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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.21 QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM was out of compliance.

A-0273 - Data Collection & Analysis - Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes .... (2) The hospital must measure, analyze, and track quality indicators ...and other aspects of performance that assess processes of care, hospital service and operations. §482.21(b) Standard: Program Data. (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and ... (3) The frequency and detail of data collection must be specified by the hospital's governing body. Based on patterns identified within current deficient practice and repeated failures within past deficient practice, the facility failed to maintain a quality program ensuring safe care related to nursing services and patient rights.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 NURSING SERVICES was out of compliance.

A-0395 - A registered nurse must supervise and evaluate the nursing care for each patient. Based on interviews and document review, the facility failed to provide nursing services in accordance with facility protocol, policy, and national guidelines. Specifically, the facility failed to ensure registered nurses (RN) assessed detox patients in fourteen of sixteen records reviewed for patients on Clinical Institute Withdrawal Assessment (CIWA) protocols (clinical assessment used to diagnose the severity of alcohol withdrawal). (Patients #1, #7- #19) Additionally, nursing staff failed to assess patients after the administration of as needed (PRN) medications in five of six medication administration records reviewed. (Patients #1, #2, #3, #5, & #6)

A-0397 - A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available. Based on observations, interviews and document review, the facility failed to ensure staff were trained and able to locate emergency supplies in two of two observations of the emergency carts.

A-0405 - Standard: Preparation and administration of drugs. (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient's care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. Based on interviews and medical record review, the facility failed to ensure medication administration was completed according to facility policy. Specifically, the facility failed to ensure staff documented the correct time medication was administered in six of six patient medication administration records reviewed. (Patients #1, #2, #3, #4, #5, and #6)

Based on patterns identified within current deficient practice and repeated failures within past deficient practice, the facility failed to maintain a quality program ensuring safe care related to nursing services and patient rights.

Findings include:

1. The facility's quality program failed to consistently identify and implement preventative measures for patient care concerns regarding patient rights and nursing services and implement performance improvement measures to prevent recurrence. The concerns were identified during concurrent surveys.

a. On 11/22/22, an immediate jeopardy was declared under the condition of Nursing Services regarding the care of patients receiving detox services. (Cross reference A385 - Nursing Services) When notified of the problem with patient assessments, the facility did not offer a performance improvement plan or evidence the problem was identified prior to the survey.

The failures included in the deficiency list were as follows:

i. The facility failed to ensure patients who were detoxing from alcohol were assessed per facility protocol, policy, and national guidelines. (Cross reference A395 - registered nurse (RN) Supervision of Nursing Care)

ii. The facility failed to ensure nurses assessed patients after the administration of as needed (PRN) medications for effectiveness. (Cross reference A395 - RN Supervision of Nursing Care)

iii. The facility failed to ensure staff were able to locate emergency equipment quickly and failed to ensure staff knew the IFUs for emergency equipment. (Cross reference A397 - Patient Care Assignments)

iv. The facility failed to ensure RN and LPN staff members documented the time medication was administered to patients. (Cross reference A405 - Administration of Drugs)

v. The facility was also cited under licensure regulations. The facility failed to develop and implement a nurse staffing committee consisting of at least 60 percent participation of clinical staff nurses and that met the requirements of Chapter 4.14.6. (Cross reference L1477 - Reserved - Nurse Staffing Committee)

b. On 8/5/22, the facility was cited under the condition of Patient Rights. (Cross reference A0115 - Patient Rights) This deficient practice represented newly identified non-compliance that developed while the facility was addressing existing non-compliance cited on 7/20/2022.

The failures included in the deficiency list were as follows:

i. The facility failed to ensure care in a safe environment by failing to immediately separate patients after allegations of abuse, in accordance with facility expectations. (Cross reference A0144 - Patient Rights: Care in a Safe Setting)

ii. The facility failed to ensure reports of abuse were reported and included in the patient's medical record. (Cross reference A0144 - Patient Rights: Care in a Safe Setting)

c. On 10/19/22, during the revisit of the 8/5/22 survey, the facility was recited under the condition of Patient Rights, evidencing a failure to have effective quality assurance performance improvement oversight. (Cross reference A0115 - Patient Rights) The facility was also cited under the condition of Medical Record Services. (Cross reference A0431 - Medical Records Services)

