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Based on observations, record reviews, interviews, and review of the hospital's policies and procedures, the hospital's nursing staff failed to provide nursing care to all patients as needed for 3 of 34 patients whose records were reviewed for nursing care and services related to vital signs, initial nursing assessments, dietary consults, and the measurements for pressure ulcers, additionally, nursing staff failed to ensure that physician orders were followed by failing to apply Sequential Compression Device(SCD) to Patient #28's lower extremities.(Patient #25, #28, #16, and #28)

The findings are

Patient #25
On 7/1/2021 at 2:25 PM, review of Patient #25's chart revealed the patient was admitted on 6/25/2021 at 5:29 PM with "Multiple Pelvic Fractures- Pelvic Pain-Unstageable Pressure Ulcer of Sacral" area. Review of the patient's chart revealed the patient received a blood transfusion that was initiated on 6/27/2021 at 4:32 PM and ended at 6:35 PM. Nursing documented the patient's vital signs during the blood transfusion on 6/27/2021 at 4:10 PM (pre transfusion), 4:32 PM, and again at 5:47 PM. There was no temperature documented with the vital signs obtained at 4:32 PM. The findings were verified by Nurse Manager #1 and Nurse Manager #2 at 3:06 PM on 07/01/2021.

Hospital policy and procedure, titled, "Transfusion of Blood and Blood Products", revealed, "Pre-transfusion- Assess vital signs (temperature, pulse, respirations, and blood pressure) within one hour of scheduled transfusion; During Transfusion-At the fifteen minute check, if the vital signs are stable, and there is no sign of reaction, the rate should be adjusted and documented to ensure transfusion within the appropriate time frame or as ordered, then vital signs should be taken every one hour by the RN responsible for the until the transfusion is completed; and Post-Transfusion- Obtain and document vital signs upon completion of the transfusion, one hour after infusion is complete for inpatients."

Temperature
On 07/01/2021 at 2:25 PM review of the patient's temperature documentation showed the patient's temperature was documented with the patient's vital signs twice. The temperature was documented on 6/27/2021 at 12:11 AM as 37.4 (Celsius) which is 99.3 Fahrenheit and documented on 6/28/2021 at 5:00 PM as 36.8 (Celsius) which is 98.2 Fahrenheit. The findings were verified by Nurse Manager #1 and Nurse Manager #2 at 3:06 PM on 07/01/2021.

Nutrition
On 6/28/2021 at 2:02 PM, in an interview with Patient #25 in the patient's room, the patient stated he/she has a problem chewing due to missing top teeth. Patient #25 stated he/she can only eat soft foods such as soup, eggs (if cooked soft), grits, and puddings. Patient #25 stated he/she does not like pureed foods. Patient #25 stated that he/she had not seen a dietitian. Patient #25 also stated he/she has sores on his/her back side, and the nurse does the dressing changes.

On 7/1/2021 at 3:07 PM, review of Patient #25's chart revealed the patient was admitted on 6/25/2021 at 5:29 PM and review of the initial nurse admission assessment on 6/25/2021 revealed the nurse documented, "No nutrition problems noted." There was no documentation that the nurse consulted the dietitian for the patient. Documentation showed the Advanced Practice Nurse(APRN) ordered a dietary consult on 6/27/2021 at 11:23 AM. The Dietitian consulted the patient on 6/28/2021 at 3:20 PM for the patient's initial nutritional assessment. The findings documented by the dietitian were "Patient meets two out of five criteria supporting a diagnosis of Severe Protein Calorie Malnutrition. Diagnoses: 1) Severe malnutrition related to chronic condition (difficulty chewing) as evidenced by inadequate intake and weight loss 2) Increased nutrition needs related to metabolic demands of wound healing as evidenced by Stage IV(4) pressure injury on sacrum 3) Chewing difficulty related to poor dentition as evidenced by unable to eat foods beyond puree/liquids textures. 4) Cardiac diet plus dietary supplement (Ensure) twice a day." On 6/29/2021 at 2:32 PM, in an interview with Dietitian #1 in a room beside the conference room on the first floor, Dietitian #1 stated, "Nutrition consults can be made by a nurse." The finding was verified by Dietitian #1 at 2:32 PM on 6/29/2021.

