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Based on observation, interview, and record review, the facility failed to ensure for one of 30 sampled patients (Patient 6), personal privacy was provided, in accordance with the facility's policy and procedure regarding Patients Rights, when Patient 6's room door was not closed and there was no privacy curtain in the patient's room during a medical procedure (blood draw).

This deficient practice resulted in Patient 6's right to dignity and personal privacy violated by being exposed to the general public within the patient care area.

Findings:

During an observation on 10/01/2024 at 4:07 p.m., with Registered Nurse 4 (RN 4), in the medical surgical unit (MSU, a specific are of a hospital where the medical team provides a medical surgical care to patients), Patient 6's room door was observed wide open and had no privacy curtains. The Phlebotomist (PL, a medical professional trained to perform blood collection) was inside Patient 6's room, drawing Patient 6's blood. Patient 6 was exposed to anyone walking into the MSU during the blood draw procedure.

During an interview on 10/1/2024 at 4:07 p.m., with RN 4, RN 4 stated the PL in Patient 6's room was drawing Patient 6's blood. RN 4 stated Patient 6's room did not have a privacy curtain and anyone walking outside Patient 6's room could see the PL drawing Patient 6's blood. RN 4 stated Patient 6's room should have a privacy curtain. RN 4 stated it was the patient's right to have privacy.

During an interview on 10/1/2024 at 4:10 p.m., with Charge Nurse 6 (CN 6), CN 6 stated the patient's door or privacy curtains should be closed when performing a medical procedure to protect the patient's privacy. CN 6 stated Patient 6's room did not have a privacy curtain, and the patient's room door should have been closed for privacy.

During an interview on 10/1/2024 at 4:12 p.m., with the PL, the PL stated she was drawing Patient 6's blood for an order of potassium levels (potassium is a mineral that is essential for all the body's functions). The PL stated she was a new employee and was not told to close the patient's door when drawing the patient's blood. The PL agreed that it was important to respect the patients and their privacy. The PL stated the patient's room should be closed for privacy.

During a review of Patient 6's "History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 9/30/2024, the H&P indicated Patient 6 was admitted for weakness.

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibilities," revised in December 2022, the P&P indicated, "The (name of the facility) recognizes and affirms the rights and responsibilities of patients which shall include ...Full consideration of privacy concerning the medical care program. Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly."

During a review of the facility's patient admission document titled, "Your rights as a patient," (undated), the document indicated, "Have your privacy respected. Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly."

Based on observation, interview, and record review, the facility failed to ensure a physician's order for the use of restraints (a device that limits a patient's movement) included the reason or indication for the restraint for one of 30 sampled patients (Patient 2), in accordance with the facility's policy and procedure regarding the use of restraints.
This deficient practice had the potential for Patient 1 to be restrained unnecessarily. This deficient practice also had the potential to result in complications of restraints use such as skin integrity issues (a break in the skin), etc.

Findings:

During an observation on 10/1/2024 at 3:05 p.m., in the Telemetry Unit (where patients receive continuous heart monitoring), Patient 2 was observed awake and calm in bed. Patient 2 had soft restraints (a device that limits a patient's movement) to both wrists.

During a concurrent interview and record review on 10/1/2024 at 3:15 p.m. with Assistant Nurse Manager (ANM) 1, the ANM 1 reviewed Patient 2's Restraint Order, dated 9/30/2024 at 11:30 p.m. ANM 1 verified that the restraint order did not include a reason for the use of soft restraints for Patient 2. ANM 1 stated the restraint order should specify the reason for the restraints to ensure patients were not restrained without cause or reason.

During a review of Patient 2's "History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 9/30/2024 at 10:42 p.m., the H&P indicated the following: (Patient 2) Presents as a transfer from another emergency department. Chief complaint: "Chest pain ...Patient (2) currently agitated (a feeling of irritability, mental distress or severe restlessness) ..."

During a review of Patient 2's physician order dated 9/30/2024 at 11:30 p.m., the physician's order indicated the following: Order: Restraints, non-violent/non-self-destructive/non-behavioral. Order Questions:
Has the physician/provider determined restraint is required? Yes.
Restraint Type? Wrist, Bilateral.
Clinical reason for restraint use of wrist and/or mitten? Other (specify in comments) ... (There was no reason indicated for the use of restraints as verified by ANM 1 during an interview on 10/1/2024).

During a review of Patient 2's physician order dated 10/01/2024 at 1:30 p.m., the physician's order indicated the following: Order: Restraints, non-violent/non-self-destructive/non-behavioral. Order Questions:
Has the physician/provider determined restraint is required? Yes.
Restraint Type? Wrist, Bilateral.
Clinical reason for restraint use of wrist and/or mitten? Other (specify in comments) ... (There was no reason indicated for the use of restraints as verified by ANM 1 during an interview on 10/1/2024).


During a review of the facility's policy and procedure (H&P) titled, "Restraint Use," dated 9/01/2022, the P&P indicated the following: "Restraint Orders: The order for restraint shall include the type of restraint to be applied and shall be based on specific behaviors that indicate the need for restraint ...Restraints for Clinical Reasons Order ...A physician order must meet the following criteria: Each new order is written by the physician ...Include the reason for the restraint ..."

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

1. The facility failed to properly assess/evaluate a patient's care needs and implement all the aspiration precautions (a set of practices that help present food or liquid from entering the airway instead of the stomach) recommended by the Speech Language Pathologist (assesses and treat people with communication or swallowing disorders) for one of 30 sampled patients (Patient 1), who was at mild risk for aspiration (breathing in a foreign substance, such as food). This deficient practice had the potential to result in aspiration for Patient 1. (Refer to A-0395)

2. The facility failed to ensure for two of 30 sampled patients (Patients 22 and Patient 5), an individualized nursing care plan (a document that helps a patient's care team communicate and organize patient care) for small bowel obstruction (SBO, blockage in the small intestine) was initiated, in accordance with facility's policy and procedure regarding care planning.

