HospitalInspections.org

Based on observation, interview and record review, the facility failed to ensure that the Condition of Participation for Patient's Rights was met as evidenced by:

1. The facility failed to ensure one (1) of thirty sampled patients' (Patient 1's) parents was notified when Patient 1 was transferred from the NICU (neonatal intensive care unit, an area of the hospital that specializes in the treatment of medically unstable or critically ill newborns) to the pediatric unit. (Refer to A - 130).

2. The facility failed to ensure the patient's right to make informed decision was implemented according to facility's policy and procedure for three (3) of 11 sampled patients (Patients 16, 19, and 25) and/or the patients' next of kin (NOK - a designee to receive information regarding the patient's medical care) as evidence by:

a. For Patient 16, the patient's NOK signed the surgical consent that is not in a language Patient 16's NOK understood (in Spanish). (Refer to A - 131).

b. For Patient 19, the documentation did not indicate the language used for interpreter for Patient 19's NOK to obtain Patient 19 consent by telephone (in Spanish). (Refer to A - 131).

c. For Patient 25, no documented evidence from Physician 1 regarding obtaining the consent from for Patient 25's bilateral skin sparing mastectomy and blood transfusion and why consent was obtained via telephone and not signed in person by Patient 25. (Refer to A - 131).

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 ensure one (1) of thirty sampled patients' (Patient 1's) parents was notified when Patient 1 was transferred from the NICU (neonatal intensive care unit, an area of the hospital that specializes in the treatment of medically unstable or critically ill newborns) to the pediatric unit.

This deficient practice resulted to Patient 1's parent not being notified of the transfer and had the potential of no being actively included in their Patient 1's plan of care.

Findings:

A record review of Patient 1's "History and Physical (H&P)," dated 6/24/2021, indicated Patient 1 was admitted to the NICU (neonatal intensive care unit, an area of the hospital that specializes in the treatment of medically unstable or critically ill newborns) for prematurity (babies born before 37 weeks of pregnancy)), neonatal respiratory distress syndrome (RDS, a common breathing disorder that affects newborns), and fetal growth restriction (FGR, a condition in which an unborn baby [fetus] is smaller than expected for the number of weeks of pregnancy).

During an interview, on 11/8/2023 at 1:07 p.m., the Clinical Nurse Specialist 2 (CNS 2) stated the decision to transfer Patient 1 to the pediatric unit was because the baby (Patient 1) was the most stable patient in the NICU at that time. CNS 2 stated the transfer of Patient 1 also occurred during COVID time when the NICU was at full capacity. CNS 2 stated the NICU will transfer patients to prioritized care as they need beds for critically ill babies. CNS 2 confirmed the parents should have been notified of the transfer, regardless of the reason the baby was being transferred. CNS 2 confirmed that the parents were not notified by the NICU that their baby had been transferred to the pediatric unit.

During an interview on 9/11/2023 at 10:40 a.m, the Director of Pediatrics 1 (PD 1) 1 stated, "There should be notification to the parent prior to transferring the baby to another unit." PD 1 stated the parent of the infant should also be given a tour of the unit to which their child will be relocated. PD 1 stated a tour of the unit ensures the family was oriented to the unit and ensures family involvement in their baby plan of care. PD 1 stated Patient 1's parents did not receive a tour of the pediatric unit prior to the transfer of their baby (Patient 1). PD 1 also stated that the parent of Patient 1 was not notified of the transfer.

During a review of the facility's policy and procedure (P&P) titled "Neonatal Standard of Care," effective February 1988, revised March 2023, the P&P indicated the purpose of the policy is "to establish consistent standards of care for all Neonatal Intensive Care Unit (NICU) patients. Each patient in the NICU shall receive quality patient care based on established standards. The following are the minimum standards of care: Patients may be monitored more frequently according to the nurse's discretion and/or as patient condition warrants. Age-appropriate/developmental care (Lippincott developmental support, neonatal) In planning an infant's care, the following components shall be considered: Include parents in all aspects of developmental assessment, interventions, and evaluations. Documentation: Families and patients shall be oriented to the unit upon admission, and this orientation shall be documented on the NICU Admission Assessment, Daily Cares flowsheet, and education record. Family/patient educational and cultural needs shall be assessed and documented as applicable ..."

During a review of the facility's policy and procedure (P&P) titled "Patient Rights and Responsibilities," dated June 20, 2021, the P&P indicated, "As a patient of the facility's hospital system, you have the right to: receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery, and outcomes of care (including unanticipated outcomes) in terms you can understand. You have the right to effective communication and to participate in the development and implementation of your plan of care. You have the right to participate in ethical questions that arise in the course of your care, including issues of conflict resolution, withholding resuscitative services, forgoing or withdrawing life-sustaining treatment, or to request an ethics consult ..."

Based on observation, interview, and record review, the facility failed to ensure the patient's right to make informed decision was implemented according to facility's policy and procedure for three (3) of 11 sampled patients (Patients 16, 19, and 25) and/or the patients' next of kin (NOK - a designee to receive information regarding the patient's medical care) as evidence by:

1. For Patient 16, the patient's NOK signed the surgical consent that is not in a language Patient 16's NOK understood (in Spanish).

2. For Patient 19, the documentation did not indicate the language used for interpreter for Patient 19's NOK to obtain Patient 19 consent by telephone (in Spanish).

3. For Patient 25, no documented evidence from Physician 1 regarding obtaining the consent from for Patient 25's bilateral skin sparing mastectomy and blood transfusion and why consent was obtained via telephone and not signed in person by Patient 25.