Hospital policy and procedure for nutrition consults revealed "RN referral may include but is not limited to results from the initial nutrition screen."

Pressure Ulcer
On 07/01/2021 at 3:07 PM, review of the nurse's initial documentation of Patient #25's Stage IV pressure ulcer dated 06/25/2021 at 12:40 AM revealed there was no documentation of the measurement(s) of the patient's stage IV pressure ulcer wound. The findings were verified by Nurse Manager #1 on 07/01/2021 at 3:35 PM.

Hospital policy and procedure for Pressure Injury revealed 1) Adequate calories, protein, vitamins, and minerals are essential to cellular activity. Poor nutritional status increases the risk of pressure injury formation." 2) Wound documentation: "All of the following is completed in the electronic medical record: location, wound type, size (measure on admission), measure using centimeters (length, width, depth), undermining, exudate and type, amount, and odor, color of wound bed, and surrounding skin color." 3) "Notify the Wound Nurse and dietary for Stage II or greater, or as needed for skin breakdown."


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Review of the medical record for Patient #28 who was a 69 year old female admitted to the hospital's Intensive Care Unit (ICU) on 6/28/2021 with a chief diagnosis of "Hyperkalemia" (higher than normal elevated level of Potassium in the Blood level). Review of the "History of Present Illness" revealed the physician documented the patient had a significant medical history for Hypertension, Gout, Hypothyroidism, Osteoarthritis, Asthma, Anxiety disorder, and End-Stage Renal Disease and on Hemodialysis. Further review revealed that on June 24, 2021, the patient recently had her tunneled dialysis catheter removed and replaced with a temporary dialysis catheter and underwent emergent Hemodialysis. The physician recommended DVT (Deep Vein Thrombosis-a blood clot that forms in the deep veins in the legs) Prophylaxis/SCD (Sequential Compression Device-method of improving blood flow in the legs).

Review of the physician order dated 6/28/2021 at 1:09 PM revealed the physician ordered "Sequential Compression Device Application ... Apply to both extremities." Review of the patient's medical record revealed there was no documentation that SCDs were applied to Patient #28's lower extremities as ordered by the physician. The above findings were verified during an interview on 7/1/2021 at 1:30 PM with the Unit Director.

The facility's policy and procedure, titled, "Prevention of Thromboembolism VTE", Original date 12/08, last reviewed 10/20, last revised 10/18 was reviewed. The policy revealed in part, "B. Initiation of VTE prevention. 1. Based on the VTE Risks assessment and potential contradictions, the appropriate VTE Prophylaxis therapy (pharmacologic, mechanical, or both) will be indicated by the provider. . . E. Responsible Person ...The Chief Nursing Officer is responsible for assuring that all Hospital adhere to the requirements of this policy, that these procedures are implemented and followed at the Hospital, and that instances of noncompliance with this policy are reported to the Chief Nursing Officer."


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On 6/30/2021 at 3:26 PM, review of Patient #16's chart revealed the patient received one (1) unit of packed red blood cells on 4/22/2021 starting at 5:00 AM. The transfusion of the packed red blood cells ended at 8:01 AM. The patient's vital signs were documented at 4:30 AM, 5:00 AM, 5:15 AM, 6:11 AM, 8:01 AM and 9:01 AM. There were no vital signs documented from 6:11 AM until 8:01 AM which was greater than one hour. On 7/1/2021 at 2:30 PM, the finding was verified by Quality Assurance Staff #3. On 6/30/2021 at 3:26 PM, review of physician orders dated 4/22/2021 at 4:02 AM revealed "POST BLOOD TRANSFUSION: Please obtain a CBC(Complete Blood Count) 1-hour post transfusion". Documentation in the nurse notes revealed the patient's blood transfusion completed at 8:01 AM. There was no documentation in the patient's chart that the post blood transfusion CBC was obtained until 2:49 PM on 04/22/2021. On 7/1/2021 at 2:30 PM, the finding was verified by Quality Assurance Staff #3.

Facility policy, entitled, " Transfusion of Blood and Blood Products", revealed, "At the fifteen (15) minute check, if the vital signs are determined stable and there is no sign of reaction, the rate should be adjusted and documented to ensure transfusion within the appropriate time frame or as ordered, then vital signs should be taken every 1-hour by the RN responsible for the transfusion until the transfusion is completed".