This deficient practice had the potential to result in delayed provision of care to the patients by not identifying Patients 22 and 5's needs and risks. (Refer to A-0396)

3. The facility failed to ensure intravenous (IV, an apparatus used to administer a fluid in a vein) tubing was labeled with the date, time, and initials (date and time of when the IV tubing needs to be changed and initials of the nurse who changed the IV tubing), in accordance with facility's policy and procedure regarding care and maintenance of IV tubing, for one of 30 sampled patients (Patient 30).

This deficient practice had the potential to place Patient 30 at risk for infection (invasion and growth of germs in the body) when it is not known as to when the IV tubing need to be changed. (Refer to A-0398)

4. The facility failed to ensure one of 30 sampled patients (Patient 30's) peripheral intravenous catheter (PIV, a soft, flexible tube placed inside a vein, usually in the hand or arm) dressing site was labeled with the date and initials of the person inserting the intravenous catheter, in accordance with facility's policy and procedure regarding care and maintenance of peripheral intravenous catheter.

This deficient practice had the potential to place Patient 30 at risk for infection (invasion and growth of germs in the body) when the intravenous catheter dressing is not changed when it is due. (Refer to A-0398)

5. The facility failed to ensure for two of 30 sampled patients (Patients 13 and 17), the policies and procedures were implemented when:

5.a. Patient 13, who was at risk for fall (an unintentional event that results in the person coming to rest on the ground or another lower level), was not wearing a fall risk armband (a yellow armband indicating the patient was at risk for fall), in accordance with the facility's policy and procedure regarding Falls prevention.

This deficient practice had the potential to result in an unsafe care that may lead to Patient 13 suffering from a fall injury. (Refer to A-0398)

5.b. Patient 17's enteral tube feeding formula (a tube feeding is a way of sending nutrition right to the stomach or small intestine through an enteral access device) was not changed within 48 hours, in accordance with the facility's policy and procedure regarding enteral tube feeding.

This deficient practice resulted in Patient 17 receiving an expired enteral feeding formula that may have the potential for the feeding formula to degrade and could cause bacterial contamination and infection to Patient 17. (Refer to A-0398)

6. The facility failed to ensure intravenous (IV, administration of fluids into a vein) fluid medications were securely locked, in accordance with policy and procedure regarding medication storage, in two of two sampled units (Units 1 and 2).
This deficient practice had the potential for IV fluid medications to be tampered with or removed by unauthorized individuals, resulting in patient harm. (Refer to A-0398)

7. The facility failed to ensure for three of 30 sampled patients (Patients 7, 15, and 21), Patients 7, 15, and 21's pain medications were administered, in accordance with the physician's order.

This deficient practice had the potential for Patients 7, 15, and 21's pain to not be managed effectively which can result in worsening of pain and may lead to prolonged hospitalization. (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 interview and record review, the facility failed to properly assess/evaluate a patient's care needs and implement all the aspiration precautions (a set of practices that help present food or liquid from entering the airway instead of the stomach) recommended by the Speech Language Pathologist (assesses and treat people with communication or swallowing disorders) for one of 30 sampled patients (Patient 1), who was at mild risk for aspiration (breathing in a foreign substance, such as food).

This deficient practice had the potential to result in aspiration for Patient 1.

Findings:

During a review of Patient 1's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 1/30/2024 at 3:36 p.m., the H&P indicated the following: Patient 1 was transferred from an outside emergency department for weakness, slurred speech for several hours, possible cerebrovascular accident (CVA or stroke, flood flow to the brain is cut off). Patient 1's diagnoses included a history of seizures (sudden, uncontrolled burst of electrical activity in the brain), hypertension (high blood pressure), gastroesophageal reflux disease (GERD, a chronic condition that occurs when stomach contents leak into the esophagus, due to the muscle at the end of the esophagus not closing properly), and microcytic anemia (smaller-then-normal red blood cells) ...Stroke Guidelines: Permission hypertension (temporarily keeping a patient's blood pressure higher than normal to achieve certain treatment goals) yes, ...Swallow screen (a quick assessment to identify if a stroke patient has a risk for aspiration and can safely take food and medication by mouth) passed: As per Registered nurse; Speech therapy pending.

During a concurrent interview and record review on 10/3/2024 at 9:36 a.m., with the DALR and the Associate Nurse Manager (ANM) 1, the Director of Accreditation, Licensing and Regulatory (DALR) and ANM 1 stated the following: Patient 1 was transferred by an outside facility and arrived at the facility on 1/30/2024 for a stroke (blood flow to the brain is cut off). Patient 1 passed a "Swallow Screen (a quick assessment to identify if a stroke patient has a risk for aspiration). The Speech Language Pathologist (SLP) performed a speech/swallow evaluation for Patient 1 on 1/31/2024 at 9:44 a.m., and determined Patient 1 was a mild risk for aspiration. SLP recommended a diet that consisted of easy to chew foods and thin liquids (examples: water, milk, and broth). The SLP also recommended "Aspiration Precautions" for Patient 1. The precautions recommended by the SLP were as follows: good frequent oral care, sit upright as tolerated, only feed when awake/alert (pay close attention to instructions and ready to respond), limit distractions, slow rate of feeding/intake, small bites/sips, alternate liquids/solids, 1:1 caregiver assistant (one healthcare worker to assist Patient 1 with feeding), double/multiple swallows, maintain upright position for at least 30 minutes after meals.
The DALR and ANM 1 reviewed Patient 1's oral intake record and verified that not all of the SLP recommendations were followed. There was no evidence that Patient 1 had 1:1 caregiver assistance with feeding, slow rate of feeding, small bites or sips, alternate liquids and solids. The DALR and ANM also verified that on 2/1/2024 Patient 1's condition deteriorated and a Rapid Response (when a team of trained medical professional are called to a patient's bedside when patients show signs of clinical decline) was called. Patient 1 aspirated (when food, liquid, and other materials enter a person's airway and eventually the lungs by accident) and subsequently passed on 2/2/2024. Additionally, the DALR stated the facility did not have a specific policy regarding aspiration precautions (a set of practices that help present food or liquid from entering the airway instead of the stomach) and staff should follow the Speech Language Pathologist recommendations for aspiration precautions.

