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Based on interviews and document review, it was determined the facility staff failed to follow policies and procedures related to informing patients of patient rights for four (4) of seven (7) patients sampled.

Findings:

The surveyors reviewed the "Conditions of Admission and Consent for Inpatient and/or Surgical Care (Consent)" which includes "Acknowledgement of Notice of Patient Rights and Responsibilities," "Notice of Privacy Practices," advanced directives, Limited Power of Attorney, that require patient initials, for seven (7) patients sampled.

A review of the Consent form for Patient #3 (P3) contained no evidence that the form was signed or initialed by the patient, and no other documentation of the reason the form was not signed. P3's form was electronically signed as witnessed by a Patient Access Representative and a witness.

A review of the Consent form for P4 contained no evidence that the form was signed or initialed by the patient. "Verbal Consent" was documented on the "Signature Required" line and the form was electronically signed as witnessed by a Patient Access Representative and a witness.

A review of the Consent form for P5 contained no evidence that the form was signed or initialed by the patient. "VC" was documented on the "Signature Required" line and the form was electronically signed as witnessed by one (1) Patient Access Representative.

A review of the Consent form for P9 contained no evidence that the form was signed or initialed by the patient. "VC" was documented on the "Signature Required" line and "... Relationship to the Patient" was documented as "Patient." The "Unable to Sign" box was left blank. The form was electronically signed by one (1) Patient Access Representative.

During an interview on 11/14/2023 at 1:46 p.m., Staff Member (SM) 23 confirmed that "VC" documented on the consent stands for "verbal consent" but the staff should have "spelled out" those words. SM23 stated that the staff will document verbal consent if a patient is not physically able to sign. SM23 explained that the facility's freestanding emergency department conducts "virtual registration" that happens through a touch screen.

On 11/15/2023 the surveyor reviewed the facility's policy "Procedure for Registration Forms and Signatures" provided by SM23. The policy contained no evidence of a process or procedure for obtaining verbal consent or for verbal consent related to the "virtual registration" process that is solely used at the facility's freestanding emergency department.

During an interview on 11/15/2023 at 11:47 a.m., SM23 described the "virtual registration" process that occurs at the freestanding emergency department. All of the Patient Access Representatives work remotely and are viewed by the patient on a large tablet. The Patient Access Representative reviews the documentation with the patient and the patient is required to sign the Consent form electronically on the tablet. SM23 stated that some patients are unable or unwilling to sign on the tablet, so the Patient Access Representative will obtain and document "verbal consent." During the interview, both SM1 and SM23 confirmed that the facility's does not have a policy or procedure that addresses "virtual registration" or obtaining "verbal consent." The surveyor noted that the facility's "Procedure for Registration Forms and Signatures" policy states that if a patient is unable or unwilling to sign consents on the tablet, then "provide the patient with paper forms to sign." SM1 stated that providing the patient a paper form to sign would be extra work for the nurse.

A review of the facility's policy titled "Procedure for Registration Forms and Signatures" states in part:
... Policy: The Patient Access Department obtains signatures on all registration forms, from the patient or legally authorized individual, prior to or during the registration process or within a reasonable time frame based upon the patient circumstance.... Reasonable attempts will be made for follow up signatures not obtained during the registration process.... 1. The Conditions of Admission and Consent for Outpatient Services (COA/COS) is obtained for all types of Registrations (Outpatient, Emergency, Observation, Surgery, Inpatient, and Newborn).... 3. Patient Bill of rights ... Guidelines for patient's inability or unwillingness to use technology: In the situation a patient is unable or unwilling to sign consents on the tablet, make reasonable effort to instruct patient how to unitize the tablet signature box and consider using a stylus. If patient is still unwilling to use the tablet, provide the patient with paper forms to sign. Once signed documents are obtained, scan into the document management system.... Guidelines for witness signatures and titles: In the event a patient, a legally authorized individual, or a family member is medically unable to sign, two staff members can act as a witness on the consent form. The two witnesses may be registration and clinical staff. A witness' signature includes a staff member's full first name, last name and title. Title abbreviations may also be used. Utilization of title abbreviations may be determined by the SSC. Special Note: If a signature is not received from the patient or telephone consent from an authorized person, no treatment should be rendered unless it is an emergency.... Patient Access: ... B. Patient unable to sign, no legally authorized/legally empowered individual, Power of Attorney for Healthcare, Legal Guardian or family is present and phone consent received or not received. Telephone consent from a legally authorized/legally empowered person or family member ... must be obtained.... Regardless of whether phone consent is or is not received, two (2) witness signatures are required on the consent in the format defined in the witness' signature and title section in this policy...

Based on medical record review, document review and interview, it was determined the facility staff failed to accurately document the use of restraints as per facility policy for two (2) of (3) patients sampled specifically for restraint review.

