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Based on interview and review, the facility failed to ensure two of thirty sampled patients (Patient 13 and Patient ?), were screened for potential abuse.

This deficient practice had the potential for being in an abusive situation.

Findings:


42937

Based on interview and review, the facility failed to ensure one (1) of thirty sampled (Patient 13) was screened for potential abuse.

This deficient practice had the potential for Patient 13 and other patients not assessed of being in an abusive situation.

Findings:

On 12/1/2023, at 3:15 PM, during concurrent interview with Registered Nurse Informaticist (RN I) and record review of Patient 13's nursing notes, dated 1/4/2023 to 1/6/2023, RN I stated there was no documentation that Patient 13 was assessed for the screening questions for abuse. RN I stated Patient 13 should have been screened for abuse after being admitted to the hospital, on 1/4/2023. RN I stated patients admitted to the nursing unit should be interviewed and assessed for signs of abuse.

A review of facility Pre-Employment Background Check policy, dated 6/30/2022, indicated the following:

1. Pre-employment background checks will be conducted on all prospective new hires and monthly government sanctions/ exclusion screenings on all employees.

2. Background investigation will include references, current and/or past employment, education, criminal or police reports, sexual offender, other public records, and credit checks.

A review of facility's Elder/Dependent Abuse and Neglect policy, dated 1/20/2023, indicated the following:

1. All hospital employees must report suspected abuse or neglect, when acting in their professional capacity or within the scope of their employment.

2. All licensed hospital personnel may be responsible for recognition and reporting, and are considered, "mandated reporters" (a person who is legally required to report observed or suspected abuse).

3. Any employee suspecting abuse is required to file an Adult Protective Services (APS - agency to help elder adults and dependent adults who are suspected of being victims of abuse) report and should contact the social worker assigned to that hospital unit, who can assist with assessment and reporting.

4. A copy of the APS form is placed in the patient's medical record and a copy is on file in the social services office.

A review of facility's Employee Handbook, dated 11/29/2023, indicated the following:

1. The new employee orientation is designed to provide information necessary to acquaint employees with their job, the hospital, and the necessity of working, including receipt of important information regarding the hospital's policies and procedures, programs, regulations, benefits, and safety.

2. Facility employees are expected to promote and protect the rights of diverse patient populations, including respecting the patient's dignity, worth, attributes, and human rights.

3. Employees are urged to be alert to the entry of unauthorized persons in any area and should report any suspicious activity to security.

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 evaluate and document psychosocial assessment (the evaluation screen on domestic violence, abuse history and suicidal tendency of a patient) on one (1) of thirty sampled patients (Patient 17). The deficient practice has the potential of failing in identifying Patient 17 and other patients, who are at risk of domestic violence, abuse, and/or suicide. (Refer to A 395).

2. The facility failed to ensure one (1) of nine (9) sampled Registered Nurses (RN 4), had completed orientation and competencies according to facility's policy and procedure (P&P) for an RN working in the assigned units (Labor & Delivery [L&D - specialized unit to prepare a woman's body to give birth to a baby] and Obstetric (OB) triage (a specialized unit where pregnant mothers were examined to determine the disposition of the woman and her fetus on arrival in the facility). RN 4 had no orientation and competencies records completed to the units worked (L&D and OB triage) to ensure specialized qualifications were met to provide care for the patients in the units worked. This deficient practice had the potential for RN 4 and other nurses working in the L&D and OB units without completed orientation and competencies, not qualified to care for the type of patients in the different units and patients were at risk for not getting proper care met. (A 397).

3. The facility failed to follow a physician order of applying a sequential compression device (SCD [a device that prevents the pooling of blood in the legs by gently squeezing the legs from the ankles up to the knee]) on two (2) of thirty (30) sampled patients (Patient 18 and 28). The deficient practice resulted to physician order not followed and had the potential to result on Patient 18 and 28 having pooling of blood and developing blood clots (clumps of blood) in the legs due to no movements and stimulation. (Refer to A 398)

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

Based on interview and record review the facility failed to evaluate and document psychosocial assessment (the evaluation screen on domestic violence, abuse history and suicidal tendency of a patient) on one (1) of thirty sampled patients (Patient 17).