Based on observation, patient reviews, review of the patient plan of cares, and review of the hospital's policies, the hospital failed to ensure that nursing staff develops, individualizes, and updates the patient's current plan of care for each patient for patients 7 of 34 patients whose records were reviewed for care plans. (Patient #24, #25, #5, #9, #14, #17, and #19)

The findings are

Patient #24
On 6/29/2021 at 10:59 AM, in an interview with Patient #24, the patient stated he/she had not eaten any food for a week, and only was drinking water. The patient stated he/she is not hungry and does not want anything to eat. The patient also stated he/she cannot not walk due to the painful sores on the bottom on his/her feet from taking chemotherapy.

On 7/1/2021 at 3:57 PM, review of Patient #24's chart revealed the patient was admitted on 6/21/2021 with past medical history of Stage IV Colon cancer with liver, renal, and bone metastasis status post partial colon resection. The patient was admitted with Dehydration after receiving chemotherapy. The patient had peeling of the lips and feet related to the chemotherapy. Review of the patient's chart revealed the patient was consulted by the dietitian on 6/22/2021 and documented, "1) Increased nutrient needs related to oncological disease 2) Severe malnutrition 3) Altered gastrointestinal function 4) diet is downgraded to fluid per patient preference and add Ensure every day as trial and will increase if tolerated or desired." On 7/01/2021 at 3:57 PM, review of Patient #24's nursing Plan Of Care(POC) revealed the patient's POC had no problems with nursing interventions documented for Pain, Nutrition, or Skin Integrity. The findings were verified by Registered Nurse(RN) #12 at 11:06 AM.

Patient #25
On 6/28/2021 at 2:02 PM, in an interview with Patient #25 in the patient's room, the patient stated he/she has a problem chewing due to the patient has no top teeth. Patient #25 stated he/she can only eat soft foods such as soup, eggs (if cooked soft), grits, and puddings. Patient #25 stated he/she does not like pureed foods.

On 7/1/2021 at 3:07 PM, review of the patient's chart revealed orders for a dietary consult dated 6/27/2021 at 11:23 AM by the Advanced Practice Nurse (APRN). Documentation showed the dietitian consulted the patient on 6/28/2021 at 3:20 PM for the initial nutrition assessment. The findings documented by the dietitian were "Patient meets two out of five criteria supporting a diagnosis of Severe Protein Calorie Malnutrition. Diagnoses: 1) Severe malnutrition related to chronic condition (difficulty chewing) as evidenced by inadequate intake and weight loss 2) Increased nutrition needs related to metabolic demands of wound healing as evidenced by Stage IV(4) pressure injury on sacrum 3) Chewing difficulty related to poor dentition as evidenced by unable to eat foods beyond puree/liquids textures. 4) Cardiac diet plus dietary supplement (Ensure) twice a day."

On 7/1/2021 at 3:51 PM, review of Patient #25's POC initiated by an RN on 6/24/2021 revealed there were no nursing problems or nursing interventions addressing the patient's nutrition status for chewing difficulty and nutrition concerns. The findings were verified by Manager #1 at 3:56 PM on 7/1/2021.

Hospital policy and procedure for Care Plan, revealed, "The RN will review the plan of care and evaluate planned interventions every shift and update as needed based on the changing condition and needs of the patient".


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Patient #5
On 6/30/2021 at 9:14 AM, review of Patient #5's chart revealed the patient was admitted to the hospital on 3/10/2021 with diagnoses of Encephalopathy and Diabetes. Review of the patient's interdisciplinary Plan of Care(POC) revealed there were no nursing interventions documented related to the patient's Diabetes. On 7/1/2021 at 2:54 PM, the finding was verified by Quality Assurance Staff #3.

Patient #9
On 6/30/2021 at 1:21 PM, review of Patient #9's chart revealed the patient was admitted to the hospital on 6/17/2021 with a diagnosis of Laryngeal in remission, Cerebral Vascular Accident (CVA), Atrial Fibrillation, Diabetes, Renal Cancer and Dysphagia with severe malnutrition with Percutaneous Endoscopic Gastrostomy (PEG - tube inserted for liquid feedings) tube placed on 6/22/2021 for tube feedings. Review of the patient's interdisciplinary POC revealed there were no nursing interventions documented related to PEG tube care, PEG tube feedings, or Diabetes. On 7/1/2021 at 3:28 PM, the finding was verified by Quality Assurance Staff #3.