These deficient practices resulted in the patients and the patients' NOK to not received the comprehensible information needed to make an informed decision regarding the patient's care.

Findings:

1. During an observation on 11/7/2023 at 2 p.m., Patient 16 was observed in the Neonatal Intensive Care Unit (NICU - specialty unit for newborn babies who need intensive medical care) asleep in the crib wrapped in blanket. Patient 16 had a peripherally inserted central catheter (PICC - an intravenous access used to deliver medications and other treatments directly to the large central veins near the heart) line on the left lower extremity.

A record review of Patient 16's Pediatric History and Physical, dated 10/16/2023, indicated Patient 16 was admitted to the facility with a chief complaint of abnormal laboratory result.

A record review of Patient 16's Basic Demograhics (Patient Information) record, dated 10/16/2023, indicated Patient 16 NOK's preferred language was Spanish.

A record review of Patient 16's physician's order, dated 10/17/2023, indicated a PICC line placement for Patient 16.

A record review Patient 16's Sedation and Analgesia For Procedures Informed Consent Information, written in English, had a signature under the "Signature of patient, parent or conservator," on 10/17/2023 at 3:05 p.m. The consent did not indicate the relationship of the person ,who signed the consent for Patient 16.

A record review on 11/7/2023, the "PICC Consent To Operation and Other Procedures," written in English, had a signature under the "signature of patient, parent or conservator" on 10/17/2023 at 3:10 p.m. The consent did not indicate the relationship of the person who signed the consent to Patient 16.

During an interview with Charge Nurse 1 (CN1) and concurrent record review of Patient 1's consents (Sedation and Analgesia For Procedures Informed Consent Information and PICC Consent To Operation and Other Procedures) on 11/7/2023, at 2 p.m., CN 1 stated Patient 16 NOK's preferred language was Spanish, and the consents signed by Patient 16's NOK should have been written in Spanish. CN 1 stated the signature on both of Patient 16's consents were like the signature of Patient 16's NOK. CN 1 stated Patient 16's consents were signed other than the patient, and the relationship to Patient 16 should have been indicated.

During a concurrent interview with the Director of Language Services (DLS) and record review of Patient 16's Sedation and Analgesia For Procedures Informed Consent Information, on 11/8/2023 at 11:38 a.m., the DLS stated Patient 16's Sedation and Analgesia For Procedures Informed Consent Information, dated 10/17/2023, written in English, indicated an interpreter was used for Patient 16's NOK to sign the consent. The DLS stated the consent did not indicate the method of interpretation used, the name of the language interpreter used, the date, and time of the interpretation.

During a concurrent interview with the DLS and record review, on 11/8/2023 at 11:38 a.m., the DLS stated Patient 16's "PICC Consent To Operation and Other Procedures," dated 10/17/2023, written in English, indicated an interpreter was used for Patient 16's NOK to sign the consent. The DLS stated the consent did not indicate the method of interpretation used, the name of the language interpreter used, the date, and time of the interpretation.

During an interview, on 11/8/2023, at 11:38 a.m., the DLS stated there were health information documents available to use that were translated and written in other languages. The DLS stated when a health care information document was available in the preferred language of the patient or the patient's NOK, the documents should be used to provide information. The DLS stated when a document was not available in the preferred language of the patient or the patient's NOK, a language interpreter should be used, and documentation of the interpretation should be completed in accordance with the facility's policy and procedure.

During a concurrent interview with Nurse Informatics 2 (NI 2) and record review of Patient 16's Sedation and Analgesia For Procedures Informed Consent Information, on 11/8/2023 at 11:40 a.m., NI 2 stated the facility had a Spanish version of the Sedation and Analgesia For Procedures Informed Consent Information. NI 2 stated the facility's "PICC Consent To Operation and Other Procedures," was only written in English.

During a review of the P&P titled, "Patient Rights and Responsibilities," revised in 06/2021, the P&P indicated, " ...Receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcome of care in terms you can understand ..."

During a review of the P&P titled, "Consent - Obtaining and Documenting," revised in 10/2023, the P&P indicated, " ...Consent forms should be written in a language the patient can understand or translated into such language. Interpreter services is available to translate forms upon request ..."

During a review of the P&P titled, "Language Assistance for Patients and Families," revised in 7/2019, the P&P indicated, " ...Document the following information in Care Connect (Electronic Health Record) as part of the legal medical record:
a. The method of interpretation used (phone, video, in-person).
b. The name of the qualified healthcare interpreter who provided language assistance.
c. The qualified healthcare interpreter's identification or badge number who provided language assistance ..."

2. During an observation on 11/7/2023 at 2:20 p.m., with Registered Nurse 7 (RN 7) 7, Patent 19 was observed in the room inside a crib, intubated (a tube inserted through the mouth into the airway to assist patient in breathing) and was receiving multiple intravenous (IV) medications. RN 7 stated Patient 19 was scheduled for a cardiac catheterization (a test or treatment for heart problems using a thin catheter guided through a blood vessel to the heart).

A review of Patient 19's Basic Demographics (Patient information) record, indicated Patient 19 was admitted on 9/23/2023. Patient 19's preferred language was Spanish.

