HospitalInspections.org

Based on interview and record review, the facility failed to meet the Condition of Participation for Patient's Rights (The Patient's Bill of Rights is a document that outlines what patients can expect when receiving health care) as evidenced by:

1. The facility failed to ensure one of 30 sampled patients (Patients 3) was provided the condition of admission (COA, a document that included provisions under which the patient provides informed consent [a process in which patients are given important information, including possible risks and benefits]) and the Important Message from Medicare (IMM - a notice given to the patient with Medicare benefits indicating the patient's rights to a hospital discharge appeal), when there was no documented attempts to obtain a signature for Patient 3's COA and IMM forms, in accordance with the facility's policy and procedure regarding Patient Rights and IMM.

This deficient practice resulted in Patient 3 and/or Patient 3's representative to not be informed of their rights as a patient, which may result in Patient 3's and/or Patient 3's representative's inability to effectively make decisions regarding Patient 3's care or treatment. (Refer to A-0117)

2. The facility failed to ensure the facility staff obtained a copy of advance directive (legal document that allows an individual to designate a health care agent to participate in the process of making health care decisions. It may also include preferences for health care that reflect the individual's preferences and values) from one of 30 sampled patients (Patient 23), when Patient 23 was admitted and had an advance directive, in accordance with the facility's policy and procedure regarding Advance Directives.

This deficient practice had the potential to result in Patient 23's advance directive not being executed and Patient 23's designee not being notified to make medical decision when needed. (Refer to A-0132)

3. The facility failed to ensure that one of 30 sampled patients (Patient 1), had continuous pulse oximetry (a non-invasive monitoring technique that continuously measures a patient's oxygen saturation [SpO2, a measure of how well the body is delivering oxygen to the tissues] and pulse rate, alerting healthcare providers to potential hypoxia -a condition in which there is an inadequate supply of oxygen to the body's tissues or respiratory distress -a condition where breathing becomes difficult or labored]) implemented, while admitted on the inpatient floor (a hospital's unit where patients are admitted for ongoing medical care, monitoring, and treatment under the supervision of healthcare providers), in accordance with a written physician order regarding continuous pulse oximetry monitoring.

This deficient practice had the potential to result in Patient 1's needs not being met and placed Patient 1 at risk of undetected hypoxia, delayed medical intervention, respiratory deterioration, and adverse patient outcomes (a harmful and negative result), including life-threatening potential complications such as death. (Refer to A-0144)

4. The facility failed to ensure that for one of 30 sampled patients (Patient 1), the application of two different types of restraints (the use of two or more physical restraints simultaneously to limit a patient's movement: bilateral wrist restraints-devices applied to both wrists to restrict arm movement and prevent self-harm or interference with medical treatment and a vest restraint - a sleeveless garment secured around the chest to limit upper body movement and prevent falls or self-injury) was carried out only after attempts to use less restrictive interventions were exhausted, in accordance with the facility's policy and procedure regarding restraints use.

This deficient practice had the potential to violate Patient 1's rights (refer to the legal and ethical entitlements of individuals receiving healthcare services) and increase Patient 1's risk of physical harm such as skin breakdown, circulation impairment (a condition where blood flow is reduced to a specific part of the body) and or respiratory distress (a condition where breathing becomes difficult). (Refer to A-0164)

5. The facility failed to ensure that for one of 30 sampled patients (Patient 1), justification for the continued use of the vest restraint (a type of mesh or cloth vest applied over the patient's chest and tied to an immovable part of each side of the bed) was documented in Patient 1's medical record, in accordance with the facility's policy and procedure regarding restraints (devices or techniques that limit a person's movement) use.

This deficient practice had the potential to violate Patient 1's rights (refer to the legal and ethical entitlements of individuals receiving healthcare services) resulting in the unnecessary use of restraints compromising Patient 1's health and well-being. (Refer to A-0188)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment.

Based on interview and record review the facility failed to ensure one of 30 sampled patients (Patients 3) was provided the condition of admission (COA, a document that included provisions under which the patient provides informed consent [a process in which patients are given important information, including possible risks and benefits]) and the Important Message from Medicare (IMM - a notice given to the patient with Medicare benefits indicating the patient's rights to a hospital discharge appeal), when there was no documented attempts to obtain a signature for Patient 3's COA and IMM forms, in accordance with the facility's policy and procedure regarding Patient Rights and IMM.

This deficient practice resulted in Patient 3 and/or Patient 3's representative to not be informed of their rights as a patient, which may result in Patient 3's and/or Patient 3's representative's inability to effectively make decisions regarding Patient 3's care or treatment.

Findings:

During a review of Patient 3's History and Physical (H&P, a formal document created upon a patient's hospital admission that includes patient's current health status, reason for admission, and initial treatment plan), dated 2/3/2025, the H&P indicated that Patient 3 was admitted on 2/3/2025 with a diagnosis of diverticulitis (an inflammation of small pouches, called diverticula, that can form in the walls of the colon). The H&P also indicated that Patient 3 was confused and had past medical history (PMH, a record of information about a person's health) of Alzheimer's (a progressive brain disorder that gradually destroys memory, thinking skills, and the ability to carry out everyday activities).

During a review of Patient 3's medical record (MR) titled, "Advance Directives and Living Will (legal documents that outline patient's preferences for medical treatment and end-of-life care in case they become unable to communicate their wishes)," uploaded on 4/7/2024, the MR indicated that Patient 3 had a designated healthcare decision-maker.

During a review of Patient 3's medical record (MR) titled. "Condition of Admission (a document outlining the terms of conditions of a patient's hospital stay, including financial responsibility, consent for treatment, and acknowledgment of hospital polices)," "Important Message from Medicare (IMM, a federally required notice given to Medicate beneficiaries upon hospital admission, informing them of their rights regarding discharge appeal processes)," and "Patients' Rights (a document outlining a patient's rights and responsibilities regarding medical care, privacy, decision making during their hospital stay)," the MR indicated that all three documents required to be signed upon admission to the hospital (to ensure that patients acknowledge their rights, understand hospital policies, and confirm consent for treatment and financial responsibilities).

During a concurrent interview and record review on 2/7/2025 at 10:42 a.m. with the Admitting Clerk (AC) and the Admitting Supervisor (AS), Patient 3's medical record (MR), was reviewed. The MR indicated that the Condition of Admission (COA) and Important Message from Medicare (IMM) forms were recorded in Patient 3's chart as "unable to obtain," and Patients' Rights were recorded to be not provided to Patient 3 and/or Patient 3's representative. Likewise, there was no documented additional attempts made to obtain signatures for the COA and the IMM forms from Patient 3's representative. The absence of documented attempts to obtain signatures were verified by the Admitting Clerk (AC).

During the same interview on 2/7/2025 at 10:42 a.m., the AC stated the following: "Whenever a patient is admitted to observation (a hospital status for patients who require short-term monitoring and assessment to determine if inpatient admission is necessary) or inpatient (a hospital admission status for patients requiring ongoing medical care and treatment that necessitates an overnight stay or longer), the patient has to sign the Conditions of Admission (COA). The patient also must be provided with Patient Rights and the Important Message from Medicare (IMM) if the admission status is inpatient. Once admitting is notified about the patient's admission, we (referring to the admitting clerk) must see the patient. If the patient is confused, we must contact the family, who can sign the documents for the patient. Attempts to reach out to family members should be made."

During an interview on 2/7/2025 at 10:30 a.m. with the Director of Licensing and Accreditation (DAL), DAL stated that the facility does not have a policy regarding the Condition of Admission (COA).

During a review of the facility's policy and procedure (P&P) titled, "Issuance of Important Message from Medicare" and "Detailed Notice of Discharge," dated 1/2024, the P&P indicated that "The Important Message (IM) from Medicare will be provided to a Medicare beneficiary who is a Hospital Inpatient to inform her/him of the right to an expedited review by a Quality Improvement Organization (QIO, reviews appeals for Medicare recipients) when the beneficiary is in disagreement with a discharge decision. The P&P also indicated the following:

5.1. 1.The initial copy of the Important Message from Medicare should be provided to the Medicare beneficiary by the Admitting staff to inform the Medicare beneficiaries of their appeal rights.

5.1.2.1.1. The initial copy should be delivered within two calendar days of a Medicare beneficiary's admission as a Hospital Inpatient using the Hospital IM form.

5.1.3.1. The IM must be delivered in person and the notice must be signed by the beneficiary. If a beneficiary has no mental capacity to sign the IM from Medicare, the form must be delivered to and signed by the beneficiary's authorized representative.

5.1.3.3.1.1. If the hospital is unable to personally deliver the IM from Medicare to an authorized representative, then the Admitting staff should telephone the representative to advise of the beneficiary's rights as a Hospital Inpatient ...

5.1.3.3.1.2. The telephone notification will be confirmed by mailing a copy of the follow-up copy of the IM from Medicare via USPS on the same day the telephone notification was completed.

5.1.3.3. 2.1. When a direct phone contact cannot be made, the Admitting staff will send the follow-up copy of the IM to the representative by certified mail, return receipt requested.

During a review of the facility's policy and procedure (P&P), titled "Patient rights and Responsibilities," dated 9/2024, the P&P indicated the following: 2.1.2 The list of patients' rights is provided to all patients, or their assigned representative, upon admission.

Based on interview and record review, the facility failed to ensure the facility staff obtained a copy of advance directive (legal document that allows an individual to designate a health care agent to participate in the process of making health care decisions. It may also include preferences for health care that reflect the individual's preferences and values) from one of 30 sampled patients (Patient 23), when Patient 23 was admitted and had an advance directive, in accordance with the facility's policy and procedure regarding Advance Directives.

This deficient practice had the potential to result in Patient 23's advance directive not being executed and Patient 23's designee not being notified to make medical decision when needed.

Findings:

During a review of Patient 23's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/6/2024, the H&P indicated, Patient 23 was admitted to the facility with diagnoses including but not limited to acute (new onset) hypoxemic (an abnormally low concentration of oxygen in the blood) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), acute heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs), cellulitis (an infection of the deeper layers of skin and the underlying tissue) and acute deep vein thrombosis (DVT - a blood clot that forms in a vein deep in the body).

During a review of Patient 23's "Hospital Condition and Admission (COA, a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.)," dated 7/6/2024, the COA indicated, Patient 23 had an advance directive (legal document that allows an individual to designate a health care agent to participate in the process of making health care decisions. It may also include preferences for health care that reflect the individual's preferences and values).

During a concurrent interview and record review on 2/6/2025 at 2:26 p.m. with the Assistant Department Administrator of Nursing Administration (ADA 1), Patient 23's "Adult Patient Profile," dated 7/6/2024, was reviewed. The "Adult Patient Profile" indicated, "Advance Directives in chart." ADA 1 stated the following: there was a link of advance directive in Patient 23's medical record but it was only accessible for Northern California system. The facility did not have access to it. The nurse should have followed up and requested the copy of advance directive from Patient 23 then scanned it to Patient 23's medical record. ADA 1 stated it was important to obtain a copy of Patient 23's advance directive because it would let the healthcare team know Patient 23's wishes and direct the team who to contact if Patient 23 lost medical decision-making capacity.

During a review of the facility's policy and procedure (P&P) titled, "Advance Directives (AHCD, Advance Health Care Directives)," dated 6/2024, the P&P indicated, "Staff and Physician Responsibilities: Admitting or designated hospital staff will also review the medical record and note whether an AHCD has been scanned into the electronic medical record ... if a patient has an AHCD with him/her, if not already in the medical record, it should be copied and placed in the inpatient chart and sent to the scanning unit ... Admitting or designated hospital staff should document in the patient's electronic medical record that a copy was requested and received ... If the patient is admitted and had executed an AHCD but does not have it with him/her, Admitting or designated hospital staff should ask the patient to provide a copy to the hospital ... Physician, Nursing and Professional Staff Responsibilities & Procedures for acting on a patient's AHCD ... Appropriate clinical staff shall be aware of the existence of the advance directive and how to access the document."

Based on interview and record review the facility failed to ensure that one of 30 sampled patients (Patient 1), had continuous pulse oximetry (a non-invasive monitoring technique that continuously measures a patient's oxygen saturation [SpO2, a measure of how well the body is delivering oxygen to the tissues] and pulse rate, alerting healthcare providers to potential hypoxia -a condition in which there is an inadequate supply of oxygen to the body's tissues or respiratory distress -a condition where breathing becomes difficult or labored]) implemented, while admitted on the inpatient floor (a hospital's unit where patients are admitted for ongoing medical care, monitoring, and treatment under the supervision of healthcare providers), in accordance with a written physician order regarding continuous pulse oximetry monitoring.

This deficient practice had the potential to result in Patient 1's needs not being met and placed Patient 1 at risk of undetected hypoxia, delayed medical intervention, respiratory deterioration, and adverse patient outcomes (a harmful and negative result), including life-threatening potential complications such as death.

Findings:

During a review of Patient 1's History and Physical (H&P, a formal documented completed by the provider upon admission, detailing patient's current medical condition and treatment plan), dated 10/15/2023, the H&P indicated that Patient 1 was admitted to the facility on 10/15/2023 with a medical diagnosis of Covid-19 pneumonia (a severe respiratory infection caused by the COVID-19 virus, leading to inflammation and fluid accumulation in the lungs, which can cause breathing difficulties and reduced oxygen levels in the blood).

During further review of Patient 1's History and Physical (H&P), dated 10/15/2023, the H&P indicated that Patient 1 had past medical history (PMH, a record of a patient's health before the current problem) of metastatic lung cancer (a stage of lung cancer [CA], in which the disease has spread beyond the lungs to other parts of the body), malignant pleural effusion (a condition where CA cells cause fluid accumulation in the area between the lungs and the chest wall, leading to difficulty breathing), PleurX catheter placement (a small tube surgically inserted into the pleural space to remove excess fluid and relieve symptoms of difficulty breathing), and atrial fibrillation (Afib, irregular and often rapid heartbeat).

During a review of Patient 1's History and Physical (H&P), dated 10/15/2023, the H&P also indicated that Patient 1 was on home-based palliative care (a special medical care focused on improving the quality of life for patients with serious illnesses) and had a code status (a patient's instructions to medical professionals about how to respond to cardiac or respiratory arrest) of DNR/DNI (DNR-do not resuscitate, a medical order indicating that no cardiopulmonary resuscitation [CPR, chest compressions] should be performed if the patient's heart stops; DNI-do not intubate, a directive specifying that the patient should be placed on mechanical ventilation [a medical device that assists or completely takes over a patient's breathing by delivering air to their lungs when they are unable to breathe adequately on their own] to help the patient breath).

During a review of Patient 1's History and Physical (H&P), dated 10/15/2023, the H&P indicated the following assessment and plan for Patient 1: "Patient (Patient 1) found to be COVID positive ...Family was leaning toward comfort measures (refer to managing symptoms like pain, nausea [the urge to throw-up], anxiety [feelings of worry or fear], and providing emotional support, rather than attempting to prolong life) however on further discussion with palliative care, the family is hoping the patient (Patient 1) will be able to die on hospice (focuses on comfort care, pain relief and symptom management) at home and hoping to help the patient (Patient 1) perk up and treat any easily reversible causes (okay to COVID treatment) and hold off on comfort measures in the hospital unless symptoms are uncontrolled ..."

During a review of Patient 1's medical record (MR) titled, "Physician's Orders," dated 10/15/2023, the MR indicated that on 10/15/2023 at 2:20 p.m., the physician (MD 4) placed an order for Patient 1 to be on continuous pulse oximetry (a request to use a pulse oximeter to monitor a patient's blood oxygen levels for an extended period).

During an interview on 2/4/2025 at 1:23 p.m., with Charge Nurse (CN 1) on the medical-surgical unit (M/S unit, provides care for patients with a wide range of acute [new onset] and chronic [lasts for an extended period] medical conditions, offering general nursing care, but may not have advanced monitoring capabilities), CN 1 stated the following regarding admitting patients with a standing order (written protocols authorizing designated members of the healthcare team to perform certain clinical tasks without needing to get explicit approval for each instance) for continuous pulse oximetry: " We do not have the capability to continuously monitor oxygen saturation rate (O2 Sats, a measurement of how much oxygen is in the blood), and this is typically not per our unit policy to admit patients requiring continuous SpO2 monitoring."

During an interview on 2/4/2025 at 2:05 p.m. with Charge Nurse (CN 2) on the medical-surgical unit (M/S unit), the CN 2 stated the following: Our unit (M/S unit) is not a monitored floor, and we can only use portable blood pressure machine to measure pulse oximetry. The machine will alarm if the oxygen (O2) saturation (O2 Sats, measurement of oxygen in the blood) drops to 89 percent (%) or below (normal O2 saturation levels typically range from 95% to 100%, with level below 90% often requiring medical intervention), but I don't know if the nurses will be able to hear the alarm at the nurse's station.

During a concurrent interview and record review on 2/4/2025 at 3:45 p.m. with the Assistant Manager Nurse (AMN 1), Patient 1's medical record (MR) and inpatient transfer (the process of moving a patient from one unit or level of care to another within the hospital based on their medical need and required level of monitoring), dated 10/15/2023, were reviewed. The AMN 1 stated that on 10/15/2023 at 2:45 p.m., Patient 1 was admitted to a medical-surgical unit (M/S unit), without cardiac monitoring (continuous electronic tracking of a patient's heart rhythm and rate), but with an order to measure pulse oximetry continuously. The AMN 1 further stated that this order should have been questioned by the nurses before or after Patient 1's arrival to the M/S unit, given the unit does not have continuous monitoring capabilities.

During an interview on 2/5/2025 at 10:11 a.m. with Chief Nurse Executive (CNE), the CNE stated that the Medical-Surgical unit (M/S unit) has the necessary technology to provide continuous oxygen saturation monitoring. However, the CNE also stated that nurses may require education or re-education on how to utilize this capability effectively and where to document the information in the medical record.

During an interview on 2/5/2025 at 11:10 a.m. with physician (MD 1, who oversees the Hospital Services), MD 1 reviewed Patient 1's admission orders placed on 10/15/2023 and stated the following: Patient 1 was initially admitted to observation (a hospital status for patients who require short-term monitoring and assessment to determine if inpatient admission is necessary) with a diagnosis of Covid-19 pneumonia. The admitting physician (MD 4) entered the Covid Order Set (standardized set of pre-approved medical orders designed to streamline the management and treatment of Covid-19 patients) which typically includes the order for measuring oxygen saturation (the percentage of oxygen in the blood) levels continuously.