During an interview on 10/4/2024 at 3:15 p.m., with the Speech Clinical Coordinator (SCC), the SCC stated the following: Patients who suffer from a stroke are evaluated by a Speech-Language Pathologist to assess their cognitive (relating to the process of thinking, learning and understanding) and aspiration risk. SLP conducts a swallow evaluation. Patient 1 was assessed to have a mild risk for aspiration. The SLP recommended for Patient 1 to have an easy to chew diet and thin liquids. In addition, the SLP recommended aspiration precautions for Patient 1. Precautions included 1:1 caregiver assistance to set up the food tray for Patient 1 and ensure Patient 1 was in a proper position to eat to reduce the risk of aspiration.

During an interview on 10/4/2024 at 11:31 a.m. with the Physician (MD 3), MD 3 stated Patient 1 most likely aspirated and possibly had aspiration pneumonia (a lung infection that occurs when one inhales food, liquid, saliva, vomit, or other foreign subjects into the lung instead of swallowing them).

During an interview on 10/4/2024 at 4:35 p.m. with the Physician (MD 1), MD 1 stated the following: MD 1 took care of Patient 1 in the Intensive Care Unit (a specialized unit that provides critical care and life support for patients with life-threatening injuries or illnesses). Patient 1 was very sick and MD 1 informed Patient 1's family that Patient 1 may expire (die). Patient 1 deteriorated quickly. Patient 1 aspirated. MD 1 stated the cause of Patient 1's death was shock (a life-threating medical condition that occurs when the body's organs and tissues are not getting enough oxygen and nutrients to function properly).
MD 1 stated it was unclear which type of shock Patient 1 experienced. It was either hemorrhagic shock (reduced tissue perfusion resulting in the inadequate delivery of oxygen) or septic shock (a life-threatening condition that occurs when sepsis [a life-threatening complication of an infection], an organ injury cause by infection, lead to dangerously low blood pressure), or aspiration pneumonia (a lung infection that occurs when food, liquid, or other substances are inhaled into the lungs instead of being swallowed).

During a review of Patient 1's physician's "Order," dated 1/30/2024 at 3:45 p.m., the order indicated, "Implement Aspiration Precautions."

During a review of Patient 1's Diet "Order," dated 1/30/2024 at 4 p.m., the order indicated "Cardiac (heart-healthy) Diet, easy to chew (IDDSI Level 7, suitable for individual who may have some difficulty with chewing hard/firm textures but do not have dysphagia or problems with swallowing)."

During a review of Patient 1's "Swallow Screen," dated 1/30/2024 at 5 p.m., indicated Patient 1 passed the swallow screen. Yes, notified physician for diet order.

During a review of Patient 1's "Initial Speech Pathology Speech-Language, Cognition and Dysphagia Evaluation (assesses a patient's ability to swallow and their risk of difficulty swallowing [dysphagia]), "dated 1/31/2024 at 9:44 a.m., the Evaluation indicated the following: Referring Diagnosis: CVA (cerebral vascular accident [stroke], blood flow to the brain is cut off). Aspiration Risk: mild secondary to (2/2) weakness. Diet Recommendations: Easy to Chew ...and Thin liquids.
Aspiration Precautions:
Good frequent oral care.
Sit upright as tolerated.
Only feed when awake/alert.
Limit distractions.
Slow rate of feeding/intake.
Small bites/sips.
Alternate liquids/solids.
1:1 Caregiver Assistance.
Double/Multiple swallows per bite/sip.
Maintain upright position for 30 minutes after intake.

During a review of Patient 1's "Acute Occupational Therapy Initial Neurological Assessment with Plan Certification," dated 1/31/2024 at 3:21 p.m., the Assessment indicated the following: Treatment Diagnosis: decreased bilateral upper extremity function for self-care activities. Feeding: standby assistance/supervision with set up required. Assessment: Patient (1) is mostly limited by bilateral (both) shoulder pain and has difficulty reaching for activities of daily living and using upper extremities to push herself into a seated position ...

During a review of Patient 1's "Medicine Progress Note," dated 1/31/2024 at 4 p.m., the progress noted indicated the following: Right-sided weakness persist. Patient (1) wanted to go home ...plan discharge tomorrow ...Mental Status: AOX4 (alert and oriented to person, place, time, and event) ...Plan DC (discharge) tomorrow ...

During a review of Patient 1's "Intake, PO (oral)," record, the Intake record indicated the following.
On 1/30/2024 at 6 p.m., 210 milliliters (ml, a unit of measurement), Dinner, Independent, Diet % (percentage) taken: 50 %.
On 1/31/2024 at 9 a.m., 210 ml, Breakfast, Independent, Diet % taken: 75 %.
On 1/31/2024 at 2 p.m., 210 ml, Lunch, Independent, Diet % taken: 75 %.
On 1/31/2024 at 5:59 p.m., 120 ml, Dinner, Independent. Diet % taken: 60 %.
On 1/31/2024 at 11:30 p.m., 50 ml, Snack; 1 packet of saltines eaten. Independent.
On 2/1/2024 at 7:13 a.m., 100 ml.
On 2/1/2024 at 10 a.m., (PO) 118 ml, Breakfast, Independent. Diet % taken: 25 %.
On 2/1/2024 at 2:30 p.m., (PO) 118 ml, Lunch, Independent. Diet % taken: 50 %.

During a review of Patient 1's "Nutrition Interventions," the Nutrition Interventions, included the following Swallow Interventions for Dysphagia (difficulty swallowing):
On 1/30/2024 at 6:18 p.m., meal set-up provided.
On 1/31/2024 at 11:25 a.m., Upright position maintained 30 minutes after intake. Meal set-up provided.

During a review of Patient 1's "Aspiration Precautions," the aspiration precautions included the following:
On 1/31/2024 at 8 a.m., awake, alert before oral intake.
On 1/31/2024 at 4:36 p.m. and 5:04 p.m., awake, alert before oral intake.
On 2/01/2021 at 9:19 a.m., upright posture maintained; respiratory status monitored; oral hygiene care promoted.
On 2/01/2024 at 12:39 p.m., Aspiration Precautions.