The failures included in the deficiency list were as follows:

i. The facility failed to notify the court-appointed guardian of medication changes for a patient who had been deemed unable to make medical decisions. (Cross reference A0130 - Patient Rights: Participation in Care Planning)

ii. The facility failed to ensure orders were countersigned by providers. (Cross reference A0454 - Content of Record: Orders Dated & Signed)

Based on interviews and document review, the facility failed to provide nursing services in accordance with facility protocol, policy, and national guidelines. Specifically, the facility failed to ensure registered nurses (RN) assessed detox patients in fourteen of sixteen records reviewed for patients on Clinical Institute Withdrawal Assessment (CIWA) protocols (clinical assessment used to diagnose the severity of alcohol withdrawal). (Patients #1, #7- #19) Additionally, nursing staff failed to assess patients after the administration of as needed (PRN) medications in five of six medication administration records reviewed. (Patients #1, #2, #3, #5, & #6)

Findings include:

Facility policies:

The Detoxification policy read, the nursing staff will assess the patient on a regular schedule. This includes but is not limited to vital signs, observation for withdrawal symptoms, level of consciousness, emotional status and any verbal complaints. The ongoing assessments are to be conducted as follows: The nursing staff will provide the level of physical care appropriate to meet the needs of the patient during detoxification.

The Use of PRN Medications policy read, the nurse who administers the "PRN" medication will document in the patient record the purpose for which the medication was given and whether the patient's outcome was effective or ineffective in response to the medication.

References:

The Alcohol Withdrawal Assessment Scoring Guidelines (CIWA- Ar) read, nursing assessment is vitally important. Early intervention for CIWA-Ar score of 8 or greater provides the best means to prevent the progression of withdrawal.

The Alcohol Withdrawal Assessment Flowsheet read, if the initial score is greater than or equal to eight, repeat every one hour for eight hours, then if stable every two hours for eight hours, then if stable, every four hours.

Consider transfer to intensive care unit (ICU) for any of the following: total score above 35, every one hour assessment for more than eight hours is required, or respiratory distress.

Scale for scoring: Total score 0-9: absent or minimal withdrawal. 10-19: mild to moderate withdrawal. More than 20: severe withdrawal.

According to the American Society of Addiction Medicine (ASAM) (2020) Clinical Practice Guidelines of Alcohol Withdrawal Management, pg. 10, in patients with moderate to severe withdrawal or those requiring pharmacotherapy (medications), reassess every 1-4 hours for 24 hours, as clinically indicated.

1. The facility failed to ensure patients who were detoxing from alcohol were assessed per facility protocol, policy, and national guidelines.

A. Record Review

i. A review of Patient #1's medical record revealed Patient #1 was admitted on 11/10/22 at 1:35 p.m. for alcohol detoxification and historically drank a case of beer and one pint of liquor daily. Patient #1 reported a possible history of delirium tremens (DTs) (the most severe form of alcohol withdrawal with symptoms including shaking, confusion and hallucinations) as well as a seizure from alcohol withdrawal. On 11/10/22 at 2:35 p.m., a physician's order was placed for CIWA protocol and Ativan administration (medication used to help treat alcohol withdrawal).

a. Review of Patient #1's Alcohol Withdrawal Assessment Flowsheet revealed CIWA assessment and vital signs were completed on 11/10/22 at 3:00 p.m. Patient #1's CIWA score was rated as a total of 17 (mild to moderate withdrawal). Patient #1's blood pressure was 189/109 (normal is less than 120/80), with a heart rate of 123 (normal range is 60 to 100). Patient #1's next CIWA assessments and vital signs were completed two hours later at 5:00 p.m. with a total score of 3, then three hours later at 8:00 p.m. with a total score of 3. After the 8:00 p.m. assessment, Patient #1's CIWA score and vital signs were not assessed until 16 hours later on 11/11/22 at 12:00 p.m., which yielded a total score of 14.