During a concurrent interview with the DLS and record review of Patient 19's signed consents, on 11/8/2023 at 11:40 a.m., the DLS stated the Patient 19 had the following consents:

a. The surgical consent for "Carotid artery (a major blood vessel that provide blood supply to the vein) cut down," dated 11/6/2023, written in English, indicated an interpreter was used for Patient 19's NOK to sign the telephone consent.

b. The surgical consent for "Cardiac catheterization," dated 11/6/2023, written in English, indicated an interpreter was used for Patient 19's NOK to sign the telephone consent.

c. The surgical consent for "Insertion of Extracorporeal Membrane Oxygenation (ECMO - is a technique of providing prolonged cardiac and respiratory support to persons whose heart and lungs are unable to provide an adequate amount of gas exchange or perfusion to sustain life)," dated 11/6/2023, written in English, indicated an interpreter was used for Patient 19's NOK to sign the telephone consent.

During a concurrent interview, on 11/8/2023 at 11:40 a.m., the DLS stated all three surgical consents had the language interpreter's first name only and had no other documentation to verify qualification of the interpreter used in each of Patient 19's consents. The DLS stated when the facility used an interpreter, the interpreter's full name and identification number should be documented to ensure verification of a qualified interpreter was used.

During a review of the P&P titled, "Language Assistance for Patients and Families," revised in 7/2019, the P&P indicated, " ...Document the following information in Care Connect (Electronic Health Record) as part of the legal medical record:
a. The method of interpretation used (phone, video, in-person).
b. The name of the qualified healthcare interpreter who provided language assistance.
c. The qualified healthcare interpreter's identification or badge number who provided language assistance ..."

3. A record review of Patient 25's Pre-Op (before surgery) History and Physical, dated 11/7/2023, indicated Patient 25 was admitted to the facility for breast reconstruction surgery.

A record review of Patient 25's Consent For Surgery or Special Diagnostic or Therapeutic Procedure, indicated Patient 25 needed to consent for bilateral skin sparing mastectomy (a surgical procedure where the breast tissue is removed while most of the health breast skin is left) and for blood transfusion. The consent was signed by Physician 1, on 11/6/2023 at 9:11 a.m., and a "Witness signature if consent was obtained by telephone," was signed by the Nurse Practitioner (NP) on 11/6/2023 at 9:15 a.m. The consent did not include Patient 25's signature. The consent indicated the following:

a. "If not signed by patient, indicate relationship," was not answered.
b. Name of person signing for patient (if applicable)," was not answered; and,
c. "Was consent obtained via telephone, email or fax? Yes."

There was no documented evidence from Physician 1, who she spoke to and who she got the consent from for Patient 25's bilateral skin sparing mastectomy and blood transfusion. There was no documented evidence from Physician 1 the reason why Patient 25's surgical consent was obtained via telephone and not signed in person by the patient (Patient 25).

During an interview on 11/9/2023 at 10:56 a.m. and concurrent record review of Patient 25's Consent For Surgery or Special Diagnostic or Therapeutic Procedure, RN 8 stated before a patient was brought to the Operating Room (OR) the consent would be verified with the patient which included the patient's name, the surgical procedure, and the signature on the consent. RN 8 stated the surgical consent was usually signed by the patient and a telephone consent would only be obtained when the patient is a minor or incapacitated and the patient's guardian was not available to sign the consent in person. RN 8 stated there was no documented evidence from Physician 1, who she spoke to and who she got the consent from for Patient 25's bilateral skin sparing mastectomy and blood transfusion. RN 8 stated there was no documented evidence from Physician 1 the reason why Patient 25's surgical consent was obtained via telephone and not signed in person by the patient (Patient 25).

During an interview, on 11/9/2023 at 11:31 a.m., RN 9 stated she was assigned in the pre-operating (Pre-op) area. RN 9 stated one of the preparations for the patient going to surgery was to verify, the patient's surgical consent. RN 9 stated the consent would be verify with the patient which included the patient's name, the surgical procedure, and the signature on the consent. RN 9 stated she remembered being the pre-op RN for Patient 25. RN 9 stated she did not remember Patient 25's telephone surgical consent. RN 9 stated she thought she verified Patient 25's signature on the consent.

During a concurrent interview and record review of Patient 25's Consent For Surgery or Special Diagnostic or Therapeutic Procedure, on 11/9/2023 at 4 p.m., Physician 2 stated he was the Medical Director for Surgical Services. Physician 2 stated the physician would often have the patient sign the consent prior to their schedule surgery date, when the patient had no access to electronic signing of the consent, a telephone consent would be obtained. Physician 2 stated Patient 25's had a surgical consent for bilateral skin sparing mastectomy and stated the consent has no documentation on the consent regarding who the consent was given to and who signed the telephone consent. Physician 2 stated, if Patient 25 signed the telephone consent, Patient 25's name should have been written in the consent.

During a review of the facility's P&P titled, "Consent - Obtaining and Documenting," revised in 10/2023, the P&P indicated the following:

a. Obtaining Informed Consent. Generally, it is presumed that an adult patient has the capacity to make health care decisions and provide consent.

b. Documenting Informed Consent in the Medical Record. Patient Confirmation. The patient (or his or her legal representative) should sign the consent form(s).

c. Verification. California law requires that, prior to non-emergency surgery, the person responsible for administering anesthesia or the surgeon must ascertain that a signed consent form for the contemplated surgical procedure is in the medical record. The signature of the patient or the patient's legal representative documents that the informed consent discussion has taken place between the physician and the patient.

d. Consent by Telephone. Telephone consent for medical or surgical treatment should only be obtained; when the patient or a person with legal capacity to consent for the patient and/or the person obtaining consent are not available to complete consent in person. When consent is granted by telephone the documentation in the medical record must explain why consent was obtained in this manner, should include witnesses, and must indicate that the informed consent discussion occurred in compliance with this policy.