During a review of a physician "Progress Note," dated 2/1/2024 at 6:37 p.m., for Patient 1, the progress note indicated the following: Rapid Response called on patient (Patient 1). Patient admitted for stroke ...plan for transfer to skilled nursing facility for rehab (rehabilitation, care that can help a patient get back, keep, or improve abilities needed for daily life). Patient with acute onset of lethargy (drowsy, tired, or not alert) and shortness of breath (difficulty breathing). On exam (examination- assessment), Patient not responsive to external rub (application of a painful stimulus with the knuckles of closed fists to the center chest of a patient who is not alert and does not respond to a verbal stimuli) ...Patient desatting (desaturating- low oxygen saturation [measurement of blood oxygen level]) to 80s (80%), placed on a face mask ...BP (blood pressure) low ...Patient not protecting airway. Anesthesia called for intubation (inserting a tube into a person's airway to keep airway open and allow oxygen to flow into the lungs) ...During intubating patient (Patient 1), with gastric content that were suctioned out ...Patient transferred to Intensive Care Unit (provides critical care and life support for patients who are very ill) ...IV (in the vein) Zosyn (a broad spectrum antibiotic, treats many bacteria) and vanc (vancomycin, treats bacterial infections) for possible aspiration pneumonia (lung infection that occurs when a large amount of material from the stomach or mouth enters the lungs) ...

During a review of Patient 1's "ICU Brief Note," dated 2/2/2024 at 8:52 a.m., the note indicated the following: "Met with patient's (Patient 1) children/granddaughter in person; explained that patient moribund (at the point of death) given on 4 pressors (medications to increase blood pressure) and still hypotensive (low blood pressure). Unclear if patient (Patient 1) with septic shock (a life-threatening condition occurs when an infection causes dangerously low blood pressure and organ failure) or cardiogenic shock (a life-threatening condition in which the heart suddenly cannot pump enough blood to meet the body's needs), ? (question mark) possible aspiration ..."

During a review of Patient 1's "Progress Note," dated 2/1/2024 at 10 p.m., the progress noted indicated the following: Repeat hemoglobin (the protein contained in red blood cells that delivery oxygen to tissues) 6.7 (low). CGE (coffee-ground emesis, can be a sign of internal bleeding) noted with NGT (nasogastric tube, a thin tube that is inserted through the nose and into the stomach) placement per nurse ...Patient, family ...informed of the need for, risk of ...benefits of and alternatives to blood transfusion (a procedure that involves transferring blood or blood components into a patient's bloodstream through an intravenous line) ...

During a review of Patient 1's "Progress note," dated 2/2/2024 at 6:53 a.m., the progress note indicated the following: Maxed (maximum) on 3 (three) pressors (medication to raise blood pressure) with persistent low blood pressure ... Patient (1) admitted for stroke. Possible aspiration yesterday and intubated ... NGT with coffee-ground output overnight ...Possible abdominal infection with large NGT output ...

During a review of Patient 1's "Death Summary," dated 2/2/2024 at 8 a.m., the Summary indicated the following: Causes of death: Shock (a life-threatening condition that occurs when the body does not have enough blood flow, which can lead to organ damage) and CVA (cerebrovascular accident, days). On 2/1/2021, persistent right-sided weakness, willing to go to Skilled Nursing Facility, RRT (Rapid Response Team) called ...for acute altered mental status/sob (shortness of breath), transferred to the ICU ... more hypotensive (low blood pressure) ...dark burgundy output from NGT (nasogastric tube, a flexible tube that is inserted through the nose and into the stomach to remove substances from the stomach). On 2/2/2024, given Patient's moribund condition, Patient's family called to come visit Patient. After they arrived, discussed her (Patient 1) condition, and family agreed Patient 1 to be DNR (Do Not Resuscitate, a legal document that instructs medical professionals not to perform cardiopulmonary resuscitation [CPR, an emergency procedure that can help save a life when someone's breathing or heartbeat has stopped] if a patient's heart or breathing stops) ...

During a review of Patient 1's "Death Note," dated 2/2/2024 at 9:51 a.m., the noted indicated the following ... "Called by RN (registered nurse) that patient (Patient 1) has expired ...The Patient (1) was pronounced expired (died) on 2/2/2024 at 9:35 a.m."

Based on interview and record review, the facility failed to ensure for two of 30 sampled patients (Patients 22 and Patient 5), an individualized nursing care plan (a document that helps a patient's care team communicate and organize patient care) for small bowel obstruction (SBO, blockage in the small intestine) was initiated in accordance with facility's policy and procedure regarding care planning.

This deficient practice had the potential to result in delayed provision of care to the patients by not identifying Patients 22 and 5's needs and risks.

Findings:

1. During a review of Patient 22's "History & (and) Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/23/2024, the H&P indicated Patient 22 was admitted to the facility for vomiting and weakness. The H&P further indicated, Patient 22's active hospital problem list included SBO (blockage in the small intestine).

During a concurrent interview and record review on 10/3/2024 at 3:00 p.m. with Registered Nurse 1 (RN 1), RN 1 verified Patient 22's care plan (a document that helps a patient's care team communicate and organize patient care) for SBO "Intestinal Obstruction" was initiated on 10/3/2024 (11 days after Patient 22 was admitted to the facility for SBO). RN 1 stated, the patient's care plan should be initiated upon admission and should be reviewed every shift so the nurses could monitor the patient's progress, and the nurses would communicate on how to treat and care for the patient.

During an interview on 10/4/2024 at 10:16 a.m., with the Director of Nursing Administration (DNA), the DNA stated, development of the patient's care plan was part of the admission process.

During a review of the facility's policy and procedure (P&P) titled, "Patient Assessment and Re-assessment," revised in 3/2022, the P&P indicated, "Admission Assessment: Complete admission assessment includes ...patient plan, and education ...A complete assessment including bio-psychosocial aspects, will be performed on each patient by a Registered Nurse (RN) at least within 24 hours of admission and documented in the adult patient profile ...Plan of Care and Education: Upon completion of the assessment, a plan of care will be developed by a Registered Nurse. The Registered Nurse will develop and document a plan of care that will best meet the individualized health care needs of the patient."