This was in contrast to the Alcohol Withdrawal Assessment Flowsheet, which read if the CIWA score was greater than or equal to eight, vital signs and assessment would be performed every hour for eight hours. This was also in contrast to the Alcohol Withdrawal Assessment Scoring Guidelines, which read nursing assessment was vitally important and early intervention for CIWA scores of eight or greater provided the best means to prevent the progression of withdrawal. Furthermore, this was in contrast to the ASAM Clinical Practice Guidelines of Alcohol Withdrawal Management provided by the facility, which read patients with moderate withdrawal or those who required pharmacotherapy should be reassessed every one to four hours as clinically indicated.

b. On 11/11/22 and 11/12/22, there were similar instances when Patient #1 scored greater than eight on the CIWA scale. CIWA assessments and vital signs were not obtained according to the facility's CIWA protocol.

This was in contrast to the Alcohol Withdrawal Assessment Flowsheet, which read transfer to ICU would be considered if the patient required every one hour assessment for more than eight hours. Patient #1 was not monitored per the CIWA protocol and therefore was unable to be evaluated for the need for a higher level of care.

c. Record review further revealed on 11/13/22 at 12:00 p.m., Patient #1 had a CIWA score of 11 (mild to moderate withdrawal). Per CIWA protocol, it was indicated for Patient #1's CIWA assessment and vital signs to be obtained every hour for eight hours. No further CIWA assessments or vital signs were documented. On 11/13/22 at 4:45 p.m., a code blue (medical emergency due to cardiac or respiratory arrest) was called on Patient #1 and he was transferred from the facility by ambulance to a higher level of care.

ii. Review of Patient #7's Alcohol Withdrawal Assessment Flowsheet revealed CIWA assessment and vital signs were obtained on 11/12/22 at 12:00 a.m. Patient #7 was assigned a score of 8 (absent or minimal withdrawal). No further vital signs were obtained until 20 hours later on 11/12/22 at 8:00 p.m.

Patient #7's CIWA assessment was completed on 11/12/22 at 8:00 a.m. and he was assigned a CIWA score of 13 (mild to moderate withdrawal). No vital signs were obtained with the assessment. No further CIWA assessments were documented until twelve hours later at 8:00 p.m.

This was in contrast to the Alcohol Withdrawal Assessment Flowsheet, which read if the CIWA score was greater than or equal to eight, vital signs and assessment would be performed every hour for eight hours. This was also in contrast to the ASAM Clinical Practice Guidelines of Alcohol Withdrawal Management provided by the facility, which read patients with moderate withdrawal should be reassessed every one to four hours as clinically indicated.

iii. Review of Patient #8's Alcohol Withdrawal Assessment Flowsheet revealed CIWA assessment and vitals signs were obtained on 11/13/22 at 12:00 p.m. Patient #8 was assigned a CIWA score of 12 (mild to moderate withdrawal). CIWA assessment and vital signs were next obtained 20 hours later on 11/14/22 at 8:00 a.m. No further vital signs were obtained on Patient #8 until 11/15/22 at 8:00 a.m.

This was in contrast to the Alcohol Withdrawal Assessment Flowsheet, which read if the CIWA score was greater than or equal to eight, vital signs and assessment would be performed every hour for eight hours. This was also in contrast to the ASAM Clinical Practice Guidelines of Alcohol Withdrawal Management provided by the facility, which read patients with moderate withdrawal should be reassessed every one to four hours as clinically indicated.

iv. Similar examples of CIWA assessments and vital signs not being completed per CIWA protocol, facility policy, and national guidelines were found during medical record review for Patients #9 through #19.

B. Interviews

i. On 11/22/22 at 9:03 a.m., an interview was conducted with RN #5. RN #5 stated CIWA assessments included a obtaining a full set of vital signs and an assessment for signs and symptoms of alcohol withdrawal. RN #5 stated Patient #1 had a higher risk of severe detox that included a risk of seizures. RN #5 also stated alcohol detox was deadly if not treated appropriately. Furthermore, RN #5 stated CIWA assessments were completed every four hours and there was not a policy for increased frequency of CIWA assessments and vital signs.

This was in contrast to the Alcohol Withdrawal Assessment Flowsheet, which read if the CIWA score was greater than or equal to eight, vital signs and assessment would be performed every hour for eight hours.

a. RN #5's personnel file was reviewed and there was no evidence of training or competency to care for patients on CIWA protocol.

ii. On 11/17/22 at 9:27 a.m., an interview was conducted with chief nursing officer (CNO) #4. CNO #4 stated the facility did not have specific nursing competencies for the CIWA protocol. CNO #4 also stated the facility did not provide medical detox, and considered the care provided by staff to be more residential in nature.