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

1. The facility failed to assess patient's skin irritation (the production of reversible damage to the skin following the application of a substance) at the affected area (underarm and left side of the body) after treatment was rendered and to document if the issue had been resolved for one (1) of 30 sampled patients. (Refer to A 395).

2. The facility failed to assess the pain level of Patient 18 and 22's pain prior to administering pain medication according to facility policy and procedure. (Refer to A 395).

3 The failed to provide nursing care according to facility's policy and procedure for three (3) of 30 sampled patients (Patients 1, 29, and 30) as evidence by:

a. Patient 1's medication (Aquaphor, an ointment used to restore, protects, and soothes extremely dry skin, cracked hands and feet, minor cuts and burns) was not scanned during medication administration by nurses. (Refer to A 398).

b. Patients 29's critical laboratory value results (Hemoglobin, protein in the blood responsible for delivery of oxygen to the tissue, Hematocrit, a percentage by volume of red cells in the blood, and potassium (a mineral essential in the body) was not communicated to the physician. (Refer to A 398).

c. Patients 30's critical laboratory value result to check troponin (a protein that is released into the bloodstream during a heart attack) was not communicated to the physician. (Refer to A 398).

4. The facility failed the ensure medications were administered according to physician's order and facility's policy and procedure (P&P) for 3 of 30 sampled patients (Patients 18, 22, and 27). (Refer to A - 405).

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care by the nursing staff.

Based on observation, interview, and record review, the facility failed to ensure appropriate nursing care for pain assessment was provided for three (3) of 30 sampled patients (Patients 1, 18 and 22).

1. The facility failed to assess Patient 1's skin irritation (the production of reversible damage to the skin following the application of a substance) at the affected area (underarm and left side of the body) after treatment was rendered and to document if the issue had been resolved.

This deficient practice placed Patient 1's health at risk for a potential unidentified underlining infection or allergic reaction that could require specific interventions.

2. The facility failed to assess the pain level of Patient 18 and 22's pain prior to administering pain medication according to facility policy and procedure.

These deficient practices had the potential to result in delay of patient treatment and uncontrolled pain for Patients 18 and 22.

Findings:

1. A review of Patient 1's "History and Physical (H&P)," dated 6/24/2021, indicated that Patient 1 was admitted to the NICU (neonatal intensive care unit, an area of the hospital that specializes in the treatment of medically unstable or critically ill newborns) for prematurity (babies born before 37 weeks of pregnancy), neonatal respiratory distress syndrome (RDS, a common breathing disorder that affects newborns), and fetal growth restriction (FGR, a condition in which an unborn baby [fetus] was smaller than expected for the number of weeks of pregnancy).

During a concurrent interview with Clinical Nurse Specialist (CNS) 1, and record review of Patient 1's "End of Shift Summary," on 11/8/2023 at 1:07 p.m., CNS reviewed and stated Patient 1's End of Shift Summary, date of service 7/14/2021 at 6:56 a.m. indicated, "Patient left side of the body underarm irritated from leads (electrodes in the form of sicker pads that are attached from the patient to a battery pack transmitting impulses to the monitor) and Detachol (an adhesive rover solution). Aquaphor ordered per Medical Doctor (MD). CNS 2 stated on 7/13/2021, during a night shift, a care partner (staff that provides support to a licensed nurse in caring for patients in a hospital) used the Detachol to loosen a telemonitor's lead on a pediatric patient (Patient 1), and as a result, the baby's skin was reddened. CNS 2 stated, "Aquaphor, an ointment was applied."

During an interview with the Director of Pediatrics (DP) 1, DP 1 stated, "Around 10:00 p.m. during the night shift, a care partner was using Detachol to remove a telemetry lead that was placed on the baby's chest, and the baby's skin became red."

During a concurrent interview with the Director of Pediatric (DP 1) and record review of Patient 1's Nursing Assessment Flow Sheet, on 11/8/2023 at 1:20 p.m. DP 1 stated the nursing assessment flow sheet section, "Skin Integrity," dated 7/13/2021 at 12:42 a.m. was reviewed and stated the flow sheet indicated, under skin integrity, "Intact." DP1 stated the record had no documentation describing the location of the affected area. The record indicated the next skin assessment was documented ten hours and forty-eight minutes later, on 7/14/2023, at 11:30 a.m., indicating "Intact." DP 1 stated that there was no documentation that indicated the patient's skin irritation to the underarm and left side of the body was effectively treated when Aquaphor had been applied or if the irritation to the skin was resolved. DP1 stated, "There should be documentation that indicates the affected area with redness has been resolved to provide continuity of care."

During an interview, on 9/11/2023 at 10:40 a.m. with the Program Manager of Wound and Ostomy Care (PMCNS) 1, PMCNS stated that if there was an unusual reaction to the skin for documentation, PMCNS 1 stated, "There should be a drop-down under integumentary and selection for description of the wound." PMCNS stated it is encouraged to create an LDA (section of lines, drains, and airways) if there is treatment ordered. PMCNS stated that the LDA column allows for continuous documentation of those skin issues. PMCNS confirmed that even if the skin problem was not a pressure injury, the document should include a description and status of the affected skin area.