During a review of Patient 1's medical record (MR) titled, "Vital Signs (VS, objective measurements of essential bodily functions, including temperature, heart rate, respiratory rate, and blood pressure, used to monitor a patient's health status) Flowsheet Data," dated 10/16/2023, the MR indicated the following oxygen (O2) saturation levels (O2 Sats) recorded for Patient 1 on 10/16/2023 from 7:00 a.m. to 6:00 p.m.:

-At 7:08 a.m.: Oxygen saturation level (O2 Sats) was 95% on 4 liters (L, unit of measure for oxygen flow rate).

-At 7:48 a.m.: O2 Sats was 92% on 5 L delivered via nasal cannula (a lightweight, flexible tube with prongs inserted into the nostrils to deliver supplemental oxygen to patients).

-At 9:00 a.m.: O2 Sats was 86%.

-At 9:04 a.m.: O2 Sats was 93% on 10 liters via an open-design oxygen mask (a type of oxygen mask that allows room air to mix with supplemental oxygen, often used when higher oxygen concentrations are needed but full face-sealing is not required).

-The MR further indicated that no additional O2 Sats measurements were recorded in Patient 1's medical record on 10/16/2023 from 9:04 a.m. to 6:00 p.m.

During an interview on 2/5/2025 at 3:10 p.m. with Registered Nurse (RN 1, the nurse who took care of Patient 1 on 10/16/2023, day shift), RN 1 stated the following: "I received the patient (Patient 1) midday as I floated into the unit, and there was another nurse taking care of the patient (Patient 1) in the morning (on 10/16/20). I remember this patient (Patient 1) had a Covid-19 diagnosis, metastatic lung cancer (CA), and passed away that day. I always check physician's orders, but I don't remember if there was an order for continuous pulse oximetry monitoring or if there was any monitoring. On that floor (referring to the MS Unit), I don't think they can monitor continuous pulse oximetry. As to vital signs (VS, measurements of body essential functions such as temperature, respiration rate, and pulse oximetry), the CNA (certified nursing assistant) was responsible for taking VS, and I remember there were VS taken in the morning. Maybe the CNA forgot to document the VS in the evening."

During an interview on 2/6/2025 at 9:35 a.m. with the physician (MD 4, the admitting physician who admitted Patient 1 on 10/15/2023), the MD 4 stated that the order for measuring pulse oximetry continuously means that the patient should be on continuous pulse oximetry monitoring. The MD 4 further stated that the standard is to monitor oxygen saturation rate continuously and to notify the physician when the oxygen levels drop to a certain point as per oxygen titration goals (a protocol that guides the adjustment of oxygen therapy based on a patient's oxygen saturation levels, ensuring adequate oxygenation while preventing hypoxia).

During the same interview on 2/6/2025 at 9:35 a.m. with the physician (MD 4), the MD 4 stated the following regarding the treatment goals for Patient 1 during Patient 1's admission stay on 10/15/2023 through 10/16/2023: Patient 1 had DNR/DNI code status and was very sick; however, Patient 1 still required treatment for Covid-19, still required continuous oxygen blood level monitoring to address and escalate oxygen needs.

During a review of Patient 1's medical record (MR) titled, "Notes," dated 10/16/2023, the MR indicated that Patient 1 expired (died) on 10/16/2023 at 5:13 p.m.

During a review of the facility's policy and procedure (P&P) titled, "Oximetry-Pulse Oximetry," dated 6/2023, the P&P indicated that pulse oximetry is measured and documented in the electronic medical record together with other vital signs or as ordered by physician and per unit protocol.

During a review of the facility's policy and procedure (P&P) titled, "Admission and Discharge-Transfer Practices-Med-Surg Units," dated 10/2022, the P&P indicated that 1.2. Patients will receive care based on a documented assessment of their needs and patient care standards ...1.5. The RN will be responsible for a full system assessment on the patient every 8 hours. Subsequent assessment performed may be focused assessment related to the patient's diagnosis and documented abnormal findings. Data gathered and documented by other nursing staff (CNA) will be reviewed by the RN and signature provided.

During a review of the facility's policy and procedure (P&P) titled, "General Standards of Care-Med-Surg," dated 9/2023, the P&P indicated that" Frequency of necessary assessments, monitoring and vital signs may be done by a physician order, protocol, or as indicated by the patient's condition.

During a review of the facility's policy and procedure (P&P) titled, "Nursing Staff Responsibilities-Medical/Surgical Unit," dated 12/2023, the P&P indicated that 1.4. The registered nurse coordinates the provision of direct patient care plans, provides, evaluates nursing care, directs and monitors activities of staff who are delivering patient care; supervises all nursing activities directly and indirectly related to patient care in a safe, effective and efficient manner. 1.5. Under the supervision of the Charge Nurse/Registered Nurse, the Nursing Assistant (CNA) provides basic direct patient care activities related to patients. 1.8. All members of the nursing staff have the responsibility to have the knowledge and skills in performing their jobs within standards that ensure safety to patients and themselves. 1.9. All members of nursing staff have the responsibility to have the knowledge and skills necessary to: Recognize and report significant abnormalities in pulmonary function parameters; assessment and evaluation of patient's condition in response to therapy.

Based on interview and record review, the facility failed to ensure that for one of 30 sampled patients (Patient 1), the application of two different types of restraints (the use of two or more physical restraints simultaneously to limit a patient's movement: bilateral wrist restraints-devices applied to both wrists to restrict arm movement and prevent self-harm or interference with medical treatment and a vest restraint - a sleeveless garment secured around the chest to limit upper body movement and prevent falls or self-injury), was carried out only after attempts to use less restrictive interventions were exhausted, in accordance with the facility's policy and procedure regarding restraints (devices or techniques that limit a person's movement) use.

This deficient practice had the potential to violate Patient 1's rights (refer to the legal and ethical entitlements of individuals receiving healthcare services) and increase Patient 1's risk of physical harm such as skin breakdown, circulation impairment (a condition where blood flow is reduced to a specific part of the body) and or respiratory distress (a condition where breathing becomes difficult).

Findings:

During a review of Patient 1's History and Physical (H&P, a formal documented completed by the provider upon admission, detailing patient's current medical condition and treatment plan), dated 10/15/2023, the H&P indicated that Patient 1 was admitted to the facility on 10/15/2023 with a medical diagnosis of Covid-19 pneumonia (a severe respiratory infection caused by the COVID-19 virus, leading to inflammation and fluid accumulation in the lungs, which can cause breathing difficulties and reduced oxygen levels in the blood).

During further review of Patient 1's History and Physical (H&P), dated 10/15/2023, the H&P indicated that Patient 1 had past medical history (PMH, a record of a patient's health before the current problem) of metastatic lung cancer (a stage of lung cancer (CA), in which the disease has spread beyond the lungs to other parts of the body), malignant pleural effusion (a condition where CA cells cause fluid accumulation in the area between the lungs and the chest wall, leading to difficulty breathing), PleurX catheter placement (a small tube surgically inserted into the pleural space to remove excess fluid and relieve symptoms of difficulty breathing), and atrial fibrillation (Afib, irregular and often rapid heartbeat).

During a review of Patient 1's History and Physical (H&P), dated 10/15/2023, the H&P also indicated that Patient 1 was on home-based palliative care (a special medical care focused on improving the quality of life for patients with serious illnesses) and had a code status of DNR/DNI (DNR-do not resuscitate, a medical order indicating that no cardiopulmonary resuscitation [CPR] should be performed if the patient's heart stops; DNI-do not intubate, a directive specifying that the patient should be placed on mechanical ventilation [a medical device that assists or completely takes over a patient's breathing by delivering air to their lungs when they are unable to breathe adequately on their own] to help the patient breath).

During a review of Patient 1's medical record (MR) titled, "Nursing Notes," dated 10/16/2023, the MR indicated the following:

"Patient (Patient 1) continuously pulling nasal cannula (NC, a small, flexible tube with two prongs that fit inside the nostrils, used to deliver supplemental oxygen to a patient by providing oxygen directly into the nose) off the face. Repositioned ...Patient (Patient 1) becoming increasingly restless, swinging legs over the bed, not verbalizing needs ...Oxygen needs increased to 6 liters (L, measuring unit) [Oxygen needs increase indicates that the patient required a higher flow of supplemental oxygen, suggesting worsening of breathing and/or increased work of breathing], medical doctor (MD) notified ... Order for restraints obtained."

During a review of Patient 1's medical record (MR) titled, "Order Information," dated 10/16/2023, the MR indicated that on 2/16/2023 at 3:45 a.m., Patient 1 was ordered to be placed in two different types of restraints (devices or techniques that limit a person's movement):

1. Soft bilateral wrist restraints, with the clinical reason for application documented as pulling tubes/lines (which refers to the patient attempting to remove or interfere with essential medical devices, potentially compromising treatment and patient safety)

2. A vest (jacket) restraint, with the clinical reason documented as climbing out of bed (which refers to the patient exhibiting behaviors that pose a risk of falling or self-injury due to agitation or confusion).

During further review of Patient 1's medical record (MR), the MR indicated that both restraint orders were placed at the same time on 10/16/2023 at 3:45 a.m. and were in place until 8 a.m. (total of 4 hours and 15 minutes).

During a review of Patient 1's medical record (MR) titled, "Restraints-Flowsheet," dated 10/16/2023, the MR indicated that the registered nurse (RN) documented the following less restrictive alternatives to continued restraints use:

-1:1 patient care (a dedicated staff member assigned to always remain with the patient to provide direct supervision and intervention if needed).
-Diversional activities (techniques used to redirect the patient's focus and reduce agitation)
-Increased frequency of nursing rounds (more frequent checks by nursing staff to assess the patient's condition).

During a review of Patient 1's medical record (MR) titled, "Nurses Flowsheets," dated 10/16/2023, the MR indicated that there was no nursing documentation indicating that less restrictive interventions such as utilizing a sitter were tried and/or documented to be used prior to contacting medical doctor (MD) for a restraint order. The MR also indicated that there was no record of attempts to try only one type of restraint at a time, as both bilateral wrist restraints and a vest restraint were applied simultaneously on 10/16/2023 at 3:45 am.

During an interview on 2/5/2025 at 1:42 p.m. with Assistant Manager Nurse (AMN 1), after reviewing Patient 1's medical record (for the visit from 10/15/2023 through 10/16/2023), the AMN 1 stated that Patient 1's medical record contained no documentation of attempting to use a sitter (a trained staff member assigned to provide continuous, one-on-one supervision to a patient to ensure safety and reduce the need for restraints) prior to simultaneously placing Patient 1 in two different types of restraints (a vest and bilateral soft wrist restraints) on 10/16/2023.

During a review of the facility's policy and procedure (P&P) titled "Restraint Use," dated 9/1/2022, the P&P indicated the following regarding restraint use:

-All patients have the right to be free from restraint use imposed as a means of convenience by staff. Restraints may only be used to ensure the immediate physical safety of the patient and must be discontinued at the earliest possible time. Restraints may only be used when less restrictive interventions have been determined to be ineffective.
-5.8.1 When an assessment has indicated the need for restraint, the least restrictive device should be utilized.
-5.8.2 A registered nurse (RN) is responsible for the assessment, monitoring, and provision of care for patients in restraints.
-The Centers for Medicare & Medicaid Services (CMS) finds the rationale that the patient should be restrained because he/she "might" fall as inadequate basis for using a restraint. When assessing and care planning for the patient, the hospital should consider whether he/she has a history of falling or a medical condition or symptom that indicates a need for a protective intervention. It is important to note that the regulation specifically states that convenience is not an acceptable reason to restraint a patient. A restraint must not serve as a substitute for adequate staffing to monitor patients.

Based on interview and record review, the facility failed to ensure that for one of 30 sampled patients (Patient 1), justification for the continued use of the vest restraint (a type of mesh or cloth vest applied over the patient's chest and tied to an immovable part of each side of the bed) was documented in Patient 1's medical record, in accordance with the facility's policy and procedure regarding restraints (devices or techniques that limit a person's movement) use.

This deficient practice had the potential to violate Patient 1's rights (refer to the legal and ethical entitlements of individuals receiving healthcare services) resulting in the unnecessary use of restraints compromising Patient 1's health and well-being.

Findings:

During a review of Patient 1's History and Physical (H&P, a formal documented completed by the provider upon admission, detailing patient's current medical condition and treatment plan), dated 10/15/2023, the H&P indicated that Patient 1 was admitted to the facility on 10/15/2023 with a medical diagnosis of Covid-19 pneumonia (a severe respiratory infection caused by the COVID-19 virus, leading to inflammation and fluid accumulation in the lungs, which can cause breathing difficulties and reduced oxygen levels in the blood).

During further review of Patient 1's History and Physical (H&P), dated 10/15/2023, the H&P indicated that Patient 1 had past medical history (PMH, a record of a patient's health before the current problem) of metastatic lung cancer (a stage of lung cancer [CA], in which the disease has spread beyond the lungs to other parts of the body), malignant pleural effusion (a condition where CA cells cause fluid accumulation in the area between the lungs and the chest wall, leading to difficulty breathing), PleurX catheter placement (a small tube surgically inserted into the pleural space to remove excess fluid and relieve symptoms of difficulty breathing), and atrial fibrillation (Afib, irregular and often rapid heartbeat).

During a review of Patient 1's History and Physical (H&P), the H&P also indicated that Patient 1 was on home-based palliative care (a special medical care focused on improving the quality of life for patients with serious illnesses) and had a code status of DNR/DNI (DNR-do not resuscitate, a medical order indicating that no cardiopulmonary resuscitation [CPR] should be performed if the patient's heart stops; DNI-do not intubate, a directive specifying that the patient should be placed on mechanical ventilation [a medical device that assists or completely takes over a patient's breathing by delivering air to their lungs when they are unable to breathe adequately on their own] to help the patient breath).

During a review of Patient 1's medical record (MR) titled, "Order Information," dated 10/16/2023, the MR indicated that on 2/16/2023 at 3:45 a.m., Patient 1 was ordered to be placed in two different types of restraints (devices or techniques that limit a person's movement):

1. Soft bilateral wrist restraints, with the clinical reason for application documented as pulling tubes/lines (which refers to the patient attempting to remove or interfere with essential medical devices, potentially compromising treatment and patient safety)

2. A vest (jacket) restraint, with the clinical reason documented as climbing out of bed (which refers to the patient exhibiting behaviors that pose a risk of falling or self-injury due to agitation or confusion).
The MR indicated that both restraint orders were placed at the same time on 10/16/2023 at 3:45 a.m.

During a review of Patient 1's medical record (MR) titled, "Restraints-Flowsheet," dated 10/16/2023, the MR indicated that on 10/16/2023 from 4:00 a.m. to 7:00 a.m., the registered nurse (RN) documented under the clinical justification for restraint use that Patient 1 was pulling lines and pulling tubes (indicated for the use of bilateral soft wrist restraints). The MR contained no documented record for the clinical justification for the vest restraint use from 4 a.m. to 7 a.m. on 10/16/2023.

During an interview on 2/5/2025 at 1:42 p.m. with the Assistant Manager Nurse (AMN 1), after reviewing Patient 1's medical record (for the visit on 10/15/2023 through 10/16/2023), the AMN 1 stated that Patient 1's medical record contained no documentation of justification (behavior that warranted the use of restraints) for the continuous use of the vest restraint. The AMN 1 stated justification for the continued use of restraints should be documented in the medical record in accordance with the facility's policy regarding restraints use.

During a review of the facility's policy and procedure (P&P) titled, "Restraint Use," dated 9/1/2022, the P&P indicated the following regarding restraint use:

-All patients have the right to be free from restraint use imposed as a means of convenience by staff. Restraints may only be used to ensure the immediate physical safety of the patient and must be discontinued at the earliest possible time. Restraints may only be used when less restrictive interventions have been determined to be ineffective.
-5.8.1 When an assessment has indicated the need for restraint, the least restrictive device should be utilized.
-5.8.2 A registered nurse (RN) is responsible for the assessment, monitoring, and provision of care for patients in restraints.
-5.8.4 The description of the patient's behavior that warranted the use of restraint and the patient's condition must be documented in the medical record

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

1. The facility failed to ensure that nursing staff performed assessment, re-assessment, and evaluation of health condition for three of 30 sampled patients (Patient 1, Patient 27, and Patient 29), when:

1.a. Nursing staff failed to perform assessment and re-assessment of Patient 1's condition when Patient 1 started declining (experiencing decline in health status, indicating worsening of symptoms or functional abilities); failed to obtain routine vital signs (VS, measurements of the body's most basic functions) every 8 hours and VS upon the detection of a change in condition; and failed to implement continuous pulse oximetry (a noninvasive method for measuring oxygen saturation in the blood) and record oxygen saturation level (O2Sats, the percentage of oxygen in the blood) as ordered by the physician and in accordance with the facility's policy and procedure regarding General Standards of Care and Nursing Staff Responsibilities.

This deficient practice had the potential for the staff's inability to determine a change in Patient 1's condition which may result in a delay in the implementation of necessary interventions. (Refer to A-0395)

1.b. Nursing staff failed to perform neurological assessment (nursing assessment including a patient's mental status, extremities movement and strength, bilateral (both) hand grips (force exerted by the hand when squeezing an object), pupils' (black center of the eye) sizes and reactivity (the ability of the pupil of the eye to constrict [smaller than normal] or dilate [larger than normal]), face symmetry, performed by a Registered Nurse [RN]), per physician order and in accordance with the facility's policies and procedures regarding Unit Based Performance Standards and Nursing Staff Responsibilities, for two of 30 sampled patients (Patient 27 and Patient 29).

This deficient practice had the potential to result in a delay in identifying a change of condition and neurological status change including possible stroke (occurs when blood flow to the brain is interrupted, leading brain cell damage or death) progression, which can lead to delay in treatment and care, thus resulting to patient harm and/or death. (Refer to A-0395)

2. The facility failed to ensure its nursing staff developed individualized nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) and reviewed nursing care plan to evaluate patient's progress for four of 30 sampled patients (Patients 8, 14, 23 and 27), in accordance with facility's policy and procedure regarding care plans when:

2.a. Patient 8 did not have a care plan developed and implemented to address a diagnosis of Diabetic Ketoacidosis (DKA, a serious complication of diabetes that can be life-threatening), upon admission on 2/5/2025.

This deficient practice had the potential for Patient 8's needs and risks to not be identified and may cause a delay in interventions which could result in complications such as diabetic coma (a life-threatening condition that occurs when blood sugar levels become dangerously high or low) and or death. (Refer to A-0396)

2.b. Patient 14 did not have a care plan developed and implemented to address Patient 14's diagnosis of Anemia (a condition marked by a deficiency of red blood cells or of hemoglobin in the blood, resulting in pallor and weariness), upon admission.