Patient #14
On 6/30/2021 at 12:32 PM, review of Patient #14's chart revealed the patient was admitted to the hospital on 4/1/2021 with diagnoses of Acute Respiratory Failure, Diabetes, and low back pain. Review of the patient's interdisciplinary POC revealed there were no nursing interventions documented related to the patient's Diabetes. On 7/1/2021 at 3:02 PM, the finding was verified by Quality Assurance Staff #3.

Patient #17
On 6/30/2021 at 11:19 AM, review of Patient #17's chart revealed the patient was admitted to the hospital on 4/9/2021 with Hematuria, Atrial Fibrillation, Cholelithiasis, altered mental status, and baseline Dysphagia. Review of the patient's chart revealed the patient received tube feedings via a Naso Gastric (NG) tube. The Registered Dietician documented daily patient assessments. Documentation in the patient's chart dated 4/16/2021 revealed the patient was alert, oriented, and after an evaluation for regular texture foods, the NG tube was removed, and an order was documented for the patient to receive a Cardiac diet with regular texture. Review of the patient's interdisciplinary POC revealed there was no documentation of nursing interventions related to the patient's nutrition issues, NG tube care, tube feedings, or update to the patient's POC when the tube feedings were changed to the Cardiac diet with a regular texture diet. On 7/1/2021 at 3:19 PM, the findings were verified by Quality Assurance Staff #3.

Patient # 19
On 6/30/2021 at 12:07 PM, review of Patient #19's chart revealed the patient was admitted to the hospital on 4/24/2021 with diagnoses of CVA with severe Dysphagia, Urinary Tract Infection (UTI), and Hypotension. Review of the patient's chart revealed a PEG tube was placed on 4/28/2021, and tube feedings were started. Review of the patient's interdisciplinary POC revealed there was no documentation for nursing interventions related to PEG tube care and nutrition. On 7/1/2021 at 3:08 PM, the finding was verified by Quality Assurance Staff #3.

Based on record reviews, interviews, and review of the hospital's policies and procedures for the administration of blood products, the hospital failed to ensure its nursing staff monitored patients receiving blood products for 3 of 34 patient charts (Patient #25, Patient #16, and #3) receiving blood transfusions and failed to follow physician orders post transfusion for 1 of 34 patient charts(Patient #16) with physician orders for CBC (Complete Blood Count) one hour post transfusion.

The findings are:

On 06/30/2021 at 3:26 PM, review of Patient #16's physician orders revealed an order 4/22/2021 at 4:02 AM for 1 unit packed red blood cells and "POST BLOOD TRANSFUSION: Please obtain a CBC 1-hour post transfusion". Review of the documentation for the blood transfusion started on 04/22/2021 at 5:00 AM and completed on 04/22/2021 at 8:01 AM revealed the patient's vital signs were obtained and documented at 4:30 AM, 5:00 AM, 5:15 AM, 6:11 AM, 8:01 AM, and 9:01 AM. There were no vital signs documented at 7:00 AM.
Patient #16's blood transfusion was completed at 8:01 AM, but the CBC was not documented as done 2:49 PM on 04/22/2021 which was not within one hour of the completion of the blood transfusion as ordered. On 7/1/2021 at 2:30 PM, the findings were verified by Quality Assurance Staff #3


On 7/1/2021 at 2:25 PM, review of Patient #25's chart revealed the patient was admitted with "Multiple Pelvic Fractures- Pelvic Pain-Unstageable Pressure Ulcer of Sacral" area. Review of the patient's chart revealed the patient received a blood transfusion initiated on 6/27/2021 at 4:32 PM and ended at 6:35 PM. Review of the patient's chart revealed nursing documented the patient's vital signs during the blood transfusion on 6/27/2021 at 4:10 PM (pre transfusion) and again at 5:47 PM. There was no post transfusion vital signs documented. There was no temperature documented with the vital signs obtained at 4:32 PM and 6:35 PM. The findings were verified by Nurse Manager #1 and Nurse Manager #2 at 3:06 PM on 07/01/2021.