During a review of the facility's policy and procedure (P&P) titled, "Assessment of Patients," effective date February 1995 and revised date March 2023, the P&P indicated the following. To comprehensively assess and document the initial admission assessment of all patients, and to ensure that each patient's physical, psychological spiritual, cultural, nutritional, and social status needs are assessed continuously ... Examples of reassessment will include but are not limited to; blood pressure, pulse, respiratory rate, temperature, and pain, if indicated. Additional reassessments will be done and documented according to the following:
a. When there ls a significant change in the patient's condition/ diagnosis
b. When there Is a change in the level of care.
c. An untoward event places the patient at risk for an adverse outcome.
d. To determine the patient's response to treatment.
e. Physician orders
f. Based upon the patient or family desire.
g. Abnormal findings from previous assessment
h. Per specialty/population specific standards of care and pertinent policy and procedures
i. Unrelieved pain

A review of the facility's policy and procedure (P&P) titled, "Documentation of Patient Care," affective date July 1982 and revised date August 2023, indicated, "The purpose of this policy is to establish the requirements and responsibilities for the documentation of nursing care in the inpatient medical record in compliance with professional nursing and regulatory standards. All nursing personnel are responsible for documenting patient care provided in the HER (electronic health record). The frequency of documentation is driven by physician/designee orders, policies, guidelines, patient condition, level of care, unit standards, and nursing judgment ... Documentation of patient care is to be completed on a timely and ongoing basis throughout the shift to ensure patient safety. Nursing interventions and patient progress toward the goals will be reflected in EHR flowsheets, nursing documentation in the Notes, Treatments, End of Shift Summary, and other appropriate related Flowsheets ..."

2. During an observation on 11/7/2023 at 2:15 p.m., Patient 18 was observed in the patient's room, sitting on the chair, and was watching a movie. Patient 18 had a left chest tube (a surgical drain that is inserted through the chest wall into the lungs to drain unwanted fluid or air).

A record review of Patient 18's Pediatric History and Physical, dated 11/2/2023, indicated Patient 18 was admitted to the facility with a chief complaint of mediastinal mass (lung tumor).

A record review of Patient 18's Chest Tube Flowsheets, indicated Patient 18's left chest tube was inserted, on 11/3/2023.

A record review on 11/8/2023, Patient 18's Medication Administration Report (MAR) indicated a physician's order of acetaminophen (pain medication) 690 milligram (mg, unit of measurement) to be given intravenous (IV, into the vein) every 6 hours as needed for mild pain for pain scale of one (1) to three (3) (pain scale level of 1 [mild pain] through 10 [severe or worst pain]). Patient 18's MAR indicated the following:

a. On 11/3/2023 at 5:42 p.m., Patient 18 was administered acetaminophen 690 mg IV. There was no documented evidence Patient 18's pain was assessed prior to administering acetaminophen on 11/3/2023 at 5:42 p.m.

During an interview with Charge Nurse Manager 1 (CNM 1), on 11/8/2023 at 2:22 p.m., CNM 1 stated Patient 18's pain level should have been assessed prior to administering the acetaminophen on 11/3/2023 at 5:42 p.m., to ensure an appropriate pain medication would be given to manage Patient 18's pain.

During a review of the facility's P&P titled, "Pain Assessment and Management Policy," revised in 8/2023, the P&P indicated, "Patients are screened for pain as part of the patient's initial evaluation and an ongoing basis, if relevant to the visit." "Patents receive prompt, effective pharmacologic, non-pharmacologic, and/or procedural management for their pain..."

3. During a concurrent observation and interview, on 11/7/23 at 3:10 p.m., Patient 22 was observed in his room, lying in bed, alert and oriented. Patient 22's right leg was surgically wrapped and elevated in a pillow, and the left thigh was covered with a dressing. Patient 22 stated there was an explosion. Patient 22 stated the explosion injured his legs. Patient 22 stated he had a surgery on the right leg, and they took the bone graft (a surgical procedure that uses transplanted bone to repair and rebuild damaged bones) from his left thigh. Patient 22 stated, "It's painful not sure why I need to ask frequently for pain meds, why can they give it to me."

A record review of Patient 22's Trauma Surgery H&P (History and Physical), dated 10/24/2023, indicated Patient 22 was admitted for trauma with open deformity (not in the normal position) to the right lower extremity.

During a record review on 11/9/2023, Patient 22's MAR indicated a physician order of oxycodone (pain medication) 15 milligram (mg, unit of measurement) to be given by mouth (po) every 6 hours as needed for severe pain (pain scale level of 1 [mild pain] through 10 [severe or worst pain]). Patient 22's MAR indicated the following administration of oxycodone:

a. On 10/28/2023 at 7:44 p.m., Patient 22 was administered oxycodone 15 mg po.
b. On 10/29/2023 at 2:14 a.m., 7:33 a.m., and 3:32 p.m., Patient 22 was administered oxycodone 15 mg po.

There was no documented evidence Patient 22's pain was assessed prior to administering oxycodone 15 mg on 10/28/2023 at 7:44 p.m. and 10/29/2023 at 2:14 a.m.

During an interview with CNM 2, on 11/9/2023 at 9:35 a.m., CNM 2 stated Patient 22's pain level should have been assessed prior to administering the pain medication to know Patient's baseline of pain and to ensure an appropriate pain medication would be given to manage Patient 22's pain.

During a review of the facility's P&P titled, "Pain Assessment and Management Policy," revised in 8/2023, the P&P indicated, "Patients are screened for pain as part of the patient's initial evaluation and an ongoing basis, if relevant to the visit." "Patents receive prompt, effective pharmacologic, non-pharmacologic, and/or procedural management for their pain..."

Based on observation, interview, and record review, the facility license nurse failed provided care according to the facility's policy and procedure (P&P) for three (3) of 30 sampled patients (Patients 1, 29, and 30) as evidence by:

1. Patient 1's medication (Aquaphor, an ointment used to restore, protects, and soothes extremely dry skin, cracked hands and feet, minor cuts and burns) was not scanned during medication administration by nurses.