On 11/22/22 at 10:59 a.m., an additional interview was conducted with CNO #4. CNO #4 then stated patients came to the facility to be medically managed while going through detox and the CIWA protocol was used to detox patients from alcohol. CNO #4 stated if the CIWA protocol was not followed, patients were at risk of having an adverse event such as a medical change in condition that required a higher level of care. Furthermore, CNO #4 stated there was not a difference in the frequency of monitoring required based on CIWA scores and vital signs and CIWA assessments were to be completed every four hours.

This was in contrast to the Alcohol Withdrawal Assessment Flowsheet, which read if the CIWA score was greater than or equal to eight, vital signs and assessment would be performed every hour for eight hours.

2. The facility failed to ensure nurses assessed patients after the administration of PRN medications for effectiveness.

A. Record Review

i. Review of Patient #1's medication administration record (MAR) revealed Catapres (medication used to treat high blood pressure) 0.1 milligrams (mg) oral (PO) was to be administered every 4 hours as needed. Catapres was administered on 11/10/22 at 3:40 p.m. The reason for administration was documented as "bp" (blood pressure). No blood pressure value was documented and there was no evidence on the MAR that Patient #1's blood pressure had been assessed for effectiveness after the medication was administered.

On 11/13/22 at 1:30 p.m., Catapres was administered to Patient #1 for a blood pressure of 174/91. There was no evidence on the MAR that Patient #1's blood pressure was assessed for effectiveness after the medication was administered.

Review of the MAR review also revealed Patient #1 was to be administered Ativan (medication used to treat alcohol withdrawal) 1 mg PO every 4 hours as needed. Ativan was administered on 11/11/22 at 6:30 a.m. and 11/12/22 at 9:53 a.m. There was no evidence on the MAR that effectiveness was assessed after the medication was administered.

Additionally, MAR review revealed Patient #1 was to be administered Vistaril (medication used to treat anxiety) 50 mg PO every 6 hours as needed. Vistaril was administered on 11/11/22 at 5:53 a.m. and 4:00 p.m. There was no evidence on the MAR that effectiveness was assessed after the medication was administered.

This was in contrast to the Use of PRN Medications policy which read, the nurse who administered the "PRN" medication would document in the patient record the purpose for which the medication was given and whether the patient's outcome was effective or ineffective in response to the medication.

ii. Review of Patient #2's MAR revealed Zyprexa (medication used to treat agitation) 10 mg sublingual (beneath the tongue) was to be administered twice daily as needed. Zyprexa was administered on 11/11/22 at 9:20 p.m. There was no evidence on the MAR that effectiveness was assessed after the medication was administered.

MAR review also revealed Patient #2 was to be administered Trazodone (medication used to treat insomnia) 100 mg every night at bedtime as needed. Trazodone was administered on 11/9/22 at 2:30 a.m. There was no evidence on the MAR that effectiveness was assessed after the medication was administered.

This was in contrast to the Use of PRN Medications policy which read, the nurse who administered the "PRN" medication would document in the patient record the purpose for which the medication was given and whether the patient's outcome was effective or ineffective in response to the medication.

iii. Similar examples of patients not being assessed after PRN medications were administered were found in medical record review for Patients #3, #5, & #6.

B. Interviews

i. On 11/22/22 at 9:03 a.m., an interview was conducted with RN #5. RN #5 stated it was an expectation for nurses to assess patients an hour after PRN medications were administered to determine if the medications were effective. RN #5 stated effectiveness of PRN medications should have been documented on the back page of the MAR.

ii. On 11/28/22 at 2:37 p.m., an interview was conducted with RN #1. RN #1 stated it was important to assess the effectiveness of PRN medications because if the medications were not effective, the nurse would need to follow up with the provider on how to further treat the patient. RN #1 also stated it was important to recheck a patient's blood pressure after the administration of Catapres. RN #1 stated if the Catapres was not effective and a patient's blood pressure was too high, there was a risk that the patient could have a stroke.

iii. On 11/29/22 at 1:01 p.m., an interview was conducted with chief nursing officer (CNO) #4. CNO #4 stated it was an expectation for nurses to document on the back of the MAR the reason a PRN medication was administered and if the medication had been effective. CNO #4 stated it was important to assess the effectiveness of PRN medications, and if the medications were not effective, the nurse would be expected to call the patient's provider for an additional medication order.