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On 6/30/2021 at 8:00 AM - 8:30 AM, review of Patient #3's chart revealed the patient was admitted on March 3, 2021 with the following diagnoses: Coronary Artery Disease status post stent on Brilinta, Gallbladder Disease, Diabetes Mellitus, Hypertension, history of Kidney stones, and Hypothyroidism, who presents with sudden onset of bright red blood in her rectum. According to review of the History and Physical dated 3/3/2021 at 2:54 PM, the hospitalist documented the patient's Hemoglobin (Red blood cells that carries oxygen throughout the body) was 8.0 (L-Low) , and Hematocrit (A measure of the percentage of Red Blood Cells in the body) 26.9 L. Further documentation revealed in part the plan for Patient #3 was: Type and cross match for Red Blood Cell and hold; keep patient NPO (nothing by mouth); and to monitor hemoglobin serially, and will transfuse for hemoglobin less than 10. Review of the patient's medical record revealed the patient's Hemoglobin dropped to 6.8.

Review of the physician order dated 3/5/2021 revealed the physician ordered for the patient to receive one unit of Packed Red Blood Cells. Review of the patient's Vital Sign(VS) sheet dated 3/5/2021 revealed Pre-transfusion VS were completed at 4:30 AM; at 5:00 AM, the blood transfusion was initiated; and 6:00 AM Vital Signs were completed. The next set of Vital Signs were not taken until 7:40 AM (40 minutes late); and the next set of Vital Signs was taken at 5:43 PM. An interview was conducted on 6/30/21 at 9:05 AM with the Quality Director who stated the nursing staff did not follow the hospital's blood transfusion policy. The Quality Director also stated that the patient's Vital Signs should have been taken at 7:00 AM and at 8:00 AM.


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Patient #25
On 7/1/2021 at 2:25 PM, review of Patient #25's chart revealed the patient was admitted on 6/25/2021 at 5:29 PM with "Multiple Pelvic Fractures- Pelvic Pain-Unstageable Pressure Ulcer of Sacral" area. Review of the patient's chart revealed the patient received a blood transfusion that was initiated on 6/27/2021 at 4:32 PM and ended at 6:35 PM. Nursing documented the patient's vital signs during the blood transfusion on 6/27/2021 at 4:10 PM (pre transfusion), 4:32 PM, and again at 5:47 PM. There was no temperature documented with the vital signs obtained at 4:32 PM. The findings were verified by Nurse Manager #1 and Nurse Manager #2 at 3:06 PM on 07/01/2021.

Hospital policy and procedure, titled, "Transfusion of Blood and Blood Products", revealed, "Pre-transfusion- Assess vital signs (temperature, pulse, respirations, and blood pressure) within one hour of scheduled transfusion; During Transfusion-At the fifteen minute check, if the vital signs are stable, and there is no sign of reaction, the rate should be adjusted and documented to ensure transfusion within the appropriate time frame or as ordered, then vital signs should be taken every one hour by the RN responsible for the until the transfusion is completed; and Post-Transfusion- Obtain and document vital signs upon completion of the transfusion, one hour after infusion is complete for inpatients."

Based on observations in the hospital's Emergency Department and Observations in Patient Room #366 and interview, the hospital failed to ensure the facility's equipment and floors were maintained in an accptable level of cleanliness and safety for chairs and floors.

The findings are:

On 6/28/2021 at 1:15 PM, observations in patient room #366 revealed one chair with a tear in the plastic on the lower right corner with the cotton is visible. Director 1 who was present during the observation removed the chair from the room and stated, "I'll get this repaired."



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On 06/28/21 at 12:51 PM, observations of the Emergency Department (ED) revealed the floor in Triage Room #1 had a red spill, the door was propped open with a chair, food was observed on top of a dirty linen container, and receptacles with soiled pulse oximeters that were waiting to be re-cycled per the ED Nurse Manager (NM). The Nurse Manager stated, "I am not sure if this room is dirty or clean. The floors do look very dirty. I will call and have the room cleaned ." A second observation on 6/28/2021 at 1:26 PM in Triage Room #1 revealed the floor still had the red substance on floor.