During a review of the facility's policy and procedure (P&P) titled, "Regional Guidelines for Care Planning and Care Plan Documentation," dated 6/14/2024, the P&P indicated, "Diagnose (Nursing) Based on assessment, determine which problem templates should be on the Patient Plan. A problem template must be applied within 8 hours of admission. All patients have an Inpatient Plan of Care template and at least one template addressing their primary reason for hospitalization. Choose a template related to the current hospital problem when possible. This should align with what the provider documented on the H&P, current Progress Note, or Hospital Problem list."

2. During a review of Patient 5's "History & (and) Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/28/2024, the H&P indicated Patient 5 was admitted to the facility with a chief complaint of abdominal pain, nausea and vomiting for 2 days. The H&P further indicated Patient 5's assessment showed Small Bowel Obstruction (SBO, blockage in the small intestine).

During a concurrent interview and record review on 10/1/2024 at 3:41 p.m. with Registered Nurse (RN) 5, RN 5 stated Patient 5's "Care Plan" (a document that helps a patient's care team communicate and organize patient care) did not have a care plan for small bowel obstruction (SBO). RN 5 said Patient 5 should have a care plan for SBO to know the treatment plan of the patient (Patient 5) and to see if the patient was progressing as per the care plan implementations.

During a concurrent interview and record review on 10/3/2024 at 10:23 a.m. with Nurse Manager 3 (NM 3), NM 3 stated Patient 5's care plan for SBO was developed on 10/1/2024 (4 days after Patient 5 was admitted and assessed for SBO). NM 3 said Patient 23's care plan for SBO should have been initiated on admission. NM 3 stated the importance of care plan was to explain to the patient the interventions and for the nurses to have nursing care guidance.

During a review of the facility's policy and procedure (P&P) titled, "Patient Assessment and Re-assessment," revised in 3/2022, the P&P indicated, "Admission Assessment: Complete admission assessment includes ...patient plan, and education ...A complete assessment including bio-psychosocial aspects, will be performed on each patient by a Registered Nurse (RN) at least within 24 hours of admission and documented in the adult patient profile ...Plan of Care and Education: Upon completion of the assessment, a plan of care will be developed by a Registered Nurse. The Registered Nurse will develop and document a plan of care that will best meet the individualized health care needs of the patient."

During a review of the facility's policy and procedure (P&P) titled, "Regional Guidelines for Care Planning and Care Plan Documentation," dated 6/14/2024, the P&P indicated, "Diagnose (Nursing) Based on assessment, determine which problem templates should be on the Patient Plan. A problem template must be applied within 8 hours of admission. All patients have an Inpatient Plan of Care template and at least one template addressing their primary reason for hospitalization. Choose a template related to the current hospital problem when possible. This should align with what the provider documented on the H&P, current Progress Note, or Hospital Problem list."

Based on observation, interview and record review, the facility failed to:

1. Ensure intravenous (IV, an apparatus used to administer a fluid in a vein) tubing was labeled with the date, time, and initials (date and time of when the IV tubing needs to be changed and initials of the nurse who changed the IV tubing), in accordance with facility's policy and procedure regarding care and maintenance of IV tubing, for one of 30 sampled patients (Patient 30). This deficient practice had the potential to place Patient 30 at risk for infection (invasion and growth of germs in the body) when it is not known as to when the IV tubing need to be changed.

2. Ensure one of 30 sampled patient's (Patient 30's) peripheral intravenous catheter (PIV, a soft, flexible tube placed inside a vein, usually in the hand or arm) dressing site was labeled with the date and initials of person inserting the intravenous catheter, in accordance with facility's policy and procedure regarding care and maintenance of peripheral intravenous catheter. This deficient practice had the potential to place Patient 30 at risk for infection (invasion and growth of germs in the body) when the intravenous catheter dressing is not changed when it is due.

3. Ensure for two of 30 sampled patients (Patients 13 and 17), the policies and procedures were implemented when:

3.a. Patient 13, who was at risk for fall (an unintentional event that results in the person coming to rest on the ground or another lower level), was not wearing a fall risk armband (a yellow armband indicating the patient was at risk for fall), in accordance with the facility's policy and procedure regarding Falls prevention.

This deficient had the potential to result in an unsafe care that may lead to Patient 13 suffering from a fall injury.

3.b. Patient 17's enteral tube feeding formula (a tube feeding is a way of sending nutrition right to the stomach or small intestine through an enteral access device) was not changed within 48 hours, in accordance with the facility's policy and procedure regarding enteral tube feeding.

This deficient practice resulted in Patient 17 receiving an expired enteral feeding formula that may have the potential for the feeding formula to degrade and could cause bacterial contamination and infection to Patient 17.

4. Ensure intravenous (IV, administration of fluids into a vein) fluid medications were securely locked, in accordance with policy and procedure regarding medication storage, in two of two sampled units (Units 1 and 2).
This deficient practice had the potential for IV fluid medications to be tampered with or removed by unauthorized individuals, resulting in patient harm.

Findings:

1. During a review of Patient 30's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 9/30/2024, the H&P indicated Patient 30 had a history including but not limited to lymphoma (a type of cancer), acute kidney injury (a sudden decrease in kidney function) and hypertension (a condition where the pressure in your blood vessels is consistently too high).

During a concurrent observation and interview on 10/1/2024 at 3:07 p.m. with Registered Nurse 1 (RN 1) in Patient 30's room, the following was observed: There was an intravenous (IV, an apparatus used to administer a fluid in a vein) fluid bag of Normal Saline (a mixture of water and salt with a salt) running at 100 mL (milliliters, a unit of measurement) per hour on a infusion pump (a medical device that delivers fluids, such as nutrients and medications, into a patient's body in controlled amounts) through Patient 30's right arm peripheral intravenous (PIV, a soft, flexible tube placed inside a vein, usually in the hand or arm) line. RN 1 verified Patient 30's IV tubing did not have a day label (indicates the day the IV tubing necessitates a change). RN 1 stated the following: There should be a day label on the IV tubing with the date, time, and initials of the person who prepared the IV tubing. The IV tubing should be changed every 4 days. If the IV tubing does not have a label, it is unknown when the tubing needs to be changed. IV tubing is labeled to decrease infection and if the tubing is not changed, the patient may be at risk for infection.

