for infection and prolonged hospitalization.

Findings:

1a. During a review of patient 1's "History and physical" (H&P -a formal and complete assessment of the patient and their medical problem), the H&P indicated, Patient 1, presented to the hospital for cough, difficult breathing, and weakness post COVID 19 (viral infection with difficulty breathing) infections.

During an observation on January 22, 2024, at 10:00 AM, in room 214B, IV tubing was observed to be hanging at patient 1's bedside without a date or label.

1b. During a review of patient 2's H&P, the H&P indicated patient 2, had a history of renal failure (failure of the kidneys), hypertension (high blood pressure) and worsening shortness of breath.

During an observation on January 22, 2024, at 10:15 AM, in room 218B, IV tubing was observed to be hanging at Patient 2's bedside without a date or label.

1c. During a review of Patient 3's H&P, the H&P indicated, Patient 3 was an 85-year-old male with past medical history of recent CVA (bleeding in the brain), hypertension, and diabetes mellitus (a condition causing high blood sugar).

During an observation on January 22, 2024, at 10:20 AM, in room 217B, IV tubing was observed to be hanging at Patient 3's bedside without a date or label.

During an interview on January 22,2024, at 10:25 am, with Registered Nurse (RN 8), RN8 stated, tubing should be changed every 96 hours if not, possiblity for the nurse to not change the tubing and it was an infection risk for the patient.

1d. During an observation on January 22, 2024, at 10:55 am, in room 223B, Patient 41's Peripheral IV located on their left arm was observed to have unlabeled with a date of insertion on the site.

1e. During a review of Patient 7's "H&P", the H&P indicated, Patient 7,had a past medical history of significant coronary artery disease (a narrowing of arteries in the heart, limiting blood flow to the heart), and hypertension.

During an observation on January 22, 2024, at 11:05am, in room 212, IV tubing was observed to be hanging at Patient 7's bedside with a label indicating "Change Wednesday" on the tubing but without a date.

1f. During a review of Patient 8's H&P, the H&P indicated, patient 8 is a 57-year-old Male with Past medical history of Hypertension and complaints of dry cough post COVID 19 infection.

During an observation on January 22, 2024, at 11:10 am, in room 207B, IV tubing was observed to be hanging at Patient 8's bedside with a label on the tubing indicating "Change Wednesday" but without a date.

1g. During a review of Patient 9's H&P, the H&P indicated, Patient 9 was a 56-year-old female with past medical history of diabetes mellitus.

During an observation on January 22, 2024, at 11:15 am, in room 208A, IV tubing was observed to be hanging at Patient 9's bedside with a label on the tubing indicating "Change Thursday" but without a date.

1h. During a review of Patient 10's "H&P", the H&P indicated, Patient 10 was presented to the facility with complaints of sudden onset of rash and coughing.

During an observation on January 22, 2024, at 11:25 am, in room 203B, IV tubing was observed to be hanging at Patient 10's bedside with a label on the tubing but without a date.

1i. During an observation on January 22, 2024, at 11:35 am, in room 204A, Patient 42's Peripheral IV located on their left arm was observed to not have a date of insertion labeled on the site.

During an interview on January 22,2024, at 10:10 am with the Chief Nursing Officer (CNO), the CNO stated, "All IV tubing should be labeled, the policy is it should be labeled for disposal every 96 hours if main line tubing and 24 hours if secondary tubing." The CNO further stated "Patients would be at risk of the tubing not being changed for more than 96 hours which is an infection control risk.

During a review of the facility policy and procedure (P&P) titled, "Intravenous Infusion: Peripheral Lines" dated March 2023, the P&P indicated," IV sites are Changed every 4 days. Any exceptions must have a written Physician order. IV sites are labeled with the start date, time, and nurses initials .... Primary, secondary and extension set tubing's are changed every 4 days."

Based on interview and record review, the facility failed to ensure medications were administered according to accepted standards of practice when one of 30 sampled patients (Patient 15) did not receive medications as ordered by the physician, when,

1a. Protonix (to reduce stomach acid) and Colace (a stool softener) administration were delayed by 1 hour and 48 minutes.

1b. Heparin (a medication to slow blood clotting) was held without a physician's prior approval.

These failures had the potential to result in harm to the patient when prescribed medications were not administered as ordered which may contribute to negative outcomes and can jeopardize the health and safety of the patient.

Findings:

1a. During a review of Patient 15's "History and Physical" (H&P) dated January 22, 2024, the "H&P" indicated Patient 15 was admitted to the hospital after falling at home and hitting his head. Patient 15 has a past medical history of Hypertension (high blood pressure), Myelofibrosis (an uncommon type of bone marrow cancer that disrupts the body's normal production of blood cells and Thrombocytopenia (a condition causing a low blood platelet count. Platelets are colorless blood cells that help blood clot).