This deficient practice had the potential for Patient 14's needs and risks to not be identified and may cause a delay in interventions which could result in complications such as abnormal heart rhythm, dizziness, and/or death. (Refer to A-0396)

2.c. Nursing staff did not review and update Patient 23's care plan regarding risk for fall (when someone unintentionally ends up on the floor or another lower level), skin injury, infection, impaired gas exchange (when the body cannot get enough oxygen) and pain management, every shift, on 7/12/2025 and 7/13/2025 for both day and night shift.

This deficient practice had the potential for Patient 23's needs and risks including response to treatment/interventions to remain unidentified and may cause a delay in the implementation of additional or alternative interventions thus resulting in worsening skin injury, etc. (Refer to A-0396)

2.d. Nursing staff did not develop care plan to address Patient 27's admitting diagnosis of ischemic stroke (occurs when a blood clot or other blockage prevents blood flow to the brain, causing brain cells to die), upon admission.

This deficient practice had the potential for Patient 27's needs and risks to not be identified and may cause a delay in interventions which could result in worsening of symptoms and prolonged hospitalization. (Refer to A-0396)

3. The facility failed to ensure nursing staff re-assessed and documented vital signs (VS, measurements of the body's basic functions, such as temperature, pulse, respiration rate, and blood pressure that provide critical information about the body's overall condition), every eight hours as per Medical-surgical unit (a hospital unit that provides care for adult patients recovering from surgery, acute illnesses, or other medical conditions) protocol, for one of 30 sampled patients (Patient 1), in accordance with the facility's policy and procedure regarding Vital Signs (VS, objective measurements of essential bodily functions, including temperature, heart rate, respiratory rate, and blood pressure, used to monitor a patient's health status) and General Standards of Care.

This deficient practice had the potential for the staff's inability to determine a change in Patient 1's condition which may result in a delay in the implementation of necessary interventions. (Refer to A-0398)

4. The facility failed to ensure nursing staff obtained and recorded the daily weight for two of 30 sampled patients (Patient 2 and Patient 7), in accordance with the facility's Medical-Surgical (M/S floor, a hospital unit that provides care for patients with a wide range of medical conditions and post-surgical recovery needs) unit protocol and physician's order.

This deficient practice had the potential for Patient 2's and Patient 7's needs not being met, including inadequate assessment of fluid balance (the regulation of the amount of water in the body), undetected weight fluctuations indicative of worsening conditions and potential delays in adjusting medical treatment plans. (Refer to A-0398)

5. The facility failed to ensure nursing staff obtained and recorded Orthostatic Blood Pressure (Ortho BP, a series of blood pressure measurements taken in different positions such as lying down, sitting, and standing, to assess for orthostatic hypotension, a condition where blood pressure drops significantly upon standing, leading to dizziness or fainting) every shift, for one of 30 sampled Patients (Patient 7), in accordance with the physician's order and the facility's policy and procedure regarding Vital Signs.

This deficient practice had the potential for Patient 7's worsening symptoms, such as dizziness, fainting, and or risk for falls (when someone unintentionally ends up on the ground or a lower level) to go unnoticed, resulting in negative health outcomes such as fracture (break in the bones) resulting from falls because of fainting, abnormal heart rhythm, etc. (Refer to A-0398)

6. The facility failed to ensure that four of four sampled open glucose (sugar in the blood) control solution bottles (a liquid used to test the accuracy of blood glucose meters), were labeled with the dates they were opened including the discard dates for each of the four glucose control solutions used for glucometers to test the blood glucose of 32 of 32 sampled patients in the 4 east medical surgical unit (a 32 bed unit that manages acute medical surgical patients with a wide range of diagnoses and care needs), in accordance with the facility's policy and procedure regarding glucose testing.

This deficient practice had the potential to result in inaccurate blood glucose meter (a portable machine that's used to measure glucose in the blood) readings, which could negatively affect the treatment provided to patients thus potentially causing excessively low or excessively high blood sugar levels. (Refer to A-0398)

7. The facility failed to ensure Nursing staff performed COVID (COVID-19, coronavirus disease, an infectious disease caused by the SAR-CoV-2 virus which causes fever, cough, and breathing difficulties) screening upon admission for three of 30 sampled patients (Patients 23, 25 and 26), in accordance with the facility's protocol regarding COVID-19 screening (a method for healthcare workers to find out if someone has COVID-19 or not).

This deficient practice had the potential for Patients 23, 25 and 26 spread the infection to other patients, staff or visitors. (Refer to A-0398)

8. The facility failed to ensure Nursing staff reported one of 30 sampled patient's (Patient 26) critical test result (laboratory or imaging test results that require immediate medical attention) of white blood cell count (WBC, a type of blood cell that play a crucial role in body's immune system, elevation in the count usually indicates an infection) to the physician, within the required timeframe of 30 minutes, in accordance with the facility's policy regarding Critical Tests and Values Reporting.

This deficient practice had the potential to put Patient 26 at risk for severe infection and sepsis (a body's overwhelming and life-threatening response to infection) due to delay in treatment and care. (Refer to A-0398)

9. The facility failed to ensure its nursing staff administered ordered medications in a timely manner for two of 30 sampled patients (Patients 23 and 29), in accordance with the facility's policy and procedure regarding medication administration when:

9.a. Nursing staff did not adjust Patient 23's heparin (an anticoagulant [blood thinner] to prevent blood clots or keep an existing clot from getting worse) drip infusing rate until 3.5 hours later from time of order.

This deficient practice had the potential to leave Patient 23's blood clot untreated and put Patient 23 at risk for developing new blood clot, which can result in complications such as Pulmonary embolism (a blood clot that blocks an artery in the lung). (Refer to A-0405)

9.b. Nursing staff did not administer hydralazine (medication to treat high blood pressure) as ordered for Patient 29's elevated (high) blood pressure. This deficient practice had the potential to leave Patient 29's elevated blood pressure untreated and lead to other complications such as stroke (occurs when a blood clot or other blockage prevents blood flow to the brain, causing brain cells to die). (Refer to A-0405)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment.

Based on interview and record review, the facility failed to ensure that nursing staff performed assessment, re-assessment, and evaluation of health condition for three of 30 sampled patients (Patient 1, Patient 27, and Patient 29), when:

1. Nursing staff failed to perform assessment and re-assessment of Patient 1's condition when Patient 1 started declining (experiencing decline in health status, indicating worsening of symptoms or functional abilities); failed to obtain routine vital signs (VS, measurements of the body's most basic functions) every 8 hours and VS upon the detection of a change in condition; and failed to implement continuous pulse oximetry (a noninvasive method for measuring oxygen saturation in the blood) and record oxygen saturation level (O2Sats, the percentage of oxygen in the blood) as ordered by the physician, and in accordance with the facility's policy and procedure regarding General Standards of Care and Nursing Staff Responsibilities.

This deficient practice had the potential for the staff's inability to determine a change in Patient 1's condition which may result in a delay in the implementation of necessary interventions.

2. Nursing staff failed to perform neurological assessment (nursing assessment including a patient's mental status, extremities movement and strength, bilateral [both] hand grips [force exerted by the hand when squeezing an object], pupils' [black center of the eye] sizes and reactivity -the ability of the pupil of the eye to constrict [smaller than normal] or dilate [larger than normal], face symmetry, performed by a Registered Nurse [RN]), per physician order, and in accordance with the facility's policies and procedures regarding Unit Based Performance Standards and Nursing Staff Responsibilities, for two of 30 sampled patients (Patient 27 and Patient 29).

This deficient practice had the potential to result in a delay in identifying a change of condition and neurological status change including possible stroke (occurs when blood flow to the brain is interrupted, leading brain cell damage or death) progression, which can lead to delay in treatment and care, thus resulting to patient harm and/or death.

Findings:

1. During a review of Patient 1's History and Physical (H&P, a formal document completed by the provider upon admission, detailing patient's current medical condition and treatment plan), dated 10/15/2023, the H&P indicated that Patient 1 was admitted to the facility on 10/15/2023 with a medical diagnosis of Covid-19 pneumonia (a severe respiratory infection caused by the COVID-19 virus, leading to inflammation and fluid accumulation in the lungs, which can cause breathing difficulties and reduced oxygen levels in the blood).

During further review of Patient 1's History and Physical (H&P), dated 10/15/2023, the H&P indicated that Patient 1 had past medical history (PMH, a record of a patient's health before the current problem) of metastatic lung cancer (a stage of lung cancer [CA], in which the disease has spread beyond the lungs to other parts of the body), malignant pleural effusion (a condition where CA cells cause fluid accumulation in the area between the lungs and the chest wall, leading to difficulty breathing), PleurX catheter placement (a small tube surgically inserted into the pleural space to remove excess fluid and relieve symptoms of difficulty breathing), and atrial fibrillation (Afib, irregular and often rapid heartbeat).

During a review of Patient 1's History and Physical (H&P), dated 10/15/2023, the H&P also indicated that Patient 1 was on home-based palliative care (a special medical care focused on improving the quality of life for patients with serious illnesses) and had a code status (a patient's instructions to medical professionals about how to respond to cardiac or respiratory arrest) of DNR/DNI [DNR-do not resuscitate, a medical order indicating that no cardiopulmonary resuscitation [CPR, chest compressions] should be performed if the patient's heart stops; DNI-do not intubate, a directive specifying that the patient should be placed on mechanical ventilation to help the patient breath).

During a review of Patient 1's History and Physical (H&P), dated 10/15/2023, the H&P indicated the following assessment and plan for Patient 1: "Patient (Patient 1) found to be COVID positive ...Family was leaning toward comfort measures (refer to managing symptoms like pain, nausea [urge to throw-up], anxiety [feeling of worry or fear], and providing emotional support, rather than attempting to prolong life) however on further discussion with palliative care, the family is hoping the patient (Patient 1) will be able to die on hospice (focuses on comfort care, pain relief and symptom management) at home and hoping to help the patient (Patient 1) perk up and treat any easily reversable causes (okay to COVID treatment) and hold off on comfort measures in the hospital unless symptoms are uncontrolled ..."

During an interview on 2/3/2025 at 1:57 p.m. with Patient 1's designated healthcare decision maker (R1), R1 stated the following: On 10/16/2023, R1 received a phone call from the facility informing R1 that Patient 1 had passed away. R1 mentioned that on 10/16/2023, Patient 1 was in the hospital being treated for COVID-19, and despite being diagnosed with terminal lung cancer, there was no indication that Patient 1 was going to die on that date. R1 stated that on 10/16/2023, Patient 1's spouse left the hospital around 2:00 p.m. or so, warning the nurse that Patient 1 was trying to remove the oxygen mask and needed to be monitored. R1 stated that only a few hours after Patient 1's spouse left the facility, Patient 1 died. R1 stated that Patient 1's family was not informed of Patient 1's rapidly declining condition on 10/16/2023, which deprived them (Patient 1's family) of the opportunity to spend the last few hours with Patient 1 before Patient 1's passing.

During a review of Patient 1's medical record (MR) titled, "Vital Signs (VS, objective measurements of essential bodily functions, including temperature, heart rate, respiratory rate, and blood pressure, used to monitor a patient's health status) Flowsheet Data," dated 10/16/2023, the MR indicated the following VS measurements were obtained and recorded on 10/16/2023 from 7:00 a.m. to 6:00 p.m.:

-At 7:48 a.m.: -Temperature (T) was 96.7 Fahrenheit (F, measuring unit of the body's internal heat).
-Pulse was 71 beats per minute (bpm, the number of heart beats per minute).
-Blood Pressure (BP, the force of blood against the artery walls; BP is measured in millimeters of mercury (mmHG)) was 143/78 mmHG (normal BP is generally considered to be around 120/80 mmHG).
-Respirations were 20 breaths per minute (the number of breaths taken per minute; normal respiratory rate typically ranges from 12-20 breaths per minute).
-The MR further indicated that no additional vital signs measurements were recorded in Patient 1's medical record on 10/16/2023 after 7:48 a.m. to 6:00 p.m.

During an interview on 2/5/2025 at 1:39 p.m. with the Chief Nurse Executive (CNE), the CNE stated that typically on a medical-surgical floor (M/S floor, a hospital unit that provides care for patients with a wide range of medical conditions and post-surgical recovery needs), vital signs should be obtained and recorded every eight hours. The CNE then confirmed that Patient 1's medical record (MR) contained no record of routine vital signs (VS) obtained after 7:48 a.m. on 10/16/2023.

During an interview on 2/5/2025 at 3:10 p.m. with Registered Nurse (RN 1, the nurse who took care of Patient 1 on 10/16/2023, day shift), RN 1 stated the following: "I received the patient (Patient 1) midday as I floated into the unit, and there was another nurse (RN 2) taking care of the patient (Patient 1) in the morning (on 10/16/20). I remember this patient (Patient 1) had a Covid-19 diagnosis, metastatic lung cancer (CA), and passed away that day. The CNA (Certified Nursing Assistant) on the floor was responsible to take the vital signs in the afternoon and I remember there were VS taken in the morning. Maybe the CNA forgot to document the VS in the evening."

During a review of Patient 1's medical record (MR) titled, "Physician's Orders," dated 10/15/2023, the MR indicated that on 10/15/2023 at 2:20 p.m., the physician (MD 4) placed an order for Patient 1 to be on continuous pulse oximetry (a request to use a pulse oximeter [ an electronic device that measures the amount of oxygen [SpO2] in your blood] to monitor a patient's blood oxygen levels for an extended period).

During an interview on 2/4/2025 at 1:23 p.m., with Charge Nurse (CN 1) on the medical-surgical unit (M/S unit, provides care for patients with a wide range of acute and chronic medical; conditions, offering general nursing care, but may not have advanced monitoring capabilities), CN 1 stated the following regarding admitting patients with a standing order for continuous pulse oximetry : " We do not have the capability to continuously monitor oxygen saturation rate ( O2 Sats/SpO2, a measurement of how much oxygen is in the blood), and this is typically not per our unit policy to admit patients requiring continuous SpO2 monitoring.

During an interview on 2/4/2025 at 2:05 p.m. with Charge Nurse (CN 2) on the medical-surgical unit (M/S unit), the CN 2 stated the following: "Our unit [M/S unit] is not a monitored floor, and we can only use portable blood pressure machine to measure pulse oximetry. The machine will alarm if the oxygen (O2) saturation (O2 Sats/SpO2, measurement of oxygen in the blood) drops to 89 percent (%) or below (normal O2 saturation levels typically range from 95% to 100%, with level below 90% often requiring medical intervention), but I don't know if the nurses will be able to hear the alarm at the nurse's station."

During a review of Patient 1's medical record (MR) titled, "Vital Signs (VS) Flowsheet Data," dated 10/16/2023, the MR indicated the following oxygen saturation levels (O2 Sats/SpO2) were recorded for Patient 1 on 10/16/2023 from 7:00 a.m. to 6:00 p.m.:

-At 7:08 a.m.: Oxygen saturation level (O2 Sats/SpO2) was 95% on 4 liters (L, unit of measure for oxygen flow rate).
-At 7:48 a.m.: O2 Sats was 92% on 5 L delivered via nasal cannula (a lightweight, flexible tube with prongs inserted into the nostrils to deliver supplemental oxygen to patients).
-At 9:00 a.m.: O2 Sats was 86%.
-At 9:04 a.m.: O2 Sats was 93% on 10 liters via an open-design oxygen mask (a type of oxygen mask that allows room air to mix with supplemental oxygen, often used when higher oxygen concentrations are needed but full face-sealing is not required).
-The MR further indicated that no additional O2 Sats measurements were recorded in Patient 1's medical record on 10/16/2023 from 9:04 a.m. to 6:00 p.m. (total 9 hours).

During an interview on 2/5/2025 at 3:10 p.m. with Registered Nurse (RN) 1, the RN 1 stated the following: "I always check physician's orders, but I don't remember if there was an order for continuous pulse oximetry monitoring or if there was any monitoring. On that floor, I don't think they can monitor continuous pulse oximetry." The RN 1 also stated that Patient 1's family wanted the patient (Patient 1) to pass away at home; it was expected for him to pass away. RN 1 said that on 10/16/2023, Patient 1's family had left the facility before Patient 1 passed away.

During the same interview on 2/5/2025 at 3:10 p.m. with Registered Nurse (RN) 1, RN 1 stated that when RN 1 was assigned Patient 1 (on 10/16/2023, late in the morning, exact time was not verified), Patient 1 appeared stable, did not look like they (Patient 1) were dying, although, RN 1 also stated that Patient 1's health was declining as the patient (Patient 1) was not responding as much. RN 1 also stated that Patient 1 seemed comfortable and there were no signs and symptoms of distress. RN 1 further stated the following: "I saw the patient (Patient 1) expire when I checked on them (Patient 1) and they (Patient 1) happened to be taking the last breath. Because the patient (Patient 1) was DNR/DNI code status, I did not call the Rapid Response Team (RRT, a group of health professionals who assess and treat patients who are at risk of clinical decline) or the code (to alert staff about a critical situation like a cardiac arrest [when the heart stops beating])."

During an interview on 2/6/2025 at 9:35 a.m. with the physician (MD 4, the admitting physician who admitted Patient 1 on 10/15/2023), the MD 4 stated that the order for using pulse oximetry continuously means that the patient should be on continuous pulse oximetry monitoring. The MD 4 further stated that the standard is to monitor oxygen saturation rate (O2 Sats/SpO2) continuously and to notify the physician when the oxygen levels drop to a certain point as per oxygen titration goals (a protocol that guides the adjustment of oxygen therapy based on a patient's oxygen saturation levels, ensuring adequate oxygenation while preventing hypoxia [a life-threatening condition that occurs when there is not enough oxygen in the body's tissues, cells, or blood]).

During the same interview on 2/6/2025 at 9:35 a.m. with the physician (MD 4), the MD 4 stated the following regarding the treatment goals for Patient 1 during Patient 1's admission stay on 10/15/2023 through 10/16/2023: "Patient 1 had DNR/DNI code status and was very sick; however, Patient 1 still required treatment such as escalation of oxygen needs, being placed on a non-rebreather mask (NRB mask, a medical device that delivers oxygen to patients who need it quickly), calling the RRT (Rapid Response Team- a group of healthcare professionals, typically including nurses, doctors, and respiratory therapists, who are readily available to quickly assess and treat patients showing signs of clinical deterioration before a full medical emergency occurs, with the goal of preventing a cardiac arrest or the need for intensive care unit admission) for a change in condition. There is no need to intubate or call the code blue (a hospital emergency code that indicates a patient needs immediate medical attention, usually due to cardiac or respiratory arrest), but the supportive treatment should still be provided."