The deficient practice has the potential of failing in identifying Patient 17 and other patients, who are at risk of domestic violence, abuse, and/or suicide.

Findings:

A review of Patient 17's "Face Sheet,'' undated, indicated Patient 17 was admitted to the facility, on 08/30/2023 at 11:58 p.m.

A review of Patient 17's, "Admission Screen Psychosocial", dated 08/31/2023, at 00:38(12:30 p.m.), indicated no entry (blank) of Patient 17 evaluation question on domestic violence, abuse, and/or suicide.

During an interview, with the Manager of Women Services (MWS), on 11/30/2023, at 11:48 a.m., the MWS stated the admitting nurse failed to complete and document Patient 17 psychosocial assessment which includes asking Patient 17's domestic violence, abuse, and suicide history. The MWS stated it (psychosocial assessment) was important for a nurse to complete. The MWS patient psychosocial assessment helps identify Patient 17'srisk of domestic violence, abuse and/or suicide. The MWS stated admitting nurse was responsible to complete the assessment and document the psychosocial assessment in Patient 17's Electronic Health Record (EHR).

A review of the facility's policy and procedure (P&P), titled, "Assessment, Reassessment and interprofessional plan of care", revised date 5/2021, indicated the roles and responsibilities of the nurse was to collect and analyze data to produce information, formulate discipline-specific treatment plans and recommendations within their scope of practice. The nurse was also expected to document patient information (assessments), and care provided in the Electronic Health Record (EHR).

Based on interview and record review, the facility failed to ensure one (1) of nine (9) sampled Registered Nurses (RN 4), had completed orientation and competencies according to facility's policy and procedure (P&P) for an RN working in the assigned units (Labor & Delivery [L&D - specialized unit to prepare a woman's body to give birth to a baby] and Obstetric (OB) triage (a specialized unit where pregnant mothers were examined to determine the disposition of the woman and her fetus on arrival in the facility). RN 4 had no orientation and competencies records completed to the units worked (L&D and OB triage) to ensure specialized qualifications were met to provide care for the patients in the units worked.

This deficient practice had the potential for RN 4 and other nurses working in the L&D and OB units without completed orientation and competencies, not qualified to care for the type of patients in the different units and patients were at risk for not getting proper care met.

Findings:

On 12/1/2023, at 4:59 PM, during a concurrent interview with Labor and Delivery Manager (L&D Mgr.) and record review of RN 4's employee file, L&D Mgr. stated RN 4's employee file had no documentation of RN 4's orientation training to L&D and OB Triage, where RN 4 was hired to work. L&D Mgr. stated there were no documented competencies for RN 4 for L&D and OB Triage units, where RN 4 was hired to work. L&D Mgr. stated RN 4 should have had documented competencies for the units RN 4 worked (L&D and OB Triage). L&D Mgr. Stated RN 4 was an RN who conducted Medical Screening Examination (MSE - evaluation by a physician or to the extent permitted by applicable law, by other health professionals, to determine if an emergency medical condition, psychiatric emergency medical condition, and/or active labor exists).

On 12/1/2023, at 4:59 p.m., during a concurrent interview with L&D Mgr. and record review of facility's P&P titled, "Medical Screening Examination (MSE) by a Registered Nurse I Women's Services; Standard Procedure," revised date 1/27/2022, indicated the following:

1. Qualified L&D RNs are authorized to perform MSE for labor evaluation and pregnancy related complaints in consultation with a medical staff (physician).

2. Qualifications and training included ability to perform standard procedures that included, "The licensed RN must have completed all OB triage RN orientation requirements: A. Assessment of obstetric patient including high risks conditions. B. Point of Care Testing (POCT) including Urine dipstick, Amnio test (check fluid in the womb surrounding the fetus [baby]), C. Advance fetal monitoring (checking the condition of fetus in the womb) competency."