During a concurrent interview and record review on January 23, 2024 at 10:30 AM, with the Director of Emergency Department, (EDD), Patient 15's active "Medication Administration Record" (MAR) dated January 23, 2024, was reviewed. The EDD stated, from looking at his chart, this patient should already have had his 9: 00 AM, medications. The EDD stated, these medications (Protonix, Heparin and Colace) are already an hour and a half late. The EDD further stated, Registered Nurse (RN) should have clarified with the physician first, if he wanted to hold or delay administration of any medications.

During an interview on January 23, 2024 at 10:45AM, with Registry Nurse 1 (RNR1), RNR1 stated, "I did not give the medications earlier because I was trying to prioritize my patients based on acuity. Based on my resources available, I was focusing on other patients." RNR1 stated, the normal timeframe for medication administration is plus or minus one hour. RNR1 further stated, to deviate from the order, the best practice was to clarify with the physician first. "I haven't had time to call the doctor yet."

During a review of Patient 15's "Medication Administration Record" (MAR) dated January 23, 2024, the "MAR" indicated, medications Colace and Protonix were scheduled to be administered at 9:00 AM and were not given until 10:48 AM, on January 23, 2024.

During an interview on January 23, 2024 at 2:00 PM, with the Medical-Surgical / Telemetry unit (MS/T) Clinical Supervisor (MSTCS), the MSTCS stated, nurses are expected to call and let the physician know if we are holding medications. The MSTCS stated, it was a physician order so it should be given as ordered or else confirmed with the physician. The MSTCS further stated, holding, or delaying administration of a med icine like Protonix because it was 'not critical' and it was still not an excuse to call the doctor for permission.

During a concurrent interview and record review on January 23, 2024 at 3:30 PM, with the MS/T Director, (MSTD), the policy and procedure (P&P) titled, "Medication Administration" dated April 2023, was reviewed. The P&P indicated, "Prior to administration, the 6 R's must be verified: ...C. Right Time: 30-60 minutes before or after the scheduled medication time." The MSTD stated, "these medications were given out of the administration window. This is not standard of practice."


1b. During a review of Patient 15's "H&P" dated January 22, 2024, the "H&P" indicated Patient 15 was admitted to the hospital after falling at home and hitting his head. Patient 15 has a past medical history of Hypertension, Myelofibrosis and Thrombocytopenia.

During a concurrent interview and record review on January 23,2024, at 10:30 AM, with the Director of Emergency Department, (EDD), Patient 15's active "MAR" dated January 23,2024, was reviewed. The EDD stated, "from looking at his chart, this patient should already have had his 9 AM medications. He should have clarified with the physician first, if he wanted to hold or delay administration of any medications.

During an interview on January 23, 2024, at 10:45AM, with Registry Nurse 1 (RNR1), RNR1 stated, he/she held the heparin because Patient 15 was going for a procedure. RNR 1 stated, he did not have time to call the doctor yet and was focusing on other patients. RNR1 further stated, to deviate from the order, best practice was to clarify with the physician first.

During a review of Patient 15's "Nurse Notes" dated January 23, 2024, at 1: 52 PM, the "Nurse Notes" indicated RNR1 documented "confirmed with the Surgeon and Anesthesia it was Okay to hold Heparin and Colace".

During an interview on January 23, 2024, at 2:00 PM, with the MS/T Clinical Supervisor (MSTCS), the MSTCS stated, licensed nurses are expected to call and let the physician know if we want to hold medications. The MSTCS stated, it was a physician order so it should be given as ordered or else confirmed with the physician. The MSTCS further stated, holding a medication without prior physician approval was not our standard practice and we must notify a physician for every medicine that is held.

During an interview on January 23, 2024, at 2:05 PM, with the Chief Nursing Officer (CNO), the CNO stated, "nurses have to use their nursing judgement on holding medications. However, best practice is that he should have communicated that with the physician prior."

During an interview on January 23, 2024 at 3:30 PM with the MS/T Director, (MSTD), the MTSD stated, "you should definitely call the physician to confirm holding or not giving a medication. That is the standard of practice as long as I have been a nurse. Most likely the physician would have said to hold, but he still needed to call to confirm."

During a review of the facility's policy and procedure (P&P) titled "Medication Administration Times" dated April 2021, the "P&P" indicated, "Medications are to be scheduled and administered according to the hospital-wide routine schedule. Any exceptions to the schedule must be communicated to the pharmacy either via a written physician order or the nursing Medication Administration Record."