This deficient practice had the potential to result in Patient 1 receiving the wrong medication or dosage and not administered according to physician order.

2. Patients 29's critical laboratory value results (Hemoglobin, protein in the blood responsible for delivery of oxygen to the tissue, Hematocrit, a percentage by volume of red cells in the blood, and potassium (a mineral essential in the body) was not communicated to the physician.

This deficient practice had the potential for the physician to not be informed of abnormal critical lab value result which may result in delay of emergent Patient 29's care treatments.

3. Patients 30's critical laboratory value result to check troponin (a protein that is released into the bloodstream during a heart attack) was not communicated to the physician.

This deficient practice had the potential for the physician to not be informed of abnormal critical lab value result which may result in delay of emergent patient treatment for Patient 30.

Findings:

1. A review of Patient 1's "History and Physical (H&P)," dated 6/24/2021, indicated that Patient 1 was admitted to the NICU (neonatal intensive care unit, an area of the hospital that specializes in the treatment of medically unstable or critically ill newborns) for prematurity (babies born before 37 weeks of pregnancy), neonatal respiratory distress syndrome (RDS, a common breathing disorder that affects newborns), and fetal growth restriction (FGR, a condition in which an unborn baby [fetus] was smaller than expected for the number of weeks of pregnancy).

During a concurrent interview with Clinical Nurse Specialist (CNS) 1, and record review of Patient 1's "End of Shift Summary," on 11/8/2023 at 1:07 p.m., CNS reviewed and stated Patient 1's End of Shift Summary, date of service 7/14/2021 at 6:56 a.m. indicated, "Patient left side of the body underarm irritated from leads (electrodes in the form of sicker pads that are attached from the patient to a battery pack transmitting impulses to the monitor) and Detachol (an adhesive rover solution). Aquaphor ordered per MD (Doctor of Medicine) and administered."

During a concurrent interview with Nurse Informatics 3 (NIF 3), and record review of Patient 1's "Medication Administration Record (MAR)," on 11/9/2023 at 10:12 a.m. NIF 3 reviewed and stated Patient 1's MAR, dated 7/13/2023 through 7/15/2023, indicated there was no administration record for Aquaphor. NIF 3 reviewed the "Medication Tracking Information (log for medication administered)" and stated, "No administration record was found for Aquaphor medication," for Patient 1. The NIF 3 showed and stated the medication tracking system indicated, "Mineral oil-hydrophilic petrolatum (Aquaphor) ointment is scheduled to start on 7/14/23 at 12:51 a.m." NIF 3 confirmed that the medication tracking information system indicated "no administration records."

During an interview on 11/9/2023 at 10:40 a.m. with Program Manager, Wound Clinical Nurse Specialist (PMCNS) 1, PMCNS 1 stated it (Aquaphor) was a medication that was distribute by pharmacy, so it (Aquaphor) should be scan in during administration. PMCNS 1 stated, "It (Aquaphor administration) should show up in the MAR."

During an interview on 11/9/2023 at 1:05 p.m. with Director of Pediatric (DP) 1, DP 1 stated she did not locate in the Patient 1's MAR of the administration of Aquaphor. DP 1 stated "Although the registered nurse documents that she had administered the Aquaphor in her end of shift note, it (Aquaphor) was a medication that requires scanning, especially that the ordered indicated it (Aquaphor) was PRN (as needed; as circumstances require) medication."

During a review of the facility's policy and procedure (P&P) titled "Medication Administration," effective date, September 1980, and revised date, May 2023, the P&P indicated, "The purpose of this policy is to specify the requirements for safe and accurate preparation, administration, storage, and documentation of medications in accordance with the facility's system standard." The P&P indicates the following:
a. Medication Administration Flow Chart Requirements of medication administration include identifying the following critical steps: right patient, right drug, right dose, right route, and right time. In areas with barcode medication administration, the nurse shall scan the patient ID band, then scan the medication barcode prior to administration.
b. Medication administration records are reviewed prior to shift change to assure all medications have been administered and documented.
c. Medication Documentation included drug name, dose, route, (site as necessary), and time are documented in the medical record on the MAR following administration.
d. All medication entries in the medical record require initials and/or signature of the individual administering the medication. With the electronic medication administration record, the individual initials will automatically be documented upon administration of the medication.

A review of the facility's medication administration flow chart, titled "Appendix A, Medication Administration Flow Chart," undated, indicated steps to follow in the medication administration process, which starts with the physician entering the medication order and continues through several checkpoints. The eleventh step within the chart is at the bedside, where the chart indicates, "Scan the patient's ID band. Verbally validate patient name with patient or family, when possible, scan medication, confirm dose and route are correct, do a final visual check of the medication, open and administer medication, chart the medication given, log out of the system, and monitor patient for adverse reaction and effectiveness."

2. A record review of Patient 29's Emergency Department (ED) Provider Notes, dated 11/8/2023, indicated Patient 29 was presented to the ED for abdominal pain and worsening laboratory test results.

A record review on 11/9/2023, Patient 29's laboratory test result indicated on 11/7/2023 at 11:37 p.m., Clinical Laboratory Scientist (CLS) 1 called and notified Registered Nurse 10 (RN 10) of Patient 29's critical laboratory test result for Hemoglobin of 6.6 (Hgb., protein in the blood responsible for delivery of oxygen to the tissue, normal value was 11.6 gram (g, unit of measurement)/deciliter (dl, unit of measurement)to 15.2 g/dl) and Hematocrit of 17.9 (Hct., percentage by volume of red cells in the blood, normal value was 34.9 percentage [%] to 45.2 %). There was no documented evidence RN 10 notified the physician for Patient 29's critical laboratory test for Hgb. and Hct.