During an interview on 2/6/2023 at 10:09 a.m. with Registered Nurse (RN) 2, the RN 2 stated the following: "[On 10/16/2023,] I got floated to the medical-surgical unit (Med-surg, a hospital unit that provides care for patients recovering from surgery or illness) for about 4 hours. I remember the CNA took vital signs (VS) in the morning, but I did my own and noticed that patient's (Patient 1) oxygen saturation level (O2Sats/SpO2) was low. I notified the physician and increased the patient's (Patient 1) oxygen flow to 10 Liters (L, measuring unit). I documented this in the patient's record. I gave report (an exchange of patient information, status, care, and orders between nurses) to the incoming nurse. I did not call RRT because I was able to stabilize the patient (Patient 1) by increasing the oxygen flow."

During the same interview om 2/6/2023 at 10:09 a.m. with Registered Nurse (RN) 2, RN 2 stated the following regarding obtaining vital signs (VS) when a change in patient's condition was identified: "I don't recall if I forgot to obtain vital signs (VS) or if I forgot to document VS when the patient's (Patient 1) oxygen saturation (O2 Sats) dropped [on 10/16/2023 at 9:00 a.m.]. I usually obtain patient's vital signs with a change in condition."

During a review of Patient 1's medical record (MR) titled, "Notes," dated 10/16/2023, the MR indicated that Patient 1 expired on 10/16/2023 at 5:13 p.m.

During a review of Patient 1's medical record (MR), dated 10/16/2023, no nursing notes were found in Patient 1's MR that would indicate that Patient 1's condition was progressively declining from 12:00 p.m. to 5:13 p.m. on 10/16/2023. The MR also indicated that there was no record of Rapid Response Team (RRT) notes in Patient 1's MR on 10/16/2023.

During a review of the facility's policy and procedure (P&P) titled, "Vital Signs-Including Orthostatic Blood Pressure (Ortho BP, a series of blood pressure measurements taken in different positions such as lying down, sitting, and standing, to assess for orthostatic hypotension, a condition where blood pressure drops significantly upon standing, leading to dizziness or fainting)," dated 10/2024, the P&P indicated that 5.1. Frequency of Vital Signs will be taken every 8 hours or as specified.

During a review of the facility's policy and procedure (P&P) titled, "General Standards of Care-Med-Surg," dated 9/2023, the P&P indicated that" Frequency of necessary assessments, monitoring and vital signs may be done by a physician order, protocol, or as indicated by the patient's condition.

During a review of the facility's policy and procedure (P&P) titled, "Nursing Staff Responsibilities-Medical/Surgical Unit," dated 12/2023, the P&P indicated that 1.4. The registered nurse coordinates the provision of direct patient care plans, provides, evaluates nursing care, directs and monitors activities of staff who are delivering patient care; supervises all nursing activities directly and indirectly related to patient care in a safe, effective and efficient manner.

During a review of the facility's policy and procedure (P&P) titled, "Admission and Discharge-Transfer Practices-Med-Surg Units," dated 10/2022, the P&P indicated that 1.2. Patients will receive care based on a documented assessment of their needs and patient care standards ...1.5. The RN will be responsible for a full system assessment on the patient every 8 hours. Subsequent assessment performed may be focused assessment related to the patient's diagnosis and documented abnormal findings. Data gathered and documented by other nursing staff (CNA) will be reviewed by the RN and signature provided.

During a review of the facility's policy and procedure (P&P) titled, "Oximetry-Pulse Oximetry," dated 6/2023, the P&P indicated that pulse oximetry is measured and documented in the electronic medical record together with other vital signs or as ordered by physician and per unit protocol.

During a review of the facility's policy and procedure (P&P) titled, "Nursing Staff Responsibilities," dated 12/2023, the P&P indicated that:

1.4. The registered Nurse (RN) coordinates the provision of direct patient care; plans, provides, evaluates nursing care, directs and monitors activities of staff who are delivering patient care. Supervises all nursing activities directly and indirectly related to patient care in a safe, effective and efficient manner. It is the responsibility of each RN on duty to notify the appropriate physician of any significant changes in the patient's condition.
1.9. All members of nursing staff have the responsibility to have the knowledge and skills necessary to: 1.9.2. Recognize and report significant abnormalities in pulmonary function parameters.
1.9.6. Assessment and evaluation of patient's condition and response to therapy

2.a. During a review of Patient 27's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/1/2025, the H&P indicated, Patient 27 was admitted to the facility with diagnosis of acute (new onset) stroke (occurs when blood flow to the brain is interrupted, leading brain cell damage or death) due to ischemia (a condition where there is a reduced blood flow to an area of the body).

During a concurrent interview and record review on 2/7/2025 at 10:20 a.m. with the Department Administrator (DA 4) of Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill), Patient 27's physician order, dated 2/1/2025, was reviewed. The physician order indicated, "measure neuro check (neurological assessment [nursing assessment including a patient's mental status, extremities movement and strength, bilateral hand grips, pupils' sizes and reactivity, face symmetry performed by a Registered Nurse]) every four (4) hours."

During a concurrent interview and record review on 2/7/2025 at 10:50 a.m. with the Stroke Coordinator Nurse (SCN), Patient 27's neurological assessment flow chart, dated from 2/1/2025 to 2/3/2025, was reviewed. The neurological assessment flow chart indicated, nursing staff performed neurological assessment on the following dates and times:
-On 2/1/2025 at 1:18 p.m., 5:30 p.m. and 9:40 p.m.
-On 2/2/2025 at 4:15 a.m., 8 a.m., 3:24 p.m. and 8 p.m. (missing 12 a.m. and 12 p.m.)
-On 2/3/2025 at 4 a.m., 8 a.m., 12 p.m., 4 p.m. and 8 p.m. (missing 12 a.m.)

During the same interview on 2/7/2025 at 10:50 a.m. with the Stroke Coordinator Nurse (SCN), SCN stated it was important to monitor stroke a patient's neurological status to know the baseline of the patient, to identify any neurological status changes and notify the physician. SCN also said that treatment for stroke was time sensitive. SCN stated nursing staff did not perform neurological assessment on Patient 27 every four (4) hours as ordered and as a result, could fail to identify progression of a stroke.

During a review of the facility's policy and procedure (P&P) titled, "Unit Based Performance Standards - DOU (direct observation unit [hospital unit providing close monitoring care to patients])," dated 2/2023, the P&P indicated, "Standard of care ... Standard II ... the patient has the right to expect assessment data to be consistent with the medical diagnoses and the plan of care ... standard of practice ... need based focused assessment may include: vital signs (measurements of the body's most basic function including body temperature, heart rate, blood pressure, respirations and pain level), review of systems, as indicated ... review of and follow through with physician orders."

During a review of the facility's policy and procedure (P&P) titled, "Nursing Staff Responsibilities," dated 2/2023, the P&P indicated, "Registered Nurses (RN) coordinate the provision of direct patient care ... it is the responsibility of each RN on duty to notify the appropriate physician of any significant changes in the patient's condition."

During a review of the facility's policy and procedure (P&P) titled, "Scope of Nursing Practice," dated 10/2021, the P&P indicated, "RN (Registered Nurse) Scope of Practice ... perform skills essential to the kind of nursing action to be taken ...effectively supervises nursing care being given by subordinates ..."

2.b. During a review of Patient 29's "History and Physical (H&P)," dated 7/4/2024, the H&P indicated, Patient 29 was admitted to the facility with diagnoses including but not limited to acute (new onset) nontraumatic subdural (the space between the skull and surface of the brain) hemorrhage (bleeding), nontraumatic cerebral (brain) edema (swelling) and diabetes (high blood sugar).

During a review of Patient 29's physician order, dated 7/5/2024, the physician order indicated, nursing to perform neuro check (neurological assessment) every hour.

During a concurrent interview and record review on 2/7/2025 at 10:55 a.m. with the Department Administrator (DA 4) of Intensive Care Unit, Patient 29's neurological assessment flowchart dated from 7/5/2024 to 7/7/2024, was reviewed. The neurological assessment flow chart indicated, nursing staff performed neurological assessment on the following dates and times:
-On 7/5/2024 at 8 a.m., 12 p.m., 4 p.m., 8 p.m. and 11:33 p.m.
-On 7/6/2024 at 4 a.m., 8 a.m., 12 p.m. 4 p.m. and 8 p.m.
-On 7/7/2024 at 12 a.m., 4 a.m. 8 a.m. 12 p.m. 4 p.m. and 7:30 p.m.

During the same interview on 2/7/2025 at 10:55 a.m. with the Department Administrator (DA 4) of Intensive Care Unit, DA 4 stated nursing staff failed to perform hourly neurological assessment per physician order. DA 4 stated there would be risk for Patient 29 to develop neurological symptoms changes and not be identified by nursing staff and may cause delay in treatment and care.

During a review of the facility's policy and procedure (P&P) titled, "Unit Based Performance Standards - DOU (direct observation unit [hospital unit providing close monitoring care to patients])," dated 2/2023, the P&P indicated, "Standard of care ... Standard II ... the patient has the right to expect assessment data to be consistent with the medical diagnoses and the plan of care ... standard of practice ... need based focused assessment may include: vital signs (measurements of the body's most basic function including body temperature, heart rate, blood pressure, respirations and pain level), review of systems, as indicated ... review of and follow through with physician orders."

During a review of the facility's policy and procedure (P&P) titled, "Nursing Staff Responsibilities," dated 2/2023, the P&P indicated, "Registered Nurses (RN) coordinate the provision of direct patient care ... it is the responsibility of each RN on duty to notify the appropriate physician of any significant changes in the patient's condition."

During a review of the facility's policy and procedure (P&P) titled, "Scope of Nursing Practice," dated 10/2021, the P&P indicated, "RN (Registered Nurse) Scope of Practice ... perform skills essential to the kind of nursing action to be taken ...effectively supervises nursing care being given by subordinates ..."

Based on interview and record review, the facility failed to ensure its nursing staff developed individualized nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) and reviewed nursing care plan to evaluate patient's progress for four of 30 sampled patients (Patients 8, 14, 23 and 27), in accordance with facility's policy and procedure regarding care plans when:

1. Patient 8 did not have a care plan developed and implemented to address a diagnosis of Diabetic Ketoacidosis (DKA, a serious complication of diabetes that can be life-threatening), upon admission on 2/5/2025.

This deficient practice had the potential for Patient 8's needs and risks to not be identified and may cause a delay in interventions which could result in complications such as diabetic coma (a life-threatening condition that occurs when blood sugar levels become dangerously high or low) and or death.

2. Patient 14 did not have a care plan developed and implemented to address Patient 14's diagnosis of Anemia (a condition marked by a deficiency of red blood cells or of hemoglobin in the blood, resulting in pallor and weariness), upon admission.

This deficient practice had the potential for Patient 14's needs and risks to not be identified and may cause a delay in interventions which could result in complications such as abnormal heart rhythm, dizziness, and/or death.

3. Nursing staff did not review and update Patient 23's care plan regarding risk for fall (when someone unintentionally ends up on the floor or another lower level), skin injury, infection, impaired gas exchange (when the body cannot get enough oxygen) and pain management, every shift on 7/12/2025 and 7/13/2025 for both day and night shift.

This deficient practice had the potential for Patient 23's needs and risks including response to treatment/interventions to remain unidentified and may cause a delay in the implementation of additional or alternative interventions thus resulting in worsening skin injury, etc.

4. Nursing staff did not develop care plan to address Patient 27's admitting diagnosis of ischemic stroke (occurs when a blood clot or other blockage prevents blood flow to the brain, causing brain cells to die), upon admission.

This deficient practice had the potential for Patient 27's needs and risks to not be identified and may cause a delay in interventions which could result in worsening of symptoms and prolonged hospitalization.

Findings:

1. During a review of Patient 8's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/5/2025 at 5:48 a.m., with Nurse Manager (NM1), the H&P indicated Patient 8 was admitted on 2/5/2025 due to diabetic ketoacidosis (DKA, a serious complication of diabetes that can be life-threatening), sepsis (a body's overwhelming and life-threatening response to infection), and right groin abscess (a pocket of pus formed in any part of the body).

During a concurrent interview and record review on 2/6/2025 at 1:50 p.m. with Nurse Manager (NM) 1, Patient 8's care plan (CP, provides a framework for evaluating and providing patient care needs related to the nursing process), dated 2/5/2025, was reviewed. The CP indicated, no Plan of Care was developed and kept for Patient 8's active hospital problem for DKA. The NM1 stated, nursing must develop a care plan for all actual or potential patient's needs, to plan patient care and interventions toward meeting those needs, but the primary nurse did not develop or implement a care plan.

During a record review of Patient's 8 blood glucose (BG) result, dated 2/05/2025 at 3:29 a.m., the blood glucose result indicated Patient 8's BG was 680 millimoles per deciliter (mmol/dL, a unit of measurement) (normal range is 70 - 100 mmol/dL).

During a review of facility's policy and procedure (P&P) titled, "Scope of Nursing Practice," dated 10/2021, the P&P indicated, "RN (Registered Nurse) Scope of Practice... formulates a nursing diagnosis through observation of the patient's physical condition, behavior, and through interpretation of information obtained from the patient and health team. Formulate a care plan in collaboration with the patient, which ensures that direct and indirect nursing care services provide the patient's safety, comfort, hygiene, and protection, and for disease prevention and restorative measures ... evaluates the effectiveness of the care plan through observation of the patient's physical condition and behavior, signs and symptoms of illness, reactions to treatment, through communication with patient and health team members, and modifies the plan as needed."

2. During a review of Patient 14's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/4/2025 at 8:08 p.m., with Nurse Manager (NM) 1, the H&P indicated Patient 14 was admitted on 2/4/2025 for respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), acute non ST elevation MI (NSTEMI, a type of heart attack where the electrocardiogram [ECG, a medical test that records the electrical activity of the heart] does not show the characteristic ST-segment elevation seen in a typical heart attack), anemia (a condition marked by a deficiency of red blood cells or of hemoglobin (a protein contained in red blood cells that is responsible for delivery of oxygen to the tissues, a sufficient hemoglobin level must be maintained to ensure adequate tissue oxygenation) in the blood, resulting in pallor [pale] and weariness) and hemoptysis (coughing up blood).

During a record review on 2/7/2025 at 10:35 a.m. with Nurse Manager (NM) 1, Patient 14's blood work result for hemoglobin, dated from 2/3/2025 to 2/7/2025, was reviewed. Patient 14's hemoglobin level range was from 7.8 to 8.9 grams per deciliter (g/dL, a unit of measurement). A normal hemoglobin level for a female is between 12.0 and 15.5 (g/dL).

During a concurrent interview and record review on 2/7/2025 at 10:40 a.m. with Nurse Manager (NM) 1, Patient 14's care plan), dated 2/6/2025, was reviewed. The CP indicated, no Plan of Care was developed and kept for Patient 14's active hospital problem for anemia. The NM 1 stated, nursing must develop a care plan for all actual or potential patient's needs to plan patient care and interventions toward meeting those needs, but the primary nurse did not develop a care plan for Anemia.

During a review of facility's policy and procedure (P&P) titled, "Scope of Nursing Practice," dated 10/2021, the P&P indicated, "RN (Registered Nurse) Scope of Practice... formulates a nursing diagnosis through observation of the patient's physical condition, behavior, and through interpretation of information obtained from the patient and health team. Formulate a care plan in collaboration with the patient, which ensures that direct and indirect nursing care services provide the patient's safety, comfort, hygiene, and protection, and for disease prevention and restorative measures ... evaluates the effectiveness of the care plan through observation of the patient's physical condition and behavior, signs and symptoms of illness, reactions to treatment, through communication with patient and health team members, and modifies the plan as needed."

3. During a review of Patient 23's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/6/2024, the H&P indicated, Patient 23 was admitted to the facility with diagnoses including but not limited to acute (new onset) hypoxemic (an abnormally low concentration of oxygen in the blood) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), acute heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs), cellulitis (an infection of the deeper layers of skin and the underlying tissue) and acute deep vein thrombosis (DVT - a blood clot that forms in a vein deep in the body).

During a review of Patient 23's "Care Plan (provides a framework for evaluating and providing patient care needs related to the nursing process)," dated from 7/6/2024 to 7/14/2024, the care plan indicated Patient 23 was at risk for fall (when someone unintentionally ends up on the floor or another lower level), skin injury, infection, impaired gas exchange (when the body cannot get enough oxygen) and pain management.

During a concurrent interview and record review on 2/6/2025 at 10:24 a.m. with the Assistant Department Administrator of Nursing Administration (ADA 1), Patient 23's "Care Planning Progress Note," dated from 7/8/2024 to 7/14/2024, was reviewed. The care planning progress note indicated, there was no documentation for care plan review and update on 7/12/2024 and 7/13/2024 by both day and night shift nursing staff. ADA 1 stated nursing staff should review care plan every shift.

During an interview on 2/6/2025 at 10:29 a.m. with the Department Administrator (DA 4) of Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill), DA 4 stated care plan was initiated upon admission and reviewed at least every shift by nursing staff. DA 4 stated it was to evaluate patient's progress towards the goals listed in the care plan. DA 4 said there would be potential delay for discharge if patient's progress was not evaluated.

During a review of facility's policy and procedure (P&P) titled, "Scope of Nursing Practice," dated 10/2021, the P&P indicated, "RN (Registered Nurse) Scope of Practice... formulates a nursing diagnosis through observation of the patient's physical condition, behavior, and through interpretation of information obtained from the patient and health team. Formulate a care plan in collaboration with the patient, which ensures that direct and indirect nursing care services provide the patient's safety, comfort, hygiene, and protection, and for disease prevention and restorative measures ... evaluates the effectiveness of the care plan through observation of the patient's physical condition and behavior, signs and symptoms of illness, reactions to treatment, through communication with patient and health team members, and modifies the plan as needed."

4. During a review of Patient 27's "History and Physical (H&P)," dated 2/1/2025, the H&P indicated, Patient 27 was admitted to the facility with diagnosis of acute (new onset) stroke (occurs when blood flow to the brain is interrupted, leading brain cell damage or death) due to ischemia (a condition where there is a reduced blood flow to an area of the body).

During an interview on 2/6/2025 at 10:21 a.m. with Assistant Department Administrator of Nursing Administration (ADA) 1, , ADA 1 stated the following: nursing staff should initiate care plan upon admission and review every shift. Nursing staff should develop care plan based on patient's diagnosis and need. Care plan should be individualized to address patient's problems with nursing intervention. The purpose of care plan was to make sure patient's need were met, to educate patient and promote healing.

During a concurrent interview and record review on 2/7/2025 at 10:41 a.m. with the Stroke Coordinator Nurse (SCN), Patient 27's care plan dated from 2/1/2025 to 2/6/2025, was reviewed. The care plan indicated, Patient 27 was at risk for fall, at risk for injury, blood pressure management and pain management. SCN stated the following: there was no care plan developed to address Patient 27's diagnosis of ischemic stroke. The care plan should address ischemic stroke and have interventions including education on patient/family on medical management, when to call 911, referral to physical therapy (therapy to enhance or restore movement and physical function) and occupational therapy (assists in improving the patient's ability to perform activities of daily living. Example: hygiene), direct nursing staff what signs and symptoms to monitor. Without the proper care plan, nursing staff could miss the proper interventions and miss the education opportunity.