The findings included:

The surveyor reviewed three (3) medical records for restraint use. In two (2) of the medical records, the nursing documentation reflected a violent level restraint. The surveyor was unable to locate a face-to-face assessment within one (1) hour or a restraint renewal order within four (4) hours. After further review, it was discovered that the orders were written as a non-violent level restraint and incorrectly documented as a violent level during the initiation of the restraint.

P13 - an order was entered on 11/9/23 at 1:51 a.m. by a medical provider that reads, in part: "Level of restraint: Non-violent...". Nurse documentation at the start of the restraint reads, in part: "... Level of restraint: Violent/self-destructive...". The order was for "Soft BUE" (bilateral upper extremity), which is what was documented as being applied.

P14 - an order was entered on 11/12/23 at 10:40 a.m. by a medical provider that reads, in part: "Level of restraint: Non-violent...". Nurse documentation at the start of the restraint reads, in part: "... Level of restraint: Violent/self-destruction...". The order was for "Soft BUE" (bilateral upper extremity", which is what was documented as being applied.

On 11/15/23, the surveyor reviewed the findings with SM1 who acknowledged that it was "documented incorrectly" and that parts of the restraint documentation flowsheet (violent versus non-violent) carry over until the order is discontinued. The surveyor discussed the concern regarding incorrectly documenting a restraint with SM1 who agreed that it is a concern and will be addressed.

The finding was reviewed with SMs 1, 2, 3, 24 and 26 during the exit conference on 11/15/23.

Based on interviews, and document review, it was determined the facility staff failed to ensure nursing care was assigned for one (1) of seven (7) patients sampled.

Findings:

The surveyor reviewed the medical record for Patient (P) 7 on 11/14/2023 with Staff Member (SM) 1. The "Emergency Patient Record" contained evidence that P7 was at the emergency department (ED) from 11:54 a.m. through 10:13 p.m. on 10/31/2023. As per the nursing notes, the patient had been transferred from the facility's free standing emergency department with the diagnosis of a pulmonary embolism (PE) and was transferred on a heparin drip for treatment of the PE. Based on the medical record documentation and interviews with their staff, SM1 and SM3 were unable to confirm P7's exact time of arrival at the main hospital ED or determine which nurse was assigned to care for P7 upon arrival. There was no documentation of nursing hand off received at the ED.

The first documented nursing note at the hospital campus ED, was at 3:18 p.m. stating "Pt moved to bed 22A. No report given." No other nursing notes were documented for P7's time in the ED, where the patient stayed until at least 10:13 p.m. that same day, as per the documentation in the electronic medical record (EMR).

During an interview via telephone on 11/14/2023 at 11:36 a.m., SM14 could not recall the time P7 arrived at the main hospital ED or which nurse was assigned to that patient, as it was "very busy" that day. SM14 recalled that P7 arrived and SM14 asked emergency medical services (EMS) transport to place the patient in the waiting room and SM14 would "put the patient on the monitor." SM14 stated that SM14 did place P7 on a portable monitor in the waiting room. SM14 was not aware if P7 was placed on a monitor in the Transitional Care Area (TCA) of the ED later that day. SM14 stated that typically EMS would give report to the nurse prior to dropping off the patient, but SM18 did not recall receiving report and did not obtain vital signs on P7 upon arrival.

During an interview via telephone on 11/15/2023 at 11:55 a.m., SM18 did not recall P7, but stated that SM18 works until 3:00 p.m. daily, so based on SM18's documentation in the patient's medical record at 3:18 p.m., SM18 must have just received that patient, made sure that the patient was "ok" and had a call bell in reach, and then SM18 left for the day.

SM1 and SM3 were unable to provide documentation of the nurse assigned to P7 upon arrival at the main hospital ED until SM18 assumed care of P7 at 3:18 p.m., as documented in the nursing note. There was no documentation provided of the nurse assigned care after SM18 left around 3:18 p.m. through the time P7 was transferred out of the Hospital ED was around 10:13 p.m. that evening.

A review of the facility's policy titled "Assessment and Reassessment of Patients" states in part:
... A. Nursing Assessment
1. A registered nurse assesses the patient's need for nursing care in all settings where nursing care is provided....
B. Nursing Reassessment
1. An RN completes the reassessment to include an update of the Plan of Care or completes the assessment portion of the nurse's notes: ...
d. When the patient is transferred from one unit to another unit ...
Documentation Requirements:
A. 1. All assessments and reassessments are documented on the patient's medical record....

Based on interviews, and document review, it was determined the nursing staff failed to ensure that one (1) of seven (7) patients were assessed and monitored as per policy and physician's orders.