During a review of Patient 30's "Medication Detail," dated 9/30/2024 at 9:24 p.m., the medication detail indicated Patient 30 had a physician's order for 0.9% Sodium Chloride (Normal Saline) IV 100mL per hour continuous (continuous infusion).

During a review of Patient 30's "Medication Administration Record (MAR, a report detailing the medications administered to a patient) dated 10/1/2024 at 9:24 p.m., the MAR indicated Sodium Chloride (Normal Saline) IV 100mL per hour was administered to Patient 30.

During a review of the facility Policy and Procedure (P&P) titled, "Care and Maintenance- Central Venous Device (CVAD, thin, flexible tube that's inserted into a vein to provide access to the bloodstream) & Implanted Port (a medical device that allows for long-term IV therapy and treatment)," dated 1/2022, the P&P indicated: " ...Frequency for Intravenous Tubing Change ... 2.9.3 IV administration tubing with new fluids shall be changed with the following frequency: 2.8.3.1 Primary and secondary continuous: every 96 hours ..."


2. During a review of Patient 30's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 9/30/2024, the H&P indicated Patient 30 had a history including but not limited to lymphoma (a type of cancer), acute kidney injury (a sudden decrease in kidney function) and hypertension (a condition where the pressure in your blood vessels is consistently too high).

During a concurrent observation and interview on 10/1/2024 at 3:07 p.m. with Registered Nurse 1 (RN 1) in Patient 30's room, the following was observed: Patient 30 had a right antecubital (RAC, relating to the front surface of the forearm or the crook of the elbow) peripheral IV (PIV, a soft, flexible tube placed inside a vein, usually in the hand or arm) line. RN 1 verified Patient 30's peripheral IV site had an IV dressing without the date [of insertion], time and initials of the person who inserted the peripheral IV written on the IV dressing. RN 1 stated the following: There should have been a date, time, and initials written on the dressing when the IV was inserted. When inserting an IV, it is important to put the date, time, and initials on the IV dressing to know when the dressing needs to be changed. IV dressings and chlorhexidine gluconate disk (CHG disk, a foam dressing that's used to reduce the risk of infections around medical catheters) should be changed every 7 days. If the dressing is not changed every 7 days, this could cause an infection. If the CHG disk is not changed, the IV site would be unable to be assessed and complications, such a phlebitis (a condition that causes inflammation in a vein, usually in the legs), could be missed.

During a review of the facility Policy and Procedure (P&P) titled, "IV Therapy: Peripheral Catheter Insertion, Maintenance, & Discontinuance," dated 8/2022, the P&P indicated: " ...Steps: 13. Label dressing with date of insertion, catheter size and initials of person inserting the catheter ...Maintenance: ...3. Change dressing and CHG disk on Wednesday's ..."

3.a. During a review of Patient 13's "History & (and) Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 10/2/2024, the H&P indicated Patient 13 was admitted to the facility with a chief complaint of altered mental status (a change in how well the brain is functioning, it can lead to changes in movement or behavior such as confusion, decreased alertness, or odd behavior) and slurred speech (weakness in the muscles used for speech).

During a concurrent observation and interview, on 10/2/2024 at 11:22 a.m., with Register Nurse (RN) 7, Patient 13's room was observed to have a "falling star (indication the patient was at risk for fall [an unintentional event that results in the person coming to rest on the ground or another lower level])" signage by the door. Patient 13 was observed in bed, alert and oriented (alert and oriented to person, place, time and event). RN 7 stated the falling star signage indicated the patient was at risk for fall. RN 7 said fall risk intervention included a yellow armband, signage on the patient's room, bed alarm, and yellow blanket. Subsequently, Patient 7 was observed not wearing a yellow fall risk armband. RN 7 stated the importance of the fall risk armband was for anyone who entered Patient's 7 room would be aware of Patient 7's fall risk and would monitor the patient closely to prevent a fall.

During a concurrent interview and record review on 10/3/2024 at 3:05 p.m. with the Interim Nurse Manager Step Down Unit (INM 1), INM 1 stated that on 10/2/2024 at 08:00 a.m., Patient 13's "Hester Davis Fall Risk Assessment (a tool use to predict anticipated falls in adult patients in a variety of settings)," score was 9 (low fall risk scores are 7-10). INM 1 verified that low fall risk intervention included the patient's need of a yellow arm band. INM 1 stated the importance of wearing a yellow fall risk ID band was for everyone to identify the patient as a fall risk and to ensure patient safety.

During a review of Patient 13's "Care Plan (a document that helps a patient's care team communicate and organize patient care)," dated 10/2/2024, the care plan for fall precaution included fall prevention intervention of, "initiate universal fall precautions (UFPs), place yellow fall risk ID band on patient."

During a review of the facility's policy and procedure (P&P) titled, "Adult Falls Prevention Policy," dated 12/2023, the P&P indicated, "All patients who are not sedated (a state of calmness or sleepiness that is induced by certain drugs) or comatose (a state of deep unconsciousness where a person is unable to be woken up and show no signs of awareness), will be evaluated using the appropriate Hester-Davis Scale (HDS) for Fall Risk Assessment...Registered Nurses are responsible for implementation and oversight of the individualized patient fall prevention care ...once the HDS score is generated the nurse will determine the level of fall risk to initiate the fall prevention and injury reduction plan for the patient: scores 7-10 Low Risk: Yellow low fall risk signage outside of the room, fall risk band, education etc."

3.b. During a review of Patient 17's record, the "GI Inpatient Procedure History & (and) Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/4/2024 indicated, Patient 17 was admitted to the facility for a PEG insertion.