During a review of the facility's policy and procedure (P&P) titled, "Scope of Nursing Practice," dated 10/2021, the P&P indicated, "RN (Registered Nurse) Scope of Practice... formulates a nursing diagnosis through observation of the patient's physical condition, behavior, and through interpretation of information obtained from the patient and health team. Formulate a care plan in collaboration with the patient, which ensures that direct and indirect nursing care services provide the patient's safety, comfort, hygiene, and protection, and for disease prevention and restorative measures ... evaluates the effectiveness of the care plan through observation of the patient's physical condition and behavior, signs and symptoms of illness, reactions to treatment, through communication with patient and health team members, and modifies the plan as needed."

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

1. Ensure nursing staff re-assessed and documented vital signs (VS, measurements of the body's basic functions, such as temperature, pulse, respiration rate, and blood pressure that provide critical information about the body's overall condition) every eight hours as per Medical-surgical unit (a hospital unit that provides care for adult patients recovering from surgery, acute illnesses, or other medical conditions) protocol for one of 30 sampled patients (Patient ?), in accordance with the facility's policy and procedure regarding Vital Signs (VS, objective measurements of essential bodily functions, including temperature, heart rate, respiratory rate, and blood pressure, used to monitor a patient's health status) and General Standards of Care.

This deficient practice had the potential for the staff's inability to determine a change in Patient 1's condition which may result in a delay in the implementation of necessary interventions.

2. Ensure nursing staff obtained and recorded the daily weight for two of 30 sampled patients (Patient 2 and Patient 7), in accordance with the facility's Medical-Surgical (M/S floor, a hospital unit that provides care for patients with a wide range of medical conditions and post-surgical recovery needs)) unit protocol and physician's order.

This deficient practice had the potential for Patient 2 and Patient 7's needs not being met, including inadequate assessment of fluid balance (the regulation of the amount of water in the body), undetected weight fluctuations indicative of worsening conditions and potential delays in adjusting medical treatment plans.

3. Ensure nursing staff obtained and recorded Orthostatic Blood Pressure ( Ortho BP, a series of blood pressure measurements taken in different positions such as lying down, sitting, and standing, to assess for orthostatic hypotension, a condition where blood pressure drops significantly upon standing, leading to dizziness or fainting) every shift for one of 30 sampled Patients (Patient 7) in accordance with the physician's order and the facility's policy and procedure regarding Vital Signs.

This deficient practice had the potential for Patient 7's worsening symptoms, such as dizziness, fainting, and or risk for falls (when someone unintentionally ends up on the ground or a lower level) to go unnoticed, resulting in negative health outcomes such as fracture (break in the bones) resulting from falls because of fainting, abnormal heart rhythm, etc.

4. Ensure that four of four sampled open glucose (sugar in the blood) control solution bottles (a liquid used to test the accuracy of blood glucose meters), were labeled with the dates they were opened including the discard dates for each of the four glucose control solutions used for glucometers to test the blood glucose of 32 of 32 sampled patients in the 4 east medical surgical unit (a 32 bed unit that manages acute medical surgical patients with a wide range of diagnoses and care needs), in accordance with the facility's policy and procedure regarding glucose testing.

This deficient practice had the potential to result in inaccurate blood glucose meter (a portable machine that's used to measure glucose in the blood) readings, which could negatively affect the treatment provided to patients thus potentially causing excessively low or excessively high blood sugar levels.

5. Ensure Nursing staff performed COVID (COVID-19, coronavirus disease, an infectious disease caused by the SAR-CoV-2 virus which causes fever, cough, and breathing difficulties) screening upon admission for three of 30 sampled patients (Patients 23, 25 and 26), in accordance with the facility's protocol regarding COVID-19 screening (a method for healthcare workers to find out if someone has COVID-19 or not).

This deficient practice had the potential for Patients 23, 25 and 26 to spread the infection to other patients, staff or visitors.

6. Ensure Nursing staff reported one of 30 sampled patient's (Patient 26) critical test result (laboratory or imaging test results that require immediate medical attention) of white blood cell count (WBC, a type of blood cell that play a crucial role in body's immune system, elevation in the count usually indicates an infection) reported to the physician within the required timeframe of 30 minutes, in accordance with the facility's policy regarding Critical Tests and Values Reporting.

This deficient practice had the potential to put Patient 26 at risk for severe infection and sepsis (a body's overwhelming and life-threatening response to infection) due to delay in treatment and care.

Findings:

1. During a review of Patient 1's History and Physical (H&P, a formal documented completed by the provider upon admission, detailing patient's current medical condition and treatment plan), dated 10/15/2023, the H&P indicated that Patient 1 was admitted to the facility on 10/15/2023 with a medical diagnosis of Covid-19 pneumonia (a severe respiratory infection caused by the COVID-19 virus, leading to inflammation and fluid accumulation in the lungs, which can cause breathing difficulties and reduced oxygen levels in the blood).

During further review of Patient 1's History and Physical (H&P), dated 10/15/2023, the H&P indicated that Patient 1 had past medical history (PMH, a record of a patient's health before the current problem) of metastatic lung cancer (a stage of lung cancer [CA], in which the disease has spread beyond the lungs to other parts of the body), malignant pleural effusion (a condition where CA cells cause fluid accumulation in the area between the lungs and the chest wall, leading to difficulty breathing), PleurX catheter placement (a small tube surgically inserted into the pleural space to remove excess fluid and relieve symptoms of difficulty breathing), and atrial fibrillation (Afib, irregular and often rapid heartbeat).

During a review of Patient 1's medical record (MR) titled, "Orders," dated 2/16/2025, the MR indicated that on 2/16/2025, the physician (MD 4) placed an order for "Measure Vital Signs (VS, objective measurements of essential bodily functions, including temperature, heart rate, respiratory rate, and blood pressure, used to monitor a patient's health status)," per unit policy (every 8 hours).

During a review of Patient 1's medical record (MR) titled, "Vital Signs (VS) Flowsheet Data," dated 10/16/2023, the MR indicated the following VS measurements were obtained and recorded on 10/16/2023 from 7:00 a.m. to 6:00 p.m.:

-At 7:48 a.m.:-Temperature (T) was 96.7 Fahrenheit (F, measuring unit of the body's internal heat).
-Pulse was 71 beats per minute (bpm, the number of heart beats per minute).
-Blood Pressure (BP, the force of blood against the artery walls; BP is measured in millimeters of mercury [mmHG]) was 143/78 mmHG [normal BP is generally considered to be around 120/80 mmHG.
-Respirations were 20 breaths per minute (the number of breaths taken per minute; normal respiratory rate typically ranges from 12-20 breaths per minute).

During a review of Patient 1's medical record (MR), the MR further indicated that no additional vital signs measurements were recorded in Patient 1's medical record on 10/16/2023 from 7:48 a.m. to 6:00 p.m.

During an interview on 2/5/2025 at 1:39 p.m. with the Chief Nurse Executive (CNE), the CNE stated that typically on a medical-surgical floor (M/S floor, a hospital unit that provides care for patients with a wide range of medical conditions and post-surgical recovery needs), vital signs should be obtained and recorded every eight hours.

During an interview on 2/5/2025 at 3:10 p.m. with Registered Nurse (RN 1, the nurse who took care of Patient 1 on 10/16/2023, day shift), RN 1 stated the following: "I received the patient (Patient 1) midday as I floated into the unit, and there was another nurse taking care of the patient (Patient 1) in the morning [on 10/16/20]. I remember this patient (Patient 1) had a Covid-19 diagnosis, metastatic lung cancer (CA), and passed away that day (10/16/2023). The CNA (Certified Nursing Assistant) on the floor was responsible to take the vital signs in the afternoon and I remember there were VS taken in the morning. Maybe the CNA forgot to document the VS in the evening."

During further interview on 2/5/2025 at 3:10 p.m. with Registered Nurse (RN 1), the RN 1 stated: "I was there when the patient (Patient 1) passed away. I went to check on them (patient 1) during my rounding, I don't remember the specific time but remember checking my patient (Patient 1) and they (Patient 1) just happened to pass away around the same time."

During a review of Patient 1's medical record (MR) titled, "Notes," dated 10/16/2023, the MR indicated that Patient 1 expired (died) on 10/16/2023 at 5:13 p.m.

During a review of the facility's policy and procedure (P&P) titled, "Vital Signs-Including Orthostatic Blood Pressure (Ortho BP, a series of blood pressure measurements taken in different positions such as lying down, sitting, and standing, to assess for orthostatic hypotension, a condition where blood pressure drops significantly upon standing, leading to dizziness or fainting)," dated 10/2024, the P&P indicated that 5.1. Frequency of Vital Signs will be taken every 8 hours or as specified.

During a review of the facility's policy and procedure (P&P) titled, "General Standards of Care-Med-Surg," dated 9/2023, the P&P indicated that" Frequency of necessary assessments, monitoring and vital signs may be done by a physician order, protocol, or as indicated by the patient's condition.

During a review of the facility's policy and procedure (P&P) titled, "Nursing Staff Responsibilities-Medical/Surgical Unit," dated 12/2023, the P&P indicated that 1.4. The registered nurse coordinates the provision of direct patient care plans, provides, evaluates nursing care, directs and monitors activities of staff who are delivering patient care; supervises all nursing activities directly and indirectly related to patient care in a safe, effective and efficient manner.

During a review of the facility's policy and procedure (P&P) titled, "Admission and Discharge-Transfer Practices-Med-Surg Units," dated 10/2022, the P&P indicated that 1.2. Patients will receive care based on a documented assessment of their needs and patient care standards ...1.5. The RN will be responsible for a full system assessment on the patient every 8 hours. Subsequent assessment performed may be focused assessment related to the patient's diagnosis and documented abnormal findings. Data gathered and documented by other nursing staff (CNA) will be reviewed by the RN and signature provided.

2.a. During a review of Patient 2's History and Physical (H&P, a formal documented completed by the provider upon admission, detailing patient's current medical condition and treatment plan), dated 2/3/2025, the H&P indicated that Patient 2 was admitted to the facility on 2/3/2025 with a diagnosis of sepsis (a life-threatening complication of an infection), pleural effusion (an abnormal accumulation of fluid in the pleural space, the thin membrane that separates the lungs from the chest wall) and had past medical history (PMH, records of information about the patient's medical, personal and family history) of cirrhosis (permanent scarring that damages the liver and interferes with its functioning).

During further review of Patient 2's History and Physical (H&P), dated 2/3/2025, the H&P indicated that Patient 2 required monitoring for fluid retention in the body (a condition where the body retains excess fluid, leading to swelling and puffiness in various areas of the body).

During a review of Patient 2's medical record (MR) titled, "Orders," dated 2/3/2025, the MR indicated that Patient 2 had an order for "Measure Weight" daily, placed by the physician on 2/3/2025 at 2:00 a.m.

During further review of Patient 2's medical record (MR) titled, "Flowsheet History-Weight," dated 2/3/2025 through 2/6/2025, the MR indicated the following:
-On 2/3/2025, Patient 2's weight was 96.6 kilograms (kg, measuring unit)
-On 2/5/2025, Patient 2's weight was 87 kg
-On 2/6/2025, Patient 2's weight was 86.6 kg
-The MR indicated that Patient 2's weight was not obtained on 2/4/2025 in accordance with the physician's order to measure daily weight.

During an interview on 2/6/2025 at 11:03 a.m. with the Assistant Manager Nurse (AMN 1), the AMN 1 stated the following: "typically, for an order to measure weight daily, nurses should try to obtain the daily weight early in the morning before breakfast." The AMN 1 then stated that if night shift nurses do not obtain the weight during their shift, the day shift nurses should follow up and capture it. The AMN 1 also stated that nurses were expected to follow physician's orders in accordance with the standards of care.

During a review of the facility's policy and procedure (P&P) titled, "General Standards of Care-Medical/Surgical," dated 9/2024, the P&P indicated the following: 1.4. Daily weights are done on physician's order or routinely for patients on diuretic (medications that help the body get rid of excess fluid and salt) therapy and dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so).

2.b. During a review of Patient 7's History and Physical (H&P, a formal documented completed by the provider upon admission, detailing patient's current medical condition and treatment plan), dated 7/27/2024, the H&P indicated that Patient 7 was admitted to the facility on 7/27/2024 with a diagnosis of near fainting. The H&P also indicated that Patient 7 had past medical history (PMH, records of information about the patient's medical, personal and family history) of hypertension (a condition in which the force of blood against the walls of the arteries is consistently too high) and atrial fibrillation (AFib, quivering or irregular heartbeat).

During a review of Patient 7's medical record (MR) titled, "Orders," dated 7/27/2024, the MR indicated that Patient 7 had an order for "Measure Weight" daily, placed by the physician on 7/27/2024 at 1:31 a.m. The MR also indicated that the order was discontinued on 7/29/2024 at 6:18 p.m. after Patient 7 was discharged from the facility.

During further review of Patient 7's medical record (MR) titled, "Flowsheet History-Weight," dated 7/27/2024 through 7/29/2024, the MR indicated that Patient 7's weight was only documented on 7/27/2024 but not obtained and recorded on 7/28/2024 and 7/29/2024 in accordance with the physician's order to measure daily weight.

During an interview on 2/6/2025 at 11:03 a.m. with the Assistant Manager Nurse (AMN 1), the AMN 1 stated the following: "typically, for an order to measure weight daily, nurses should try to obtain the daily weight early in the morning before breakfast." The AMN 1 then stated that if night shift nurses do not obtain the weight during their shift, the day shift nurses should follow up and capture it. The AMN 1 also stated that nurses were expected to follow physician's orders in accordance with the facility's nursing standards of care.

During a review of the facility's policy and procedure (P&P) titled, "General Standards of Care-Medical/Surgical," dated 9/2024, the P&P indicated the following: 1.4. Daily weights are done on physician's order or routinely for patients on diuretic (medications that help the body get rid of excess fluid and salt) therapy and dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so).

3. During a review of Patient 7's History and Physical (H&P, a formal documented completed by the provider upon admission, detailing patient's current medical condition and treatment plan), dated 7/27/2024, the H&P indicated that Patient 7 was admitted to the facility on 7/27/2024 with a diagnosis of near fainting. The H&P also indicated that Patient 7 had past medical history (PMH, records of information about the patient's medical, personal and family history) of hypertension (a condition in which the force of blood against the walls of the arteries is consistently too high) and atrial fibrillation (AFib, quivering or irregular heartbeat).

During a review of Patient 7's medical record (MR) titled, "Orders," dated 7/27/2024, the MR indicated that Patient 7 had an order for "Measure Orthostatic Blood Pressure - Including Orthostatic Blood Pressure (Ortho BP, a series of blood pressure measurements taken in different positions such as lying down, sitting, and standing, to assess for orthostatic hypotension, a condition where blood pressure drops significantly upon standing, leading to dizziness or fainting)," every shift, placed on 7/27/2024 by the admitting physician.

During a concurrent interview and record review on 2/7/2025 at 9:51 a.m. with the Assistant Manager Nurse (AMN 1), Patient 7's medical record (MR) titled, "Flowsheet-Orthostatic Blood Pressure," dated 7/27/2024 through 7/29/2024, was reviewed. The MR contained no record of obtained and documented orthostatic blood pressure measurements daily throughout Patient 7's stay at the facility (7/27/2024 through 7/29/2024). The AMN 1 stated that nurses did not obtain and document Patient 7's orthostatic blood pressure as was ordered by the physician. AMN 1 further stated that nurses were expected to follow physician orders in accordance with the facility's standards of nursing care.

During a review of the facility's policy and procedure (P&P) titled, "Vital Signs-Including Orthostatic Blood Pressure ( Ortho BP, a series of blood pressure measurements taken in different positions such as lying down, sitting, and standing, to assess for orthostatic hypotension, a condition where blood pressure drops significantly upon standing, leading to dizziness or fainting)," dated 10/2024, the P&P indicated that: 3.2. Orthostatic BP is defined as a drop in systolic or diastolic BP of greater than 20 mmHG or greater than 10 mmHG, respectively (refers to a significant drop in blood pressure, specifically a decrease of at least 20 mmHg [millimeters of mercury, measuring unit] in systolic blood pressure (the pressure when the heart contracts) or 10 mmHg in diastolic blood pressure (the pressure when the heart relaxes) that occurs within a few minutes of standing up from a sitting or lying position; essentially, it's a measurement of how the blood pressure changes when a person stands up, and a drop exceeding these values is considered "orthostatic hypotension). 5.1. Frequency of Vital Signs will be taken every 8 hours or as specified. 8.1. Document the results in Vital Signs Flowsheet.

4. During a concurrent observation and interview on 02/04/2025 at 3:11 p.m., with the Charge nurse (CN 4), it was observed that four of four open glucose (sugar) control solution bottles (a liquid used to test the accuracy of blood glucose meters) in the 4 east nurses' station had no written expiration date on each of the four bottles. The Charge nurse (CN 4) confirmed that four of 4 open glucose control solution had no written expiration date on the bottle.

During the same interview on 2/4/2025 at 3:11 p.m. with the Charge Nurse (CN 4), CN 4 stated that the policy was for nurses to label the glucose control solution bottles with the new expiration date once opened. CN 4 further saif that the new expiration date was 3 months after opening the glucose control solution bottle. It was the responsibility of the staff nurse to write the new expiration date on the bottle. CN 4 also said the solution expires 90 days after opening, and it needs to be tracked by nursing staff to ensure accurate results when testing a blood glucose meter.

During a review of the facility's policy and procedure (P&P) titled, "Glucose Testing Using ACCU-CHEK® Inform II Meter," with revised date of 06/07/2023, the P&P indicated the following:

ACCU-CHEK Inform II Controls: Controls and linearity expire on the date printed on the vial label, or 3 months after opening, whichever comes first. Label the controls with the new expiration date upon opening.

5.a. During a review of Patient 23's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/6/2024, the H&P indicated, Patient 23 was admitted to the facility with diagnoses including but not limited to acute (new onset) hypoxemic (an abnormally low concentration of oxygen in the blood) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), acute heart failure (a chronic [long term] condition in which the heart does not provide adequate blood flow to meet the body's needs), cellulitis (an infection of the deeper layers of skin and the underlying tissue) and acute deep vein thrombosis (DVT - a blood clot that forms in a vein deep in the body).