Findings:

A review of the medical record for Patient (P) 7 on 11/14/2023 contained evidence that P7 was diagnosed with a pulmonary embolism (PE) at the facility's free standing emergency department and placed on a heparin drip. A review of the "Bridge Orders - ED" from 10/31/2023 at 5:44 a.m. contained evidence of orders for vital signs every four (4) hours. P7 was transferred to the main hospital Emergency Department (ED) with documented evidence of P7 in the "inpatient holding" on 10/31/2023 from 11:54 a.m. through 10:13 p.m.

A review of the medical record for P7 with Staff Member (SM) 1 contained evidence of the last set of vital signs obtained at the free standing emergency department at 11:30 a.m. and the next set of vital signs documented at the main hospital ED at 7:41 p.m., more than eight (8) hours after the last set of vital signs. There was no evidence that vital signs were obtained, no documentation of the nurse assigned to care for P7, and no documentation of nursing report received, upon P7's arrival at the main hospital ED, and this was confirmed by SM1.

The first documented nursing note at the main hospital ED was at 3:18 p.m. stating "Pt moved to bed 22A. No report given." No other nursing notes were documented for P7's time in the ED where the patient stayed until at least 10:13 p.m. that same day, as per the electronic medical record documentation (EMR).

During an interview via telephone on 11/14/2023 at 11:36 a.m., SM14 could not recall the time P7 arrived at the main hospital ED or which nurse was assigned to that patient, as it was "very busy" that day. SM14 recalled that the P7 arrived and SM14 asked Emergency Medical Services (EMS) transport to place the patient in the waiting room, and then SM14 placed P7 on a portable monitor. SM14 was not aware if P7 was placed on a monitor in the Transitional Care Area (TCA) of the ED later that day. SM14 stated that typically EMS would give report to the nurse prior to dropping off the patient, but SM18 did not recall receiving report and did not obtain vital signs on P7 upon arrival.

During an interview via telephone on 11/15/2023 at 11:55 a.m., SM18 did not recall P7, but stated that SM18 works until 3:00 p.m. daily, and based SM18's documentation in the patient's medical record at 3:18 p.m., SM18 must have just received that patient, made sure that the patient was "ok", and had a call bell in reach, and then SM18 left for the day.

A review of the facility's policy titled "Assessment and Reassessment of Patients" states in part:
... A. Nursing Assessment
1. A registered nurse assesses the patient's need for nursing care in all settings where nursing care is provided....
B. Nursing Reassessment
1. An RN completes the reassessment to include an update of the Plan of Care or complete the assessment portion of the nurse's notes: ...
d. When the patient is transferred from one unit to another unit ...
Documentation Requirements:
A. 1. All assessments and reassessments are documented on the patient's medical record....

Based on medical record review, and document review, it was determined the facility staff failed to complete medication administration and medication documentation as per facility policy for one (1) of (7) patients sampled.

The findings included:

A review of Patient #3's (P3) medication administration record revealed the following medication administrations did not contain a one (1) hour reassessment or the medication was not administered as ordered:

During the ED stay, one (1) 5 mg (milligram) tablet of oxycodone (a narcotic pain medication) administered on:

9/9/23 at 11:28 p.m. for a verbalized pain intensity of "5" out of 10. At 1:01 a.m. on 9/10/23, a pain reassessment note documented a reassessment was not conducted because "pt [patient] sleeping".

9/10/23 at 10:36 a.m. for a verbalized pain intensity of "7" out of 10. At 11:07 a.m., there was no documentation to indicate a pain reassessment was conducted.

9/10/23 at 3:53 p.m. for a verbalized pain intensity of "7" out of 10. At 4:23 p.m., there was no documentation to indicate a pain reassessment was conducted.

There were two (2) administrations on 9/12/23 at 8:20 a.m. and 1:13 p.m., with a note stating "barcode was torn would not scan at bedside". There was no pain intensity assessment documented or pain reassessment documented for those two entries.

A dulera HFA 200/5 mcg HFA - per puff inhaler was ordered on 9/9/23 at 10:20 p.m. for "BID" (BID - twice a day) administration. On 9/10/23 at 8:00 p.m., there was no documented administration of the medication. On 9/11/23 at 7:39 a.m., a nurse documented "not on my shift" for the previously scheduled administration.

While on the 6 Front unit, P3 had an order for hydralazine 25 mg tablet PO (by mouth) Q6H. On 9/15/23 an entry at 0400 documented the following: "Not administered... Missed medication not loaded and too close to next dose".

The findings regarding the missed medication administrations were reviewed with SMs 1, 2, 3, 24 and 26 during the exit conference on 11/15/23.

A facility policy titled, Adult Medication Orders & Administration, was reviewed and reads, in part: "PURPOSE STATEMENT: To establish a process for the organized systematic control, distribution, monitoring and administration of medications... G. Administration 1. General guidelines should be observed when administering medications. a. Scheduled medications should be administered within 60 minutes around the time the medication is due... 10. Chart the effectiveness of PRN [as needed] medications 1 hour after administration in the appropriate Meditech intervention screen or nurses notes...".