During a concurrent observation and interview on 10/1/2024 at 3:17 p.m. with Charge Nurse 4 (CN 4), Patient 17 was observed lying in bed with a percutaneous endoscopic gastrotomy (PEG, a surgery to place a feeding tube) tube. Patient 17 was receiving enteral tube feeding of Glucose Support (type of feeding formula) at 55 milliliter per hour (ml/hr, a unit of measurement) via PEG. CN 4 stated Patient 17's enteral tube feeding bag was dated 9/29/2024.

During a concurrent interview and record review on 10/3/2024 at 9:49 a.m. with Nurse Informatics 1 (NI 1), NI 1 verified Patient 17 had a tube feeding order for Glucose Support 1.2 (formula) on continuous rate of 55 ml/hr, started on 9/5/2024.

During the same interview and record review on 10/3/2024 at 9:49 a.m., NI 1 verified Patient 17's "Flow sheet tube feed," dated 9/29/2024 through 10/1/2024, indicated that Patient 17's tube feeding set were changed on 9/29/2024 at 4:00 p.m. NI 1 stated the next tube feeding set change was on 10/1/2024 at 10:54 p.m. (a total of 54 hours and 54 minutes since Patient 17's tube feeding set was last changed).

During a concurrent interview and record review on 10/4/2024 at 9:34 a.m. with CN 5, CN 5 verified Patient 17's tube feedings set was changed, between 9/29/2024 at 4:00 p.m. and 10/1/2024 at 10:54 p.m., past 48 hours (enteral tube feeding formula expiration). CN 5 stated, it was important to change the tube feeding no more than 48 hours per policy and procedure, and manufacture instructions to prevent infection and diseases to the patient.

During a review of the facility's policy and procedure (P&P) titled, "Enteral Nutrition and Oral Nutrition Supplement Guidelines for Food and Nutrition," revised in 6/2024, the P&P indicated, "A closed system is the preferred method of feeding all enteral patients using sanitary handling methods with a hang time no more than 48 hours or per the manufacturer's instructions."

During a review of the manufacturer guideline titled, "(Brand name of the formula) Glucose Support -manufacture label," undated, the label indicated, "Once spiked, use within 48 hours."

4.a. During an observation and interview on 10/2/2024 at 10:00 a.m. with the Nurse Manager 2 (NM 2) in Unit 1, there were 23 patients on the unit. The NM 2 verified the storage room door on Unit 1 was unlocked. The NM 2 further verified the Unit 1 storage room contained multiple bags of intravenous (IV, administration of fluids into a vein) fluids.

During the same interview on 10/2/2024 at 10:00 a.m., the NM 2 stated the following: There is one storage room [on Unit 1]. The storage room is where the IV fluids are stored. IV fluids are considered medications that require a physician's order (a doctor's written instruction for the treatment and care of a patient) for administration. Only licensed staff, such as Registered Nurses, can administer IV fluids because they have the education and training to give medications. The IV fluids should be stored in the medication room (which is locked) or a locked room. Only licensed staff and authorized individuals, such as pharmacy technicians and pharmacists, should have access to medications. Because the storage room is unlocked, anyone can gain access to the IV fluids. If IV fluids are not in a locked room, they can be stolen, tampered with, or utilized inappropriately, which can cause patient harm.

During a review of the facility's Policy and Procedure (P&P) titled, "Medication Administration," dated 4/2024, the P&P indicated: "3. All medication storage places are to be kept securely locked at all times. Only licensed personnel authorized to administer drugs may have access to medications. 4. Licensed staff may grant access to the medication storage area to Environmental Services and Materials Management for the purposes of cleaning and stocking supplies ..."

4.b. During an observation and interview on 10/2/2024 at 10:37 a.m. with the Nurse Manager 2 (NM 2) in Unit 2, there were 24 patients on the unit. The NM 2 verified the storage room door on Unit 2 was unlocked. The NM 2 further verified the Unit 2 storage room contained multiple bags of intravenous (IV, administration of fluids into a vein) fluids.

During the same interview on 10/2/2024 at 10:37 a.m., the NM 2 stated the following: There is one storage room [on Unit 2]. The storage room is where the IV fluids are stored. IV fluids are considered medications that require a physician's order (a doctor's written instruction for the treatment and care of a patient) for administration. Only licensed staff, such as Registered Nurses, can administer IV fluids because they have the education and training to give medications. The IV fluids should be stored in the medication room (which is locked) or a locked room. Only licensed staff and authorized individuals, such as pharmacy technicians and pharmacists, should have access to medications. Because the storage room is unlocked, anyone can gain access to the IV fluids. If IV fluids are not in a locked room, they can be stolen, tampered with, or utilized inappropriately, which can cause patient harm.

During a review of the facility's Policy and Procedure (P&P) titled, "Medication Administration," dated 4/2024, the P&P indicated: "3. All medication storage places are to be kept securely locked at all times. Only licensed personnel authorized to administer drugs may have access to medications. 4. Licensed staff may grant access to the medication storage area to Environmental Services and Materials Management for the purposes of cleaning and stocking supplies ..."

Based on interview and record review, the facility failed to ensure for three of 30 sampled patients (Patients 7, 15, and 21), Patients 7, 15, and 21's pain medications were administered in accordance with the physician's order.

This deficient practice had the potential for Patients 7, 15, and 21's pain to not be managed effectively which can result in worsening of pain and may lead to prolonged hospitalization.

Findings:

1. During a review of Patient 7's "History & (and) Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/30/2024, the H&P indicated Patient 7 was admitted to the facility for abdominal discomfort, nausea (a feeling of discomfort in the stomach that comes with an urge to throw up), and vomiting.

During a review of a Patient 7's "Medication Administration Report (MAR, a report detailing the medications administered to a patient)," dated 10/3/2024, the MAR indicated a physician's order for Patient 7 to receive the following:

- Percocet (narcotic pain medication) 5-325 mg (mg-a unit of measurement) 1 tablet by mouth every 4 hours as needed (PRN) for moderate pain (pain score of 4-6 is moderated pain), with a start date of 9/30/2024; and,

- Morphine (narcotic pain medication) 1 mg intravenous (IV- in the vein) every 6 hours PRN (as needed) for severe pain (pain score 7-10 is severe pain), with a start date of 10/2/2024.