During an interview on 2/4/2025 at 1:41 p.m. with Charge Nurse (CN) 1, CN 1 stated nursing staff would do COVID-19 (COVID-19, coronavirus disease, an infectious disease caused by the SAR-CoV-2 virus which causes fever, cough, and breathing difficulties) screening to ask a patient if he or she had any COVID symptoms and exposure upon admission.

During a concurrent interview and record review on 2/6/2025 at 9:47 a.m. with the Quality Coordinator (QC 2), Patient 23's "T COVID-19 screening," dated 7/6/2024, was reviewed. The "COVID-19 screening" indicated, "COVID-19 screening: does the patient have any recent symptoms or exposure to COVID-19?" answer was blank. QC 2 state the COVID-19 screening questionnaire was not done.

During an interview on 2/7/2025 at 2:08 p.m. with the Senior Director of Infection Prevention (ICP 1), ICP 1 stated the following: the facility performed COVID-19 screening by passive screening and secondary screening. Passive screening was done by posting COVID-19 poster signage to prompt patients to notify nurses if they experienced any symptoms. Secondary screening was performed upon admission when nursing staff complete the questionnaire "if patient had any recent symptoms or exposure of COVID-19" with patients. If the answer was yes, it would trigger more in depth assessment and possible COVID-19 testing.

During a review of the facility's regional infection prevention and control "COVID-19 Admission Testing Transitional Guidance (COVID-19 screening protocol)," dated 4/2023, the COVID-19 screening protocol indicated, "1. Routine admission testing is not required when all the following are met: patient is asymptomatic AND patient has no known exposure to someone positive for COVID-19 in the prior 10 days ... 2. Upon admission, all patients will be screened for COVID-19 diagnosis in the prior 10 days, signs and symptoms of COVID-19 or known exposure to a person positive for COVID-19 in the prior 10 days."

5.b. During a review of Patient 25's History and Physical (H&P), dated 2/3/2025, the H&P indicated, Patient 25 was admitted to the facility with diagnoses of urinary tract infection (UTI, an infection in any part of the urinary system), urinary retention (inability to completely empty the bladder) and pneumonia (lung infection).

During a concurrent interview and record review on 2/6/2025 at 2:31 p.m. with the Department Administrator (DA 4) of Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill), Patient 25's "COVID-19 screening," dated 1/31/2025, was reviewed. The "COVID-19 screening" indicated, "COVID-19 screening was last completed on 1/31/2025. DA 4 stated it (referring to the COVID-19 screening) was done prior to admission. DA 4 stated nursing staff did not complete COVID-19 screening for Patient 25 on this admission (admit date: 2/3/2025).

During an interview on 2/7/2025 at 2:08 p.m. with the Senior Director of Infection Prevention (ICP 1), ICP 1 stated the following: the facility performed COVID-19 screening by passive screening and secondary screening. Passive screening was done by posting COVID-19 poster signage to prompt patients to notify nurses if they experienced any symptoms. Secondary screening was performed upon admission when nursing staff complete the questionnaire "if patient had any recent symptoms or exposure of COVID-19" with patients. If the answer was yes, it would trigger more in depth assessment and possible COVID-19 testing.

During a review of the facility's regional infection prevention and control "COVID-19 Admission Testing Transitional Guidance (COVID-19 screening protocol)," dated 4/2023, the COVID-19 screening protocol indicated, "1. Routine admission testing is not required when all the following are met: patient is asymptomatic AND patient has no known exposure to someone positive for COVID-19 in the prior 10 days ... 2. Upon admission, all patients will be screened for COVID-19 diagnosis in the prior 10 days, signs and symptoms of COVID-19 or known exposure to a person positive for COVID-19 in the prior 10 days."

5.c. During a review of Patient 26's History and Physical (H&P), dated 1/20/2025, the H&P indicated, Patient 26 was admitted to the facility with diagnosis of colitis (an inflammation of the large intestine) likely clostridium difficile colitis (C Diff - inflammation of the colon caused by the bacteria Clostridium difficile causing serious bowel problems including diarrhea).

During a concurrent interview and record review on 2/6/2025 at 3:01 p.m. with the Department Administrator (DA 4) of Intensive Care Unit, Patient 26's "COVID-19 screening," dated 1/20/2025, was reviewed. The "COVID-19 screening" indicated, "COVID 19 screening: does the patient have any recent symptoms or exposure to COVID-19?" answer was blank. DA 4 stated the COVID-19 screening was not done.

During an interview on 2/7/2025 at 2:08 p.m. with the Senior Director of Infection Prevention (ICP 1), ICP 1 stated the following: the facility performed COVID-19 screening by passive screening and secondary screening. Passive screening was done by posting COVID-19 poster signage to prompt patients to notify nurses if they experienced any symptoms. Secondary screening was performed upon admission when nursing staff complete the questionnaire "if patient had any recent symptoms or exposure of COVID-19" with patients. If the answer was yes, it would trigger more in depth assessment and possible COVID-19 testing.

During a review of the facility's regional infection prevention and control "COVID-19 Admission Testing Transitional Guidance (COVID-19 screening protocol)," dated 4/2023, the COVID-19 screening protocol indicated, "1. Routine admission testing is not required when all the following are met: patient is asymptomatic AND patient has no known exposure to someone positive for COVID-19 in the prior 10 days ... 2. Upon admission, all patients will be screened for COVID-19 diagnosis in the prior 10 days, signs and symptoms of COVID-19 or known exposure to a person positive for COVID-19 in the prior 10 days."

6. During a review of Patient 26's History and Physical (H&P), dated 1/20/2025, the H&P indicated, Patient 26 was admitted to the facility with diagnosis of colitis (an inflammation of the large intestine) likely clostridium difficile colitis (C Diff - inflammation of the colon caused by the bacteria Clostridium difficile causing serious bowel problems including diarrhea).

During a concurrent interview and record review on 2/6/2025 at 3:40 p.m. with the Assistant Department Administrator of Nursing Administration (ADA 1), Patient 26's laboratory work of complete cell count (CBC, a routine blood test that provides information about the various cells in the blood), dated 1/23/2025, was reviewed. The CBC result indicated:

-On 1/23/2025 at 6:35 a.m. white blood cell count (WBC, a type of blood cell that play a crucial role in body's immune system, elevation in the count usually indicates an infection) was 40.3 (normal range was 4 - 11). Critical result called to Registered Nurse (RN 4) at 8:26 a.m. by laboratory staff
-On 1/23/2025 at 10:06 a.m. white blood cell count was 43.5. Critical result called to RN 4 at 10:39 a.m. by laboratory staff

During the same interview on 2/6/2025 at 3:40 p.m. with the Assistant Department Administrator of Nursing Administration (ADA 1), ADA 1 stated the following: the nurse who received critical result must be reported to the physician within thirty (30) minutes. Nurse was required to document the communication with the physician regarding critical results in the critical value flowchart. RN 4 did not call or document that the critical results were reported to any physicians. It was important to report the critical result of WBC to the physician because elevated WBC could indicate sepsis. Delay in reporting might cause delay of treatment and patient could die.

During a review of the facility's policy and procedure (P&P) titled, "Critical Tests and Values Reporting," dated 4/2023, the P&P indicated, "to promote timely and reliable communication of critical test results to the physician/ practitioner/ authorized agent who can take action ...for inpatient nursing units: inpatient critical values will be reported to the nurse responsible for the care of the patient. NOTE: if the result receiving person is not the patient's primary nurse, then this person must report to the primary nurse immediately for the latter person to take actions for informing the physician within 30 minutes the critical value was reported. The nurse receiving the critical test value results will perform the following ... as soon as this information is communicated between licensed personnel and clinical laboratory scientist (CLS), the person receiving the result will ensure that this information has been transmitted to the physician responsible for the care of the patient (rounding team doctor/ medical on duty [MOD]) within 30 minutes. Document the notified physician's last name and first initial ... document the time the physician was notified about the critical value ..."

Based on interview and record review, the facility failed to ensure its nursing staff administered ordered medications, in a timely manner, for two of 30 sampled patients (Patients 23 and 29), in accordance with the facility's policy and procedure regarding medication administration when:

1. Nursing staff did not adjust Patient 23's heparin (an anticoagulant [blood thinner] to prevent blood clots or keep an existing clot from getting worse) drip infusing rate until 3.5 hours later from time of order.

This deficient practice had the potential to leave Patient 23's blood clot untreated and put Patient 23 at risk for developing new blood clot, which can result in complications such as Pulmonary embolism (a blood clot that blocks an artery in the lung).

2. Nursing staff did not administer hydralazine (medication to treat high blood pressure) as ordered for Patient 29's elevated (high) blood pressure. This deficient practice had the potential to leave Patient 29's elevated blood pressure untreated and lead to other complications such as stroke (occurs when a blood clot or other blockage prevents blood flow to the brain, causing brain cells to die).

Findings:

1. During a review of Patient 23's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/6/2024, the H&P indicated, Patient 23 was admitted to the facility with diagnoses including but not limited to acute (new onset) hypoxemic (an abnormally low concentration of oxygen in the blood) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), acute heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs), cellulitis (an infection of the deeper layers of skin and the underlying tissue) and acute deep vein thrombosis (DVT - a blood clot that forms in a vein deep in the body).

During an interview on 2/6/2025 at 10:49 a.m. with the Department Administrator (DA 4) of Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill), DA 4 stated Patient 23 was on heparin (an anticoagulant [blood thinner] to prevent blood clots or keep an existing clot from getting worse) drip protocol with heparin infusion running at a rate of 1500 units per hour (units/hr, unit of measure) for his (Patient 23) DVT. The heparin drip protocol was started on 7/7/2024 at 1:27 a.m.

During an interview on 2/6/2025 at 11:16 a.m. with the Assistant Department Administrator of Nursing Administration (ADA 1), ADA 1 stated the pharmacist would be the one adjusting the heparin dosage based on lab (laboratory) results when a patient was on heparin drip protocol.

During a review of Patient's 23's "Pharmacy Heparin Follow-Up Progress Notes," dated 7/7/2024, the "Pharmacy Heparin Follow-Up Progress Notes" indicated, "anticoagulation (blood thinner) indication: DVT ... heparin therapeutic goal: anti-factor Xa (a blood test that measures the activity of anticoagulants) level goal 0.3 - 0.7 international units per milliliter (IU/ml, a unit of measure) ... antifactory Xa (7/72024: less than 0.10 IU/ml) below desired range. Do not give bolus (a single, large dose of medicine) and increase rate to 1850 units/hr."

During a review of Patient 23's physician order, dated 7/7/2024 at 8:32 a.m., the physician order indicated, Heparin ordered dose change to 1850 units/hr.

During a concurrent interview and record review on 2/6/2025 at 12:01 p.m. with the Clinical Pharmacist (PHARM 1), Patient 23's Medication Administration Record (MAR), dated 7/7/2024, was reviewed. The MAR indicated Heparin rate was changed to 1850 units per hour (infusing rate per hour) at 12:06 p.m. PHARM 1 stated the following: there was a delay in changing the rate of Patient 23's heparin drip from time of order (order was placed at 8:32 a.m. hence 3.5 hours from the order). Nursing staff should change the heparin infusion rate within thirty minutes to an hour once ordered. Heparin was a high alert medication (a drug that has a high risk of causing harm if used incorrectly), and it (referring to adjusting the dose based on the order) should be a priority. The delay of rate change could cause Patient 23's clot to be untreated and Patient 23 may develop new clot.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration Policies," the P&P indicated, "Six rights of medication administration will be followed for all medications. Right patient, right drug, right dose, right date/time, right route, and right person. Nurse and physician/prescriber should review all orders immediately after entering into [facility's electronic medical record system]"

2. During a review of Patient 29's "History and Physical (H&P)," dated 7/4/2024, the H&P indicated, Patient 29 was admitted to the facility with diagnoses including but not limited to acute (new onset) nontraumatic subdural (the space between the skull and surface of the brain) hemorrhage (bleeding), nontraumatic cerebral (brain) edema (swelling) and diabetes (high blood sugar).

During a review of Patient 29's physician order, dated 7/4/2024, the physician order indicated, "hydralazine 10 milligrams (mg, a unit of measure) intravenously (into the vein) every 3 hours as needed for systolic blood pressure (SBP, the top number of blood pressure reading) above 140 millimetre of mercury (mmHg, a unit of measure).

During a concurrent interview and record on 2/7/2025 at 11:08 a.m. with the Department Administrator (DA 4) of Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill), Patient 29's vital signs flowchart, dated 7/6/2024, was reviewed. The vital signs flowchart indicated, Patient 29's blood pressure at 6 p.m. was 159/73 mmHg. DA 4 stated no hydralazine was given to Patient 29 on 7/6/2024. DA 4 stated the nurse should have given the hydralazine as ordered for blood pressure control.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration Policies," the P&P indicated, "Six rights of medication administration will be followed for all medications. Right patient, right drug, right dose, right date/time, right route, and right person. Nurse and physician/prescriber should review all orders immediately after entering into [facility's electronic medical record system]"

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

1. The facility failed to ensure for one of 30 sampled patients (Patients 8), Patient 8's written consent form for procedure, was completed (informed consent form filled out and with Patient 8's signature), prior to procedure (incision and drainage [I&D, a surgical procedure used to treat abscesses]), in accordance with the facility's policy and procedures regarding informed consent (a process in which a healthcare professional educates a patient about the risks, benefits, and alternatives of a given procedure or intervention).

This deficient practice had the potential for Patient 8 to not be adequately informed and for patient 8 to indicate understanding of the risks and benefits involved in a proposed treatment/procedure including the opportunity to ask questions. (Refer to A-0466)

2. The facility failed to ensure that the medical records for five (5) of 30 sampled patients (Patient 1, Patient 2, Patient 7, Patient 27 and Patient 29) contained the pertinent medical information documented and filed in the patients' medical charts so that the health care staff involved in the patients' care could access and retrieve the information in order to monitor the patients' condition when:

2.a. Patient 1 had no record of continuous pulse oximetry (a non-invasive monitoring technique that continuously measures a patient's oxygen saturation [SpO2, a measure of how well the body is delivering oxygen to the tissues and pulse rate, alerting healthcare providers to potential hypoxia- a condition in which there is an inadequate supply of oxygen to the body's tissues] or respiratory distress [a condition where breathing becomes difficult or labored]), documented to be measured continuously while admitted on the inpatient medical-surgical floor (M/S, a hospital's unit where patients are admitted for ongoing medical care, monitoring, and treatment under the supervision of healthcare providers), in accordance with a written physician order regarding continuous pulse oximetry monitoring.

This deficient practice had the potential to result in Patient 1's needs not being met and increase the risk of undetected hypoxia, delayed medical intervention, respiratory deterioration, and adverse patient outcomes (a harmful and negative result), including life-threatening potential complications such as death. (Refer to A-0467)

2.b. Patient 1 had no vital signs (VS, measurements of the body's basic functions, such as temperature, pulse, respiration rate, and blood pressure that provide critical information about the body's overall condition) documented every eight hours as per Medical-Surgical unit protocol and in accordance with the facility's policy and procedure regarding Vital Signs (VS, objective measurements of essential bodily functions, including temperature, heart rate, respiratory rate, and blood pressure, used to monitor a patient's health status) and General Standards of Care.

This deficient practice had the potential for the staff's inability to determine a change in Patient 1's condition, which may result in a delay in the implementation of necessary interventions. (Refer to A-0467)

2.c. Patient 1 had no code status (refers to a patient's preferences regarding medical interventions in case of a cardiac arrest or life-threatening situations, specifically the type of resuscitation effects that should be undertaken) order, placed by the physician upon admission.

This deficient practice had the potential to compromise Patient 1's care, leading to emotional and psychological distress for Patient 1 and Patient 1's family if resuscitation was attempted against the patient's (Patient 1) wishes. (Refer to A-0467)

2.d. Patient 2 and Patient 7 had no recorded daily weight, in accordance with the facility's Medical-Surgical (M/S) unit protocol and the physician's order.

This deficient practice had the potential for Patient 2 and Patient 7's needs not being met, including inadequate assessment of fluid balance (the regulation of the amount of water in the body), undetected weight fluctuations indicative of worsening conditions and potential delays in adjusting medical treatment plans. (Refer to A-0467)

2.e. Patient 7 had no recorded Orthostatic Blood Pressure (Ortho BP, a series of blood pressure measurements taken in different positions such as lying down, sitting, and standing, to assess for orthostatic hypotension, a condition where blood pressure drops significantly upon standing, leading to dizziness or fainting) every shift, in accordance with the physician's order and the facility's policy and procedure regarding Vital Signs.

This deficient practice had the potential for Patient 7's worsening symptoms, such as dizziness, fainting, and or risk for falls (when someone unintentionally ends up on the ground or a lower level) to go unnoticed, resulting in negative health outcomes such as fracture (break in the bones) resulting from falls because of fainting, abnormal heart rhythm, etc. (Refer to A-0467)

2.f. Patient 27 and 29 had no recorded neurological assessment (nursing assessment including a patient's mental status, extremities movement and strength, bilateral (both) hand grips (force exerted by the hand when squeezing an object), pupils' (black center of the eye) sizes and reactivity (the ability of the pupil of the eye to constrict [smaller than normal] or dilate [larger than normal]), and face symmetry) in their (Patient 27 and Patient 29) medical records, performed and documented by a Registered Nurse [(RN]), as per physician order.

This deficient practice had the potential to result in a delay in identifying a change of condition and neurological status change including possible stroke (occurs when blood flow to the brain is interrupted, leading brain cell damage or death) progression, which can lead to delay in treatment and care, thus resulting in patient harm and/or death. (Refer to A-0467)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment.

Based on interview and record review, the facility failed to ensure for one of 30 sampled patients (Patients 8), Patient 8's written consent form for procedure, was completed (informed consent form filled out and with Patient 8's signature), prior to procedure (incision and drainage [I&D, a surgical procedure used to treat abscesses]), in accordance with the facility's policy and procedures regarding informed consent (a process in which a healthcare professional educates a patient about the risks, benefits, and alternatives of a given procedure or intervention).

This deficient practice had the potential for Patient 8 to not be adequately informed and for Patient 8 to indicate understanding of the risks and benefits involved in a proposed treatment/procedure including the opportunity to ask questions.

Findings:

During a review of Patient 8's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/5/2025 at 5:48 a.m., the H&P indicated Patient 8 was admitted on 2/5/2025 due to diabetic ketoacidosis (DKA, a serious complication of diabetes [high blood sugar] that can be life-threatening)), sepsis (a body's overwhelming and life-threatening response to infection), and right groin abscess (a pocket of pus formed any part of the body).