Based on observations, interviews and document review, the facility failed to ensure staff were trained and able to locate emergency supplies in two of two observations of the emergency carts.

Findings include:

Facility policies:

The Hospital Plan for the Provision of Nursing Care policy read, staffing will be sufficient at all times to ensure emergency and safety requirements for patient care are met.

The Emergency Equipment policy read, an emergency response cart, vital sign machine, automated external defibrillator (AED) (a device used to shock a patient who has an abnormal heart rhythm), suction and oxygen (O2) will be maintained throughout the hospital. The contents of the cart are listed on the daily cart checklist located with the emergency cart.

The Code Blue policy read, emergency carts are located at each nursing station. Each code blue response requires an AED, portable suction, airway management and O2 delivery system. Every 30 days the emergency cart will be inventoried based on the supply list.

References:

The Basic Life Support (BLS) Healthcare Provider Adult Cardiac Arrest Algorithm, updated 2015, provided by the facility read, the staff member responding to the scene should shout for nearby help, activate the emergency response system and get an AED and emergency equipment.

The Medium Mask IFU read, the medium concentration mask is a small capacity variable mask. The mask can deliver 6-8 liters per minute (L/min) of oxygen.

1. The facility failed to ensure staff were able to locate emergency equipment quickly and failed to ensure staff knew the IFUs for emergency equipment.

a. On 11/16/22 at 1:15 p.m., observations were conducted on the 200 unit, an adult psychiatric and inpatient detox unit. Observations revealed the emergency cart located in the 200 unit did not have sufficient emergency supplies as determined by facility policy. For example:

The emergency cart did not have two oxygen masks, although the emergency cart checklist was signed off as having two masks. The mask on the cart was a medium concentration mask (a small capacity mask), only able to provide 6-8 L/min of oxygen.

i. During the observations, an interview was conducted with registered nurse (RN) #6. RN #6 erroneously identified the medium concentration mask in the emergency cart as a non-rebreather mask (a mask that allows a higher concentration of oxygen delivery, usually between 10-15 L/min of oxygen). RN #6 further explained the mask could deliver 6-12 L of oxygen to a patient. This was in contrast to the IFUs for the medium concentration mask.

ii. On 11/16/22 at 1:30 p.m., RN #8 was interviewed. RN #8 erroneously identified the medium concentration mask in the emergency cart as a non-rebreather mask. She further explained the mask could provide up to 15 L of oxygen delivery to a patient and could be utilized if the patient was having difficulty breathing. Again, this was in contrast to the medium concentration mask IFUs.

b. On 11/16/22 at 1:49 p.m., observations were conducted on the 300 unit, an inpatient psychiatric unit.

Observations of the emergency cart located in the 300 unit revealed the cart only had one medium concentration oxygen mask, although the emergency cart checklist was signed off as having two masks. The mask present was a medium concentration mask (a small capacity mask), only able to provide 6-8 L/min of oxygen.

i. During observations of the emergency cart, RN #7 was interviewed. RN #7 stated she was trained on emergency equipment and response at the facility when she was hired. However, when asked, RN #7 was unable to identify where the cardiopulmonary resuscitation (CPR) back board (a board placed underneath a patient while receiving CPR in order to create a hard surface for adequate compressions) or the AED on the emergency cart was located. RN #7 stated if she needed those items, she would go look for them.

Further observations of the emergency cart revealed the AED and CPR backboard were present on the emergency cart.

RN #7 was asked about the medium concentration mask in the emergency cart. RN #7 was unsure what concentration of oxygen was to be used with the mask in the cart.

c. On 11/29/22 at 1:03 p.m., an interview was conducted with chief nursing officer (CNO) #4. CNO #4 stated staff were trained on how to use an AED or an Ambu bag (a handheld device used to ventilate patients who were not breathing) during their BLS (basic life support) certification. CNO #4 stated it was important for staff to know where equipment was and how to locate equipment because the patient's condition could worsen quickly in an emergency.

Based on interviews and medical record review, the facility failed to ensure medication administration was completed according to facility policy. Specifically, the facility failed to ensure staff documented the correct time medication was administered in six of six patient medication administration records reviewed. (Patients