3. Evaluation of RN competency in the performance of standard procedure functions will be performed in the following manner:

a. . Successful completion of an orientation period in the OB triage and L&D.

b. Validation of nursing skills required for performing an OB MSE.

c. Demonstrated competence in the performance of vaginal examination of the pregnant patient to include dilation (opening of the cervix the lower, narrow of the uterus [womb]), status of the membranes [layer of tissue holds in the fluid the surrounds the baby in the womb), and station (how far down a baby's head had descended into the pelvis).

d. Demonstrate competency in fetal heart rate monitoring.

e. Demonstrate competency in the performance of a MSE and supervised by a designated evaluator.

A review of facility's Employee Handbook, dated 11/29/2023, indicated the new employee orientation was designed to provide information necessary to acquaint employees with their job, the hospital, and the necessity of working, including receipt of important information regarding the hospital's policies and procedures, programs, regulations, benefits, and safety.

Based on interview and record review the facility failed to follow a physician order of applying a sequential compression device (SCD [a device that prevents the pooling of blood in the legs by gently squeezing the legs from the ankles up to the knee]) on two (2) of thirty (30) sampled patients (Patient 18 and 28 ).

The deficient practice resulted to physician order not followed and had the potential to result on Patient 18 and 28 having pooling of blood and developing blood clots (clumps of blood) in the legs due to no movements and stimulation.

Findings:

1. A review of Patient 18's Electronic Medical Record (EMR - the systematized collection of patient and population electronically stored health information in a digital format, which can be shared across different health care settings) indicated Patient 18 had a physician order to apply SCD when given an epidural (an injection to a patient's back to stop them from feeling pain in certain part of their body). Patient 18 was given an epidural on 8/30/23 at 1159 p.m. There was no documentation that an SCD was applied on Patient 18.

During an interview, with the Manager of Women Services (MWS) on 12/01/2023, at 3:27 p.m., MWS stated that the nurse failed to document and apply an SCD on Patient 18 as ordered by the physician. The MWS, the nurse providing care and treatment to patient must follow physician orders and document treatment provided.

A review of the facility's policy and procedure (P&P), titled, "Assessment, Reassessment and interprofessional plan of care," revised date 5/2021, indicated that part of the roles and responsibilities of the nurse is to provide care, treatment, and services as defined by their job description, professional license, laws, and regulations. It is also expected that Nurse document patient information/data collected, and care provided in the Electronic Health Record (EHR).

2. A review of Patient 28's Electronic Medical Record (EMR) indicated that Patient 28 had a physician order to apply SCD when given an epidural (an injection to a patient's back to stop them from feeling pain in certain part of their body). Patient 28 was given an epidural on 6/30/23 at 1:00 p.m. There was no documentation that an SCD was applied on Patient 28.

During an interview, with the Manager of Women Services (MWS) on 12/01/2023, at 3:27 p.m., MWS stated that the nurse failed to document and apply the SCD on Patient 28 as ordered by the physician. The MWS, the nurse providing care and treatment to patient must follow physician orders and document treatment provided.

A review of the facility's policy and procedure (P&P), titled, "Assessment, Reassessment and interprofessional plan of care," revised date 5/2021, indicated that part of the roles and responsibilities of the nurse is to provide care, treatment, and services as defined by their job description, professional license, laws, and regulations. It is also expected that Nurse document patient information/data collected, and care provided in the Electronic Health Record (EHR).

Based on interview and record review, the facility failed to ensure one of thirty sampled patients (Patient 6) had an updated physical examination for any changes in patient's condition, that was completed and documented, within 24 hours after patient was admitted.

This deficient practice had the potential for adverse events during or after surgery.

Findings:

On 11/30/2023, at 11:48 AM, during concurrent interview with Clinical Educator (Educator) and record review of Patient 6's Informed Consent for cesarean section (the surgical delivery of a baby through a cut made in the mother's abdomen and uterus), dated 10/8/2023, indicated patient was pregnant with twins, and recommended surgery to get the babies out.

Concurrently, Educator stated patient had a history and physical (H&P - the most formal and complete assessment of the patient and the problem), dated 10/3/2023, which indicated the following:
1. Pregnancy was at 33 6/7 weeks and not near term, which is 40 weeks.
2. Patient was in preterm labor.
3. Patient had twins.