During a record review on 2/6/2025 at 1:50 p.m. with Nurse Manager 1 (NM 1), Patient 8's emergency department (ED, provides medical and surgical care to patients arriving at the hospital in need of immediate care) note, dated 2/5/2025 at 4:03 a.m., was reviewed. The ED note indicated, incision and drainage (I&D, a surgical procedure used to treat abscesses) was performed by ED physician on 2/5/2025 at 5:40 a.m., verbal consent was obtained from patient for I&D at abdomen area, I&D was performed at abdomen with local anesthetic (a substance that induces insensitivity to pain).

During a concurrent interview and record review on 2/6/2025 at 1:55 p.m. with NM 1, Patient 8's medical records, was reviewed. Patient 8's medical records indicated that there was no informed consent form (which should have Patient 8's signature) found in Patient 8's medical records. NM 1 stated, prior to a procedure, patients were asked to sign a consent form attesting that informed consent discussion occurred with physician, also, allowing patient to ask further question. NM 1 confirmed that there should be a signed informed consent form by patient and physician for Patient's 8 I&D procedure. NM 1 also confirmed that there was no signed informed consent for Patient 8's I&D procedure (procedure done on 2/5/2025).

During a concurrent interview and record review on 2/7/2025 at 5:20 p.m., with the Regional Senior Director Accreditation Regulation and Licensing (RSDARL), Patient 8's medical record, was reviewed. RSDARL stated that the ED physician who performed the I&D for Patient 8 documented consent was obtained on the ED note. However, a completed informed consent form was not found in Patient 8's medical record.

During a review of the facility's policy and procedure (P&P) titled, Informed Consent, Written Consent and Refusal of Consent, policy number, SC.QRM.PS.029, dated 1/30/2025, with RSDARL, the P&P indicated "Patient Rights: prior to consenting to any treatment or procedure, patients have the right to know the relevant risks of the treatment or procedure, expected or hoped for benefits of the treatment or procedure, treatment alternatives and potential problems that might occur during recuperation. Patients also have the right to receive information in a manner they understand ... After the discussion, the physician/AHP must document in the patient's medical record that they discussed the proposed procedure with the patient/LRHCDM and obtained informed consent. Before the treatment or procedure, the patient/LRHCDM is asked to sign a consent form attesting that the informed consent discussion occurred with the physician/AHP and the patient/LRHCDM had an opportunity to ask and have their questions answered." The P&P also indicated that all invasive procedures under local anesthesia required informed consent.

Based on interview and record review, the facility failed to ensure that the medical records for five (5) of 30 sampled patients (Patient 1, Patient 2, Patient 7, Patient 27 and Patient 29) contained the pertinent medical information documented and filed in the patients' medical charts so that the health care staff involved in the patients' care could access and retrieve the information in order to monitor the patients' condition when:

1.a. Patient 1 had no record of continuous pulse oximetry (a non-invasive monitoring technique that continuously measures a patient's oxygen saturation [SpO2, a measure of how well the body is delivering oxygen to the tissues and pulse rate, alerting healthcare providers to potential hypoxia- a condition in which there is an inadequate supply of oxygen to the body's tissues] or respiratory distress [a condition where breathing becomes difficult or labored]), documented to be measured continuously while admitted on the inpatient medical-surgical floor ( M/S, a hospital's unit where patients are admitted for ongoing medical care, monitoring, and treatment under the supervision of healthcare providers), in accordance with a written physician order regarding continuous pulse oximetry monitoring.

This deficient practice had the potential to result in Patient 1's care needs not being met and increase the risk of undetected hypoxia, delayed medical intervention, respiratory deterioration, and adverse patient outcomes (a harmful and negative result), including life-threatening potential complications such as death.

1.b. Patient 1 had no vital signs (VS, measurements of the body's basic functions, such as temperature, pulse, respiration rate, and blood pressure that provide critical information about the body's overall condition) documented every eight hours as per Medical-Surgical unit protocol and in accordance with the facility's policy and procedure regarding Vital Signs (VS, objective measurements of essential bodily functions, including temperature, heart rate, respiratory rate, and blood pressure, used to monitor a patient's health status) and General Standards of Care.

This deficient practice had the potential for the staff's inability to determine a change in Patient 1's condition, which may result in a delay in the implementation of necessary interventions.

1.c. Patient 1 had no code status (refers to a patient's preferences regarding medical interventions in case of a cardiac arrest or life-threatening situations, specifically the type of resuscitation effects that should be undertaken) order, placed by the physician upon admission.

This deficient practice had the potential to compromise Patient 1's care, leading to emotional and psychological distress for Patient 1 and Patient 1's family if resuscitation was attempted against the patient's (Patient 1) wishes.

2. Patient 2 and Patient 7 had no recorded daily weight, in accordance with the facility's Medical-Surgical (M/S) unit protocol and the physician's order.

This deficient practice had the potential for Patient 2 and Patient 7's needs not being met, including inadequate assessment of fluid balance (the regulation of the amount of water in the body), undetected weight fluctuations indicative of worsening conditions and potential delays in adjusting medical treatment plans.

3. Patient 7 had no recorded Orthostatic Blood Pressure (Ortho BP, a series of blood pressure measurements taken in different positions such as lying down, sitting, and standing, to assess for orthostatic hypotension, a condition where blood pressure drops significantly upon standing, leading to dizziness or fainting) every shift, in accordance with the physician's order and the facility's policy and procedure regarding Vital Signs.

This deficient practice had the potential for Patient 7's worsening symptoms, such as dizziness, fainting, and or risk for falls (when someone unintentionally ends up on the ground or a lower level) to go unnoticed, resulting in negative health outcomes such as fracture (break in the bones) resulting from falls because of fainting, abnormal heart rhythm, etc.

4. Patient 27 and 29 had no recorded neurological assessment (nursing assessment including a patient's mental status, extremities movement and strength, bilateral (both) hand grips (force exerted by the hand when squeezing an object), pupils' (black center of the eye) sizes and reactivity (the ability of the pupil of the eye to constrict [smaller than normal] or dilate [larger than normal]), and face symmetry) in their (Patient 27 and Patient 29) medical records, performed and documented by a Registered Nurse [(RN]), as per physician order.

This deficient practice had the potential to result in a delay in identifying a change of condition and neurological status change including possible stroke (occurs when blood flow to the brain is interrupted, leading brain cell damage or death) progression, which can lead to delay in treatment and care, thus resulting to patient harm and/or death.

Findings:

1.a. During a review of Patient 1's History and Physical (H&P, a formal documented completed by the provider upon admission, detailing patient's current medical condition and treatment plan), dated 10/15/2023, the H&P indicated that Patient 1 was admitted to the facility on 10/15/2023 with a medical diagnosis of Covid-19 pneumonia (a severe respiratory infection caused by the COVID-19 virus, leading to inflammation and fluid accumulation in the lungs, which can cause breathing difficulties and reduced oxygen levels in the blood).

During further review of Patient 1's History and Physical (H&P), dated 10/15/2023, the H&P indicated that Patient 1 had past medical history (PMH, a record of a patient's health before the current problem) of metastatic lung cancer (a stage of lung cancer [CA] in which the disease has spread beyond the lungs to other parts of the body), malignant pleural effusion (a condition where CA cells cause fluid accumulation in the area between the lungs and the chest wall, leading to difficulty breathing), PleurX catheter placement (a small tube surgically inserted into the pleural space to remove excess fluid and relieve symptoms of difficulty breathing), and atrial fibrillation (Afib, irregular and often rapid heartbeat).

During a review of Patient 1's medical record (MR) titled, "Physician's Orders," dated 10/15/2023, the MR indicated that on 10/15/2023 at 2:20 p.m., the physician (MD 4) placed an order for Patient 1 to be on continuous pulse oximetry (a request to use a pulse oximeter to monitor a patient's blood oxygen levels for an extended period).

During an interview on 2/5/2025 at 11:10 a.m., with physician (MD 1, who oversees the Hospital Services), MD 1 reviewed Patient 1's admission orders placed on 10/15/2023 and stated the following: Patient 1 was initially admitted to observation (hospital status for patients who require short-term monitoring and assessment to determine if inpatient admission is necessary) with a diagnosis of Covid-19 pneumonia. The admitting physician (MD 4) entered the Covid Order Set (standardized set of pre-approved medical orders designed to streamline the management and treatment of Covid-19 patients) which typically includes the order for measuring oxygen saturation (the percentage of oxygen in the blood) levels continuously.

During a review of Patient 1's medical record (MR) titled, "Vital Signs (VS, objective measurements of essential bodily functions, including temperature, heart rate, respiratory rate, and blood pressure, used to monitor a patient's health status) Flowsheet Data," dated 10/16/2023, the MR indicated the following oxygen (O2) saturation levels (O2 Sats) were recorded for Patient 1 on 10/16/2023 from 7:00 a.m. to 6:00 p.m.:

-At 7:08 a.m.: Oxygen saturation level (O2 Sats) was 95% on 4 liters (L, unit of measure for oxygen flow rate).
-At 7:48 a.m.: O2 Sats was 92% on 5 L delivered via nasal cannula (a lightweight, flexible tube with prongs inserted into the nostrils to deliver supplemental oxygen to patients).
-At 9:00 a.m.: O2 Sats was 86%.
-At 9:04 a.m.: O2 Sats was 93% on 10 liters via an open-design oxygen mask (a type of oxygen mask that allows room air to mix with supplemental oxygen, often used when higher oxygen concentrations are needed but full face-sealing is not required).
-The MR further indicated that no additional O2 Sats measurements were recorded in Patient 1's medical record on 10/16/2023 from 9:04 a.m. to 6:00 p.m.

During an interview on 2/6/2025 at 9:35 a.m. with the physician (MD 4, the admitting physician who admitted Patient 1 on 10/15/2023), the MD 4 stated that the order for measuring pulse oximetry continuously means that the patient should be on continuous pulse oximetry monitoring. The MD 4 further stated that the standard was to monitor oxygen saturation rate continuously and to notify the physician when the oxygen levels drop to a certain point as per oxygen titration goals (a protocol that guides the adjustment of oxygen therapy based on a patient's oxygen saturation levels, ensuring adequate oxygenation while preventing hypoxia).

During a review of the facility's policy and procedure (P&P) titled, "Oximetry-Pulse Oximetry," dated 6/2023, the P&P indicated that pulse oximetry is measured and documented in the electronic medical record together with other vital signs or as ordered by physician and per unit protocol.

1.b. During a review of Patient 1's History and Physical (H&P, a formal documented completed by the provider upon admission, detailing patient's current medical condition and treatment plan), dated 10/15/2023, the H&P indicated that Patient 1 was admitted to the facility on 10/15/2023 with a medical diagnosis of Covid-19 pneumonia (a severe respiratory infection caused by the COVID-19 virus, leading to inflammation and fluid accumulation in the lungs, which can cause breathing difficulties and reduced oxygen levels in the blood).

During further review of Patient 1's History and Physical (H&P), dated 10/15/2023, the H&P indicated that Patient 1 had past medical history (PMH, a record of a patient's health before the current problem) of metastatic lung cancer (a stage of lung cancer [CA]in which the disease has spread beyond the lungs to other parts of the body), malignant pleural effusion (a condition where CA cells cause fluid accumulation in the area between the lungs and the chest wall, leading to difficulty breathing), PleurX catheter placement (a small tube surgically inserted into the pleural space to remove excess fluid and relieve symptoms of difficulty breathing), and atrial fibrillation (Afib, irregular and often rapid heartbeat).

During a review of Patient 1's medical record (MR) titled, "Orders," dated 2/16/2025, the MR indicated that on 2/16/2025, the physician (MD 4) placed an order for "Measure Vital Signs (VS, objective measurements of essential bodily functions, including temperature, heart rate, respiratory rate, and blood pressure, used to monitor a patient's health status)," per unit policy (every 8 hours).

During a review of Patient 1's medical record (MR) titled, "Vital Signs (VS) Flowsheet Data," dated 10/16/2023, the MR indicated the following VS measurements were obtained and recorded on 10/16/2023 from 7:00 a.m. to 6:00 p.m.:

-At 7:48 a.m.: -Temperature (T) was 96.7 Fahrenheit (F, measuring unit of the body's internal heat).
-Pulse was 71 beats per minute (bpm, the number of heart beats per minute).
-Blood Pressure (BP, the force of blood against the artery walls; BP is measured in millimeters of mercury (mmHG) was 143/78 mmHG (normal BP is generally considered to be around 120/80 mmHG).
-Respirations were 20 breaths per minute (the number of breaths taken per minute; normal respiratory rate typically ranges from 12-20 breaths per minute).

During a review of Patient 1's medical record (MR) titled, "Vital Signs (VS) Flowsheet Data," dated 10/16/2023, the MR further indicated that no additional vital signs measurements were recorded in Patient 1's medical record on 10/16/2023 from 7:48 a.m. to 6:00 p.m.

During an interview on 2/5/2025 at 1:39 p.m. with the Chief Nurse Executive (CNE), the CNE stated that typically on a medical-surgical floor (M/S floor, a hospital unit that provides care for patients with a wide range of medical conditions and post-surgical recovery needs), vital signs should be obtained and recorded every eight hours.

During an interview on 2/5/2025 at 3:10 p.m. with Registered Nurse (RN 1, the nurse who took care of Patient 1 on 10/16/2023, day shift), RN 1 stated the following: "I received the patient (Patient 1) midday as I floated into the unit, and there was another nurse taking care of the patient (Patient 1) in the morning [on 10/16/20]. I remember this patient (Patient 1) had a Covid-19 diagnosis, metastatic lung cancer (CA), and passed away that day (10/16/2023). The CNA (Certified Nursing Assistant) on the floor was responsible to take the vital signs in the afternoon and I remember there were VS taken in the morning. Maybe the CNA forgot to document the VS in the evening."

During a review of the facility's policy and procedure (P&P) titled, "Vital Signs-Including Orthostatic Blood Pressure ( Ortho BP, a series of blood pressure measurements taken in different positions such as lying down, sitting, and standing, to assess for orthostatic hypotension, a condition where blood pressure drops significantly upon standing, leading to dizziness or fainting)," dated 10/2024, the P&P indicated that 5.1. Frequency of Vital Signs will be taken every 8 hours or as specified.

During a review of the facility's policy and procedure (P&P) titled, "Admission and Discharge-Transfer Practices-Med-Surg Units," dated 10/2022, the P&P indicated that 1.1. Each patient will have a Flow Record (electronic medical record or chart used to continuously monitor and record specific clinical parameters or patient data over-time.

During a review of the facility's policy and procedure (P&P) titled, "Admission and Discharge-Transfer Practices-Med-Surg Units," dated 10/2022, the P&P indicated that 1.2. Patients will receive care based on a documented assessment of their needs and patient care standards ...1.5. The RN will be responsible for a full system assessment on the patient every 8 hours. Subsequent assessment performed may be focused assessment related to the patient's diagnosis and documented abnormal findings. Data gathered and documented by other nursing staff (CNA) will be reviewed by the RN and signature provided.

During a review of the facility's policy and procedure (P&P) titled, "Admission and Discharge-Transfer Practices-Med-Surg Units," dated 10/2022, the P&P indicated that 1.1. Each patient will have a Flow Record (electronic medical record or chart used to continuously monitor and record specific clinical parameters or patient data over-time.

1.c. During a review of Patient 1's History and Physical (H&P, a formal document completed by the provider upon admission, detailing patient's current medical condition and treatment plan), dated 10/15/2023, the H&P indicated that Patient 1 was admitted to the facility on 10/15/2023 with a medical diagnosis of Covid-19 pneumonia (a severe respiratory infection caused by the COVID-19 virus, leading to inflammation and fluid accumulation in the lungs, which can cause breathing difficulties and reduced oxygen levels in the blood).

During further review of Patient 1's History and Physical (H&P), dated 10/15/2023, the H&P indicated that Patient 1 had past medical history (PMH, a record of a patient's health before the current problem) of metastatic lung cancer (a stage of lung cancer [CA], in which the disease has spread beyond the lungs to other parts of the body), malignant pleural effusion (a condition where CA cells cause fluid accumulation in the area between the lungs and the chest wall, leading to difficulty breathing), PleurX catheter placement (a small tube surgically inserted into the pleural space to remove excess fluid and relieve symptoms of difficulty breathing), and atrial fibrillation (Afib, irregular and often rapid heartbeat).

During a review of Patient 1's History and Physical (H&P), the H&P also indicated that Patient 1 was on home-based palliative care (a special medical care focused on improving the quality of life for patients with serious illnesses) and had a code status (a patient's instructions to medical professionals about how to respond to cardiac or respiratory arrest) of DNR/DNI (DNR-do not resuscitate, a medical order indicating that no cardiopulmonary resuscitation [CPR, chest compressions] should be performed if the patient's heart stops; DNI-do not intubate, a directive specifying that the patient should be placed on mechanical ventilation to help the patient breath).

During an interview on 2/5/2025 at 11:51 a.m. with the physician (MD 1), the MD 1 stated that a code status should be ordered by the admitting physician (MD 4) upon admission. MD 1 then reviewed Patient 1's admission orders and said that the code status for Patient 1 was not ordered on admission on 10/15/2023 because MD 4 did not use the "Admission Order Set" (a predefined set of orders that streamline the admission process and ensure all necessary orders are placed upon patient arrival to the unit).

During a review of Patient 1's medical record (MR) titled, "Code Status, DNR with Do Not Intubate ...," dated 10/16/2023, the MR indicated that the physician (MD 4) placed an order for Patient 1's code status for DNR/DNI on 10/16/2023 at 8:00 a.m., which was more than 18 hours after Patient 1 was admitted to the facility on 10/15/2023 at 1:32 p.m.

During a review of the facility's policy and procedure (P&P) titled, "Code Status orders and Limits to Resuscitation," dated 12/2024, the P&P indicated the following: Physicians are responsible for discussing code status orders (is a written order) with patients or legally recognized healthcare decision makers and documenting these discussions in the medical record with the purpose of making, documenting, and implementing decisions about code status and initiating or changing Do Not Resuscitate (DNR) and related orders.

2.a. During a review of Patient 2's History and Physical (H&P, a formal documented completed by the provider upon admission, detailing patient's current medical condition and treatment plan), dated 2/3/2025, the H&P indicated that Patient 2 was admitted to the facility on 2/3/2025 with a diagnosis of sepsis (a life-threatening complication of an infection), pleural effusion (an abnormal accumulation of fluid in the pleural space, the thin membrane that separates the lungs from the chest wall) and had past medical history (PMH, records of information about the patient's medical, personal and family history) of cirrhosis (permanent scarring that damages the liver and interferes with its functioning).

During further review of Patient 2's History and Physical (H&P), dated 2/3/2025, the H&P indicated that Patient 2 required monitoring for fluid retention in the body (a condition where the body retains excess fluid, leading to swelling and puffiness in various areas of the body).