During a concurrent interview and record review on 10/3/2024 at 9:46 a.m., with the Interim Nurse Manager Step down Unit (INM 1), INM 1 verified Patient 7's MAR indicated on 10/3/2024 at 3:11 a.m., Patient 7 was given Percocet 5-325 mg (ordered for moderate pain) 1 tablet by mouth with comment: "medication given between morphine PRN doses." INM 1 verified Patient 7's corresponding pain assessment was 8 (severe pain).

During a concurrent interview and record review on 10/3/2024 at 11:14 a.m. with the Nurse Manager (NM) 3, NM 3 stated it was important to give medication according to physician's orders for a safe medication administration. NM 3 confirmed that Patient 7's order for Percocet was for moderate pain and Patient 7 had severe pain.

During the same interview on 10/3/2024 at 11:14 a.m., NM 3 stated if Patient 7's Morphine was not due to be given and the patient's pain was severe, the nurse should have contacted the physician to address Patient 7's severe pain.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," dated 04/2024, the P&P indicated, "The patient care provider administering the medication is responsible for ensuring the five rights of medication administration: i. Right medication, ii. Right Patient, iii. Right Dose, iv. Right Route, v. Right time."

During a review of the facility's policy and procedure (P&P) titled, "Acute Pain Management," dated 09/2023, the P&P indicated, "Pain control is a legitimate therapeutic goal essential to the patient's physical and emotional well-being. Pain control approaches may be collaborative and interdisciplinary in nature and utilize input from members of the health care team ..."

2. During a review of Patient 15's "Surgery History &(and) Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/27/2024, the H&P indicated Patient 15 was admitted to the facility with a chief complaint of abdominal pain.

During a review of Patient 15's "Medication Administration Record (MAR, a report detailing the medications administered to a patient)," dated 9/30/2024, the MAR indicated a physician's order for Patient 15 to receive the following:

- Morphine (narcotic pain medication) 2 milligrams (mg, a unit of measurement) to be given intravenous (IV, in the vein) every 2 hours as needed (PRN) for moderate pain (pain score of 4-6 is considered moderate pain), with a start date of 9/27/2024; and,

-Morphine 4 mg to be given IV every 2 hours PRN for severe pain (pain score of 7-10 is considered severe pain), with a start date of 9/27/2024.

During a concurrent interview and record review on 10/2/2024 at 2:30 p.m. with the Nurse Manager 1 (NM 1), NM 1 verified Patient 15's MAR indicated Patient 15 was given Morphine 2 mg IV on 9/30/24 at 6:52 a.m.

During the same interview and record review on 10/2/2024 at 2:30 p.m., NM 1 verified Patient 15's "Flowsheet -Pain Assessment," dated 9/30/2024, Patient 15's pain level was not assessed (no documentation whether Patient 15 had moderate or severe pain which will determine the dose of Morphine to be administered to Patient 15) prior to administration of Morphine 2 mg IV at 6:52 a.m. NM 1 stated Patient 15's pain should have been assessed prior to giving pain medication to ensure appropriate medication would be administered to the patient.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," dated 04/2024, the P&P indicated, "The patient care provider administering the medication is responsible for ensuring the five rights of medication administration: i. Right medication, ii. Right Patient, iii. Right Dose, iv. Right Route, v. Right time."

During a review of the facility's policy and procedure (P&P) titled, "Acute Pain Management" revision dated 9/23, the P&P indicated, "There shall be a pain assessment performed for all patients in the In-Patient Nursing Units ...Ongoing Pain Management Pain Assessment and reassessment for patients will occur with each new report of pain, following any pain control intervention within one hour and at regular intervals appropriate to individual patient status."

3. During a review of Patient 21's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/28/2024, the H&P indicated Patient 21 was presented to the Emergency Department (provides medical and surgical to patients arriving to the hospital in need of immediate care) with a chief complaint of nausea (a feeling of discomfort in the stomach that comes with an urge to throw up), vomiting, constipation, and abdominal pain.

During a review of Patient 21's "Medication Administration Record (MAR, a report detailing the medications administered to a patient)," the MAR indicated a physician's order for Patient 21 to receive the following:

- Morphine (narcotic pain medication) 2 mg (milligram) via IV (in the vein) every 4 hours as needed (PRN) for moderate pain (pain score of 4-6 is moderate pain), to start on 9/28/2024; and,

- Morphine 4 mg via IV every 4 hours PRN for severe pain (pain score 7-10 is severe pain), to start on 9/28/2024.

During a concurrent interview and record review on 10/3/2024 at 11:52 a.m. with the Nursing Informatics 1 (NI 1), NI 1 verified Patient 21's MAR indicated, Patient 21 was given Morphine 2 mg (ordered to be given for moderate pain) IV on 10/3/2024 at 9:03 a.m., NI 1 verified the corresponding pain assessment score of Patient 21 was 8 (severe pain). NI 1 stated it was important to give the correct pain medication as ordered to ensure the patient pain was treated appropriately.

During an interview on 10/3/2024 at 3:06 p.m. with Registered Nurse 1 (RN 1), RN 1 stated Patient 21 should have been given Morphine 4 mg IV (ordered to be given for severe pain) instead of 2 mg on 10/3/2024 at 9:03 a.m., because Patient 21's pain level score was 8 (severe pain).

During a review of the facility's policy and procedure (P&P) titled, "Acute Pain Management," revised in 9/2023, the P&P indicated, "Patients will have their pain assessed and/or self-reported ...at intervals appropriate to the patient's needs ...Medication administration based on pain intensity level is defined as follows on a 0-10 scale: 1/10 to 3/10 = Mild Pain, 4/10 to 6/10 = Moderate Pain, 7/10-10/10 = Severe Pain"

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," dated 04/2024, the P&P indicated, "The patient care provider administering the medication is responsible for ensuring the five rights of medication administration: i. Right medication, ii. Right Patient, iii. Right Dose, iv. Right Route, v. Right time."