Concurrently, Director of Quality (DOQ) stated there should have been an update to the patient's H&P, to indicate there were no significant changes in Patient 6's condition, prior to patient's cesarean section delivery.

A review of facility's Pre-Op Assessment Prior to Surgery policy, dated 10/7/2020, indicated the following:
1. A completed history and physical (H&P - the most formal and complete assessment of the patient and the problem), within 30 days and an updated patient assessment documented 24 hours prior to surgery.
2. A complete preoperative H&P assessment prior to any operative (surgery)/ invasive procedure (a deliberate access to the body by an incision, puncture by a needle or instrument through a natural orifice) will be performed, including any indicated laboratory and radiographic examinations appropriate to the patient's condition, consented procedure, and documented in the patient's medical record.
3. The minimum elements documented in the medical record, prior to operative/ invasive procedure include assessment of the heart and lungs, documentation of vital signs (clinical measurements of the pulse rate, temperature, respiratory rate, and blood pressure), examination of the operative/ invasive procedure site, venous access, chest x-ray, documentation of recent bathing, and a surgeon's note regarding the emergent necessity for the surgery or procedure.

A review of the facility's Medical Staff Rules and Regulations, dated 10/26/2017, indicated the following:
1. All inpatients and outpatients must have a H&P completed prior to surgery or major invasive procedure.
2. If the H&P is performed more than 24 hours prior to admission or surgery, any subsequent changes in the patient's status must be reflected in an interval H&P note recorded in the medical record within 24 hours of admission or not more than 24 hours prior to surgery.


42937

Based on interview and record review, the facility failed to ensure one (1) of thirty sampled patients (Patient 6) had an updated physical examination for any changes in patient's condition, that was completed and documented, within 24 hours after patient was admitted.

This deficient practice had the potential for adverse events during or after surgery.

Findings:

On 11/30/2023, at 11:48 AM, during concurrent interview with Clinical Educator (Educator) and record review of Patient 6's Informed Consent for cesarean section (the surgical delivery of a baby through a cut made in the mother's abdomen and uterus), dated 10/8/2023, indicated patient was pregnant with twins, and recommended surgery to get the babies out. Educator stated Patient 6 had a history and physical (H&P - the most formal and complete assessment of the patient and the problem), dated 10/3/2023, which indicated the following:

1. Pregnancy was at 33 weeks and 6 days. Patient 6 was not near full term (40 weeks of pregnancy).

2. Patient was in preterm labor.

3. Patient had twins.

On 11/30/2023, at 11:48 AM, during an interview, Director of Quality (DOQ) stated there should have been an update to the Patient 6's H&P, to indicate there were no significant changes in Patient 6's condition, prior to patient's cesarean section delivery.

A review of facility's Pre-Op Assessment Prior to Surgery policy, dated 10/7/2020, indicated the following:
1. A completed history and physical (H&P - the most formal and complete assessment of the patient and the problem), within 30 days and an updated patient assessment documented 24 hours prior to surgery.

2. A complete preoperative H&P assessment prior to any operative (surgery)/ invasive procedure (a deliberate access to the body by an incision, puncture by a needle or instrument through a natural orifice) will be performed, including any indicated laboratory and radiographic examinations appropriate to the patient's condition, consented procedure, and documented in the patient's medical record.

3. The minimum elements documented in the medical record, prior to operative/ invasive procedure include assessment of the heart and lungs, documentation of vital signs (clinical measurements of the pulse rate, temperature, respiratory rate, and blood pressure), examination of the operative/ invasive procedure site, venous access, chest x-ray, documentation of recent bathing, and a surgeon's note regarding the emergent necessity for the surgery or procedure.

A review of the facility's Medical Staff Rules and Regulations, dated 10/26/2017, indicated the following:

1. All inpatients and outpatients must have a H&P completed prior to surgery or major invasive procedure.

2. If the H&P was performed more than 24 hours prior to admission or surgery, any subsequent changes in the patient's status must be reflected in an interval H&P note recorded in the medical record within 24 hours of admission or not more than 24 hours prior to surgery.