A record review on 11/9/2023, Patient 29's laboratory test result indicated on 11/7/2023 at 10:54 p.m., CLS 2 called and notified RN 10 of Patient 29's critical laboratory test result for potassium (electrolyte in the body, with low level of potassium can cause muscle cramp and abnormal heart rhythms) of 2.9 millimoles per liter (mmol/L) (normal value was 3.6 mmol/L to 5.3 mmol/L).

During an interview and concurrent record review of Patient 29 laboratory results, on 11/9/2023 at 3:15 p.m., Unit Director 2 (UD 2) stated when a patient had a critical laboratory test result, the CLS would immediately call the unit and report to the RN, then the RN who received the critical laboratory test result would immediately report it (laboratory result) to the physician to address the results and give the orders. UD stated there was not documented evidence that RN 10 notified the physician for Patient 29's critical laboratory test result for Hgb., Hct., and potassium. UD 2 stated the reporting of the critical laboratory test results from the CLS to the RN to the Physician should be documented in accordance with the facility's P&P.

3. A record review Patient 30's ED Service Report, dated 11/7/2023, indicated Patient 30 was presented to the ED with chest pain.

A record review on 11/9/2023, Patient 30's laboratory test result indicated on 11/7/2023 at 4:49 p.m., Clinical Laboratory Scientist (CLS) 3 called and notified RN 11 of Patient 30's critical laboratory test result for Troponin of 1,980 nanogram (ng)/liter (L) (a protein that is released into the bloodstream during a heart attack, normal values are below 14 ng/L). There was no documented evidence RN 11 notified the physician for Patient 30's critical laboratory test for Troponin.

During an interview on 11/9/2023 at 3:15 p.m., UD 2 stated when a patient had a critical laboratory test result, the CLS would immediately call the unit and report to the RN, then the RN who received the critical laboratory test result would immediately report it to the physician to address the results and give the orders. UD 2 stated there was not documented evidence that RN 11 notified the physician for Patient 30's critical laboratory test for Troponin. UD 2 stated the reporting of the critical laboratory test results from the CLS to the RN to the Physician should be documented in accordance with the facility's P&P.

During a review of the facility's P&P titled, "Reporting of Critical Results and Values," revised in 8/2021, the P&P indicated the following:

a. All critical values - are reported within the departmental defined critical value time interval to the responsible licensed caregiver who can act on the results determined by the department.

b. The person who provides the telephone report of critical values perform the following: report the critical value, record time and name of the person receiving the report, and record that the critical value was read back and confirmed.

Based on observation, interview, and record review, the facility failed the ensure medications were administered according to physician's order and facility's policy and procedure (P&P) for 3 of 30 sampled patients (Patients 18, 22, and 27).

These deficient practices resulted to delay of treatment for Patient 18, 22, and 27. The deficient practices had the potential to cause adverse health outcomes which could negatively affect the patient's health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death.

Findings:

1. During an observation on 11/7/2023 at 2:15 p.m., Patient 18 was observed in the patient's room, sitting on the chair, and was watching a movie. Patient 18 had a left chest tube (a surgical drain that is inserted through the chest wall into the lungs to drain unwanted fluid or air).

A record review of Patient 18's Pediatric History and Physical, dated 11/2/2023, indicated Patient 18 was admitted to the facility with a chief complaint of mediastinal mass (lung tumor).

A record review of Patient 18's Chest Tube Flowsheets, indicated Patient 18's left chest tube was inserted, on 11/3/2023.

A record review on 11/8/2023, Patient 18's Medication Administration Report (MAR) indicated a physician's order of acetaminophen (pain medication) 690 milligram (mg, unit of measurement) to be given intravenous (IV, into the vein) every 6 hours as needed for mild pain for pain scale of one (1) to three (3) (pain scale level of 1 [mild pain] through 10 [severe or worst pain]). Patient 18's MAR indicated the following:

a. On 11/3/2023 at 12:49 a.m., Patient 18 was administered acetaminophen 690 mg IV. The corresponding pain assessment on 11/3/2023 at 12:49 a.m., indicated Patient 18's "Pain score 10 - worst pain."

b. On 11/3/2023 at 5:42 p.m., Patient 18 was administered acetaminophen 690 mg IV. There was no documented evidence Patient 18's pain was assessed prior to administering acetaminophen on 11/3/2023 at 5:42 p.m.

During an interview with Clinical Nurse Manager 1 (CNM 1), on 11/8/2023 at 2:22 p.m., CNM 1 stated the acetaminophen administered to Patient 18 on 11/3/2023 at 12:49 a.m. was not in accordance with the physician's order because it was for mild pain. Patient 18's pain level was severe pain (pain scale of 7 to 10). CNM 1 stated the Registered Nurse (RN) should have called the physician for order of pain medication that would help managed Patient 18's severe pain. CNM 1 stated Patient 18's pain level should have been assessed prior to administering the acetaminophen on 11/3/2023 at 5:42 p.m., to ensure an appropriate pain medication would be given to manage Patient 18's pain.

A review of the facility's P&P titled, "Medication Administration," revised date 5/2023, the P&P indicated, "...Requirement of medication administration include...right drug, right dose..." "Before administration, the individual administering the medication must...verifies that the medication is being administered...in the prescribed dose..."