During a review of Patient 2's medical record (MR) titled, "Orders," dated 2/3/2025, the MR indicated that Patient 2 had an order for "Measure Weight" daily, placed by the physician on 2/3/2025 at 2:00 a.m.
During further review of Patient 2's medical record (MR), titled, "Flowsheet History-Weight," dated 2/3/2025 through 2/6/2025, the MR indicated the following:

-On 2/3/2025, Patient 2's weight was 96.6 kilograms (kg, measuring unit)
-On 2/5/2025, Patient 2's weight was 87 kg
-On 2/6/2025, Patient 2's weight was 86.6 kg
-The MR indicated that Patient 2's weight was not obtained and recorded on 2/4/2025 in accordance with the physician's order to measure daily weight.

During an interview on 2/6/2025 at 11:03 a.m. with the Assistant Manager Nurse (AMN 1), the AMN 1 stated the following: "typically, for an order to measure weight daily, nurses should try to obtain the daily weight early in the morning before breakfast." The AMN 1 then stated that if night shift nurses do not obtain the weight during their shift, the day shift nurses should follow up and capture it. The AMN 1 also stated that nurses were expected to follow physician's orders in accordance with the standards of care.

During a review of the facility's policy and procedure (P&P) titled, "Admission and Discharge-Transfer Practices-Med-Surg Units," dated 10/2022, the P&P indicated that 1.1. Each patient will have a Flow Record (electronic medical record or chart used to continuously monitor and record specific clinical parameters or patient data over time.

During a review of the facility's policy and procedure (P&P) titled, "General Standards of Care-Medical/Surgical," dated 9/2024, the P&P indicated the following: 1.4. Daily weights are done on physician's order or routinely for patients on diuretic (medications that help the body get rid of excess fluid and salt) therapy and dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so).

2.b. During a review of Patient 7's History and Physical (H&P, a formal documented completed by the provider upon admission, detailing patient's current medical condition and treatment plan), dated 7/27/2024, the H&P indicated that Patient 7 was admitted to the facility on 7/27/2024 with a diagnosis of near fainting. The H&P also indicated that Patient 7 had past medical history (PMH, records of information about the patient's medical, personal and family history) of hypertension (a condition in which the force of blood against the walls of the arteries is consistently too high) and atrial fibrillation (AFib, quivering or irregular heartbeat).

During a review of Patient 7's medical record (MR) titled, "Orders," dated 7/27/2024, the MR indicated that Patient 7 had an order for "Measure Weight" daily, placed by the physician on 7/27/2024 at 1:31 a.m. The MR also indicated that the order was discontinued on 7/29/2024 at 6:18 p.m. after Patient 7 was discharged from the facility.

During further review of Patient 7's medical record (MR) titled, "Flowsheet History-Weight," dated 7/27/2024 through 7/29/2024, the MR indicated that Patient 7's weight was only documented on 7/27/2024, but not obtained and recorded on 7/28/2024 and 7/29/2024 in accordance with the physician's order to measure daily weight.

During an interview on 2/6/2025 at 11:03 a.m. with the Assistant Manager Nurse (AMN 1), the AMN 1 stated the following: "typically, for an order to measure weight daily, nurses should try to obtain the daily weight early in the morning before breakfast." The AMN 1 then stated that if night shift nurses do not obtain the weight during their shift, the day shift nurses should follow up and capture it.

During a review of the facility's policy and procedure (P&P) titled, "General Standards of Care-Medical/Surgical," dated 9/2024, the P&P indicated the following: 1.4. Daily weights are done on physician's order or routinely for patients on diuretic (medications that help the body get rid of excess fluid and salt) therapy and dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so).

During a review of the facility's policy and procedure (P&P) titled, "Admission and Discharge-Transfer Practices-Med-Surg Units," dated 10/2022, the P&P indicated that 1.1. Each patient will have a Flow Record (electronic medical record or chart used to continuously monitor and record specific clinical parameters or patient data over-time.

3. During a review of Patient 7's History and Physical (H&P, a formal documented completed by the provider upon admission, detailing patient's current medical condition and treatment plan), dated 7/27/2024, the H&P indicated that Patient 7 was admitted to the facility on 7/27/2024 with a diagnosis of near fainting. The H&P also indicated that Patient 7 had past medical history (PMH, records of information about the patient's medical, personal and family history) of hypertension (a condition in which the force of blood against the walls of the arteries is consistently too high) and atrial fibrillation (AFib, quivering or irregular heartbeat).

During a review of Patient 7's medical record (MR) titled, "Orders," dated 7/27/2024, the MR indicated that Patient 7 had an order for "Measure Orthostatic Blood Pressure - Including Orthostatic Blood Pressure ( Ortho BP, a series of blood pressure measurements taken in different positions such as lying down, sitting, and standing, to assess for orthostatic hypotension, a condition where blood pressure drops significantly upon standing, leading to dizziness or fainting),"" every shift, placed on 7/27/2024 by the admitting physician.

During a concurrent interview and record review on 2/7/2025 at 9:51 a.m. with the Assistant Manager Nurse (AMN 1), Patient 7's medical record (MR) titled, "Flowsheet-Orthostatic Blood Pressure," dated 7/27/2024 through 7/29/2024, was reviewed. The MR contained no record of obtained and documented orthostatic blood pressure measurements daily throughout Patient 7's stay at the facility (7/27/2024 through 7/29/2024). The AMN 1 stated that nurses did not obtain and document Patient 7's orthostatic blood pressure as was ordered by the physician. AMN 1 further stated that nurses were expected to follow physician orders in accordance with the facility's standards of nursing care.

During a review of the facility's policy and procedure (P&P) titled, "Vital Signs-Including Orthostatic Blood Pressure ( Ortho BP, a series of blood pressure measurements taken in different positions such as lying down, sitting, and standing, to assess for orthostatic hypotension, a condition where blood pressure drops significantly upon standing, leading to dizziness or fainting)," dated 10/2024, the P&P indicated that: 3.2. Orthostatic BP is defined as a drop in systolic or diastolic BP of greater than 20 mmHG or greater than 10 mmHG, respectively (refers to a significant drop in blood pressure, specifically a decrease of at least 20 mmHg [millimeters of mercury, measuring unit] in systolic blood pressure (the pressure when the heart contracts) or 10 mmHg in diastolic blood pressure (the pressure when the heart relaxes) that occurs within a few minutes of standing up from a sitting or lying position; essentially, it's a measurement of how the blood pressure changes when a person stands up, and a drop exceeding these values is considered "orthostatic hypotension). 5.1. Frequency of Vital Signs will be taken every 8 hours or as specified. 8.1. Document the results in Vital Signs Flowsheet.

During a review of the facility's policy and procedure (P&P) titled, "Admission and Discharge-Transfer Practices-Med-Surg Units," dated 10/2022, the P&P indicated that 1.1. Each patient will have a Flow Record (electronic medical record or chart used to continuously monitor and record specific clinical parameters or patient data over-time.

4.a. During a review of Patient 27's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/1/2025, the H&P indicated, Patient 27 was admitted to the facility with diagnosis of acute (new onset) stroke (occurs when blood flow to the brain is interrupted, leading brain cell damage or death) due to ischemia (a condition where there is a reduced blood flow to an area of the body).

During a concurrent interview and record review on 2/7/2025 at 10:20 a.m. with the Department Administrator (DA 4) of Intensive Care Unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill), Patient 27's physician order, dated 2/1/2025, was reviewed. The physician order indicated, "measure neuro check (neurological assessment -nursing assessment including a patient's mental status, extremities movement and strength, bilateral [both] hand grips ]force exerted by the hand when squeezing an object], pupils' [black center of the eye] sizes and reactivity (the ability of the pupil of the eye to constrict [smaller than normal] or dilate [larger than normal]), face symmetry performed by a Registered Nurse) every four (4) hours."

During a concurrent interview and record review on 2/7/2025 at 10:50 a.m. with the Stroke Coordinator Nurse (SCN), Patient 27's neurological assessment flow chart, dated from 2/1/2025 to 2/3/2025, was reviewed. The neurological assessment flow chart indicated, nursing staff performed neurological assessment on the following dates and times:
-On 2/1/2025 at 1:18 p.m., 5:30 p.m. and 9:40 p.m.
-On 2/2/2025 at 4:15 a.m., 8 a.m., 3:24 p.m. and 8 p.m. (missing 12 a.m. and 12 p.m.)
-On 2/3/2025 at 4 a.m., 8 a.m., 12 p.m., 4 p.m. and 8 p.m. (missing 12 a.m.)

During the same interview on 2/7/2025 at 10:50 a.m. with the Stroke Coordinator Nurse (SCN), SCN stated it was important to monitor a patient's neurological status to know the baseline of the patient, to identify any neurological status changes and notify the physician. SCN also said that treatment for stroke was time sensitive. SCN stated nursing staff did not perform neurological assessment on Patient 27 every four (4) hours as ordered and as a result, could fail to identify progression of a stroke.

During a review of the facility's policy and procedure (P&P) titled, "Unit Based Performance Standards - DOU (direct observation unit [hospital unit providing close monitoring care to patients])," dated 2/2023, the P&P indicated, "Standard of care ... Standard II ... the patient has the right to expect assessment data to be consistent with the medical diagnoses and the plan of care ... standard of practice ... need based focused assessment may include: vital signs (measurements of the body's most basic function including body temperature, heart rate, blood pressure, respirations and pain level), review of systems, as indicated ... review of and follow through with physician orders."

4.b. During a review of Patient 29's "History and Physical (H&P)," dated 7/4/2024, the H&P indicated, Patient 29 was admitted to the facility with diagnoses including but not limited to acute (new onset) nontraumatic subdural (the space between the skull and surface of the brain) hemorrhage (bleeding), nontraumatic cerebral (brain) edema (swelling) and diabetes (high blood sugar).

During a review of Patient 29's physician order, dated 7/5/2024, the physician order indicated, nursing to perform neuro check (neurological assessment) every hour.

During a concurrent interview and record review on 2/7/2025 at 10:55 a.m. with the Department Administrator (DA 4) of Intensive Care Unit, Patient 29's neurological assessment flowchart dated from 7/5/2024 to 7/7/2024, was reviewed. The neurological assessment flow chart indicated, nursing staff performed neurological assessment on the following dates and times:
-On 7/5/2024 at 8 a.m., 12 p.m., 4 p.m., 8 p.m. and 11:33 p.m.
-On 7/6/2024 at 4 a.m., 8 a.m., 12 p.m. 4 p.m. and 8 p.m.
-On 7/7/2024 at 12 a.m., 4 a.m. 8 a.m. 12 p.m. 4 p.m. and 7:30 p.m.

During the same interview on 2/7/2025 at 10:55 a.m. with the Department Administrator (DA 4) of Intensive Care Unit, DA 4 stated nursing staff failed to perform and record hourly neurological assessment per physician order. DA 4 stated there would be risk for Patient 29 to develop neurological symptoms changes and not be identified by nursing staff and may cause delay in treatment and care.

During a review of the facility's policy and procedure (P&P) titled, "Unit Based Performance Standards - DOU (direct observation unit [hospital unit providing close monitoring care to patients])," dated 2/2023, the P&P indicated, "Standard of care ... Standard II ... the patient has the right to expect assessment data to be consistent with the medical diagnoses and the plan of care ... standard of practice ... need based focused assessment may include: vital signs (measurements of the body's most basic function including body temperature, heart rate, blood pressure, respirations and pain level), review of systems, as indicated ... review of and follow through with physician orders."

Based on interview and record review, the facility failed to ensure its infection prevention and control committee addressed the facility's healthcare-associated infection (HAIs, infections that occur while receiving medical care) including clostridium difficile (C diff, a bacterium that can cause inflammation of the colon [large intestine], a common cause of antibiotic-associated diarrhea) cases and collaborated with the facility's quality oversight committee (QOC, facility's quality assurance performance improvement [QAPI], a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) to analyze C diff cases data and provide/develop/implement an action plan in 2024, in a timely manner, to address an increase in the facility's c diff cases, in accordance with the facility's policy regarding QAPI plan.

This deficient practice had the potential to delay interventions to prevent and stop the spread and increase of HAIs including c diff cases.

Findings:

During an interview on 2/7/2025 at 1:45 p.m. with the Infection Control Preventionist (ICP 2), ICP 2 stated the facility followed Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN, nation's most widely used healthcare-associated infection tracking system) to monitor the facility's healthcare-associated infections (HAIs, infections that occur while receiving medical care) including catheter-associated urinary tract infection (CAUTI, a urinary tract infection associated with urinary catheter use), central line-associated bloodstream infection (CLABSSI, a serious infection that occurs when bacteria or other germs enter the bloodstream through a central venous catheter [CVC, a tube inserted into a large vein to provide medications, fluids or collect blood]), surgical site infection (SSI, an infection that occurs at or near the incision site after a surgical procedure) and clostridium difficile (C diff, a bacterium that can cause inflammation of the colon [large intestine], a common cause of antibiotic-associated diarrhea).

During a concurrent interview and record review on 2/7/2025 at 1:54 p.m. with the Senior Director Infection Prevention (ICP 1), the facility's "Infection Prevention and Control Committee Meeting Minutes (IP meeting minutes)," dated from 2/22/2024 to 10/24/2024, were reviewed and indicated the following:

-IP meeting minutes, dated 2/22/2024, indicated, total number of C diff for year of 2023 was five (5) cases;
-IP meeting minutes, dated 4/25/2024, indicated total number of C diff from January to February 2024 was zero (0);
-IP meeting minutes, dated 5/23/2024, indicated, total number of C diff increased from zero to eight (8) cases for March 2024 with no action plan noted to address the sudden increase of C diff cases;
-IP meeting minutes, dated 7/18/2024, indicated, total number of C diff increased to nine (9) cases up to May 2024 with no action plan noted to address the continue increase of C diff cases;
-IP meeting minutes, dated 9/16/2024, indicated, total number of C diff infection continued to increase to twelve (12) up to July 2024 with no action plan noted to address the continue increase of C diff cases;
-IP meeting minutes, dated,10/24/2024, indicated total number of C diff infection was thirteen (13) up to September 2024 with no action noted to address continue increase of C diff cases.
-IPC 1 stated the IP meeting minutes did not reflect any action plan done to address the C diff cases.

During an interview on 2/7/2025 at 1:57 p.m. with the Assistant Administrator (AA), the AA said there was a HAIs work group which started in January 2025 to work on any action plan for the facility's HAIs including C diff. AA stated that if there was any action taken to address the issue, it should be in the IP meeting minutes.

During an interview on 2/7/2025 at 3:28 p.m. with the Director of Quality Improvement (DQI), DQI stated the infection prevention and control committee started to report facility's HAIs data including C diff cases and provided with action plan to quality oversight committee (QOC, facility's quality assurance performance improvement [QAPI], a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all of the services provided by the hospital) in September 2024. DQI stated there was no reporting of HAIs to QOC prior to September 2024.

During a review of the facility's "Hospital Quality and Patient Safety Program Description Annual Work Plan and Evaluation (QAPI plan)," dated 5/9/2024, the QAPI plan indicated, "the purpose of this plan is ... to demonstrate a consistent and collaborative approach to deliver safe, effective, efficient, equitable, patient centered, and timely care within a quality assurance and performance improvement (QAPI) framework ... the foundational elements of all quality and patient safety initiatives and activities provide a framework that also supports quality improvement processes at the hospital ... assuring compliance with all state and national regulatory, accreditation, and certification standards supporting quality and patient safety. Ongoing identification, sharing, and appropriate implementation of successful practices from other parts of the organization, other healthcare organizations, and organizations outside of healthcare ... Leadership is responsible for ... appointing committees, work groups, performance improvement teams and other forums to ensure multidisciplinary and interdepartmental collaboration on issues of mutual concern ... implementing changes in existing processes to improve the quality of care provided ... establishing quality of care and patient safety metrics, which can be monitored through the hospital's plan ... [the facility's] quality oversight committee, and performance improvement committee serve as the committee to implement, monitor and enhance operational systems to ensure quality improvement, performance improvement and patient safety for the hospital."

Based on interview and record review, the facility failed to adhere to facility's policy and procedure (P&P) of notifying anesthesiologist (a doctor who manages pain and anesthesia during medical procedures and surgery) of a high blood pressure (blood pressure in the arteries is elevated above normal levels) for one of six (6) sampled surgical patients (Patient 22).

This deficient practice had the potential to lead to complications during the procedure due to uncontrolled blood pressure levels that could result in negative outcomes for the patient such as heart attack, increased risk of bleeding during surgery, etc.

Findings:

During a review of Patient 22's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 01/27/2025, the H&P indicated that Patient 22 was a 43 years old male who was scheduled to have ocular(eye) surgery on 02/04/2025.

During a concurrent interview and record review on 02/04/2025 at 11:45 a.m. with Registered Nurse (RN) 3, Patient 22's electronic medical record (EMR, a digital version of paper charting), was reviewed. The nursing pre-operative assessment (a review of a patient's medical history and current conditions to identify risk factors for surgery) indicated that Patient 22's blood pressure of 161/83 on 02/04/2025 at 11:15 a.m. was "flagged" (a clinical alert or marker within a patient's chart that automatically appears when their recorded blood pressure reading falls into a high or concerning range).

During the same interview on 2/04/2025 at 11:45 a.m. with Registered Nurse (RN) 3, RN 3 stated that Patient 22's blood pressure of 161/83 was flagged because it was abnormally high, and it exceeds the normal acceptable range. RN 3 added that there was no documentation that Patient 22's high blood pressure incident was reported to the anesthesiologist. RN 3 stated that anytime a blood pressure was flagged, the nurse must call and notify the anesthesiologist, document the notification and any medical orders or intervention given.

During an interview on 02/07/2025 at 4:04 p.m. with the Quality Coordinator (QC 1), QC 1 stated that in Epic (an electronic health record system that the hospitals use to manage patient records and improve care), a clinical alert will trigger for a systolic blood pressure (the first number in a blood pressure reading. It measures the pressure in your arteries when your heart contracts) above 139.

During a review of the facility's policy and procedure (P&P) titled, "Pre-Op (Pre-operative) Holding (a designated space in a hospital or surgical center where a patient waits immediately before surgery) Standards of Care," with effective date of 09/18/2023, the P&P indicated the following:
-Prompt notification to physician or anesthesiologist of problems concerning pre-op lab (laboratory)/test values, patient readiness for surgery and other relevant concerns.

During a review of the facility's policy and procedure (P&P) titled, "Admission of Patients to Pre-op Holding," with effective date of 10/17/2024, the P&P indicated the following:
-Check temperature, pulse, blood pressure, respiration rate, height, and weight. If any abnormal findings are found, notify the anesthesiologist.