During a review of the facility's P&P titled, "Pain Assessment and Management Policy," revised date 8/2023, the P&P indicated, "Patients are screened for pain as part of the patient's initial evaluation and an ongoing basis, if relevant to the visit." "Patents receive prompt, effective pharmacologic, non-pharmacologic, and/or procedural management for their pain..."

2. A record review of Patient 22's Trauma Surgery H&P (History and Physical), dated 10/24/2023, indicated Patient 22 was admitted for trauma with open deformity (not in the normal position) to the right lower extremity.

A record review of Patient 22's MAR indicated a physician order of Zosyn (piperacillin/tazobactam [antibiotic]) 3.375 grams (g, unit of measurement) to be given intravenous (IV) every 6 hours with a start date of 10/26/2023 at 6:30 p.m. Patient 22's MAR indicated the following administration of Zosyn:

a. On 10/26/2023 at 9:02 p.m., Patient 22 was administered the first dose of Zosyn (2 hours and 30 minutes after the scheduled first dose of Zosyn).

b. On 10/27/2023 at 12 midnight, Patient 22's Zosyn was not given with a reason of "time adjusted."

c. On 10/27/2023 at 5:30 a.m., Patient 22 was administered Zosyn (8 hours and 30 minutes after the last dose of Zosyn administration).

d. On 10/27/2023 at 2:40 p.m., Patient 22 was administered Zosyn (9 hours after the last dose of Zosyn administration).

e. On 10/27/2023 at 9:15 p.m., Patient 22 was administered Zosyn.

f. On 10/28/2023 at 2:33 a.m., Patient 22's Zosyn was not given with a reason of "time adjusted."

g. On 10/28/2023 at 6:28 a.m., Patient 22 was administered Zosyn (9 hours after the last dose of Zosyn administration).

During an interview with Pharmacist 2 and concurrent record review of Patient 22's MAR, on 11/9/2023 at 9 a.m., Pharmacist 2 stated on review of Patient 22's MAR, the order for Zosyn 3.375 g was to be given IV every 6 hours with a start date of 10/26/2023 at 6:30 p.m. Pharmacist 2 stated, on 10/26/2023 at 6:04 p.m. Zosyn was available to be administered and the first dose should have been given at 6:30 p.m., as ordered by the physician. Pharmacist 2 stated when a new antibiotic was ordered for the patient, it would be started as soon as the antibiotic was verified and available for administration. Pharmacist 2 stated for the subsequent doses of antibiotic, when there is a change in the schedule administration, the Registered Nurse (RN) should notify the Pharmacist to change the dosing schedule for the patient.

During an interview on 11/9/2023 at 9:35 a.m., CNM 2 stated Patient 22's first dose of Zosyn was delayed. CNM 2 stated Zosyn was available and should have been administered as ordered on 10/26/2023 at 6:30 p.m. CNM 2 stated Patient 22's subsequent Zosyn doses were delayed and not given in accordance with the physician's order. CNM 2 stated when there is a need for adjustment of scheduled time administration, the RN should notify the Pharmacist so that it would be adjusted in the MAR and the antibiotic dosing time would be followed as ordered by the physician.

During a review of the facility's P&P titled, "Standard Medication Administration Times," revised in 6/2020, the P&P indicated the following:

a. New IV antibiotics: After an antibiotic order is entered, the first dose will be administered as soon as possible and will not hold for a standard administration time. Subsequent doses should be staggered back the selected standard (routine) administration schedule.

b. If a dose is delayed or missed, the nurse will give the next dose as soon as possible and follow the chart title How to Stagger medications to Return to Standard Administration Times to return to standard schedule.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," revised in 5/2023, the P&P indicated, "...Requirement of medication administration include...right drug, right dose, right route and right time..."

3. A record review of Patient 27's Neurocritical (area regarding intensive care of the brain or nervous system) Care Attending Note, dated 8/31/2023, indicated Patient 27 was admitted to the facility, on 8/30/2023, for status epilepticus (a seizure that lasts longer than 5 minutes, or having more than 1 seizure within 5 minutes period without returning to a normal level of consciousness between episodes).

A record review of Patient 27's physician's order indicated meropenem (antibiotic) 2 g to be given intravenous (IV) every 8 hours for lower respiratory tract infection.

A record review of Patient 27's medication administration report (MAR) indicated the following:

a. On 11/7/2023 at 7:44 a.m., meropenem 2 g IV was administered to Patient 27.

b. On 11/7/2023 at 5:25 p.m., meropenem 2 g IV was administered to Patient 27 (9 hours and 30 minutes after the last dose of meropenem).

c. On 11/9/2023 at 12:06 a.m., meropenem 2 g IV was administered to Patient 27.

d. On 11/9/2023 at 9:43 a.m., meropenem 2 g IV was administered to Patient 27 (9 hours and 45 minutes after the last dose of meropenem).

During an interview, on 11/9/2023 at 1:09 p.m., the Unit Director (UD 1) stated per P&P the medication administration times for every 8-hour schedule was 8 a.m., 4 p.m., and 12 a.m.

UD 1 stated Patient 27's meropenem 2 g IV administration was administered late on 11/7/2023 at 5:25 p.m., and on 11/9/2023 at 9:43 a.m.

During a review of the facility's P&P titled, "Medication Administration," revised in 5/2023, the P&P indicated, "...Requirement of medication administration include...right drug, right dose, right route and right time..."

During a review of the facility's policy and procedure titled, "Standard Medication Administration Times," revised in 6/2020, the P&P indicated, "...Q8H (every 8 hours) Scheduled Times: 08 - 16 (4 p.m.) - 24 (12 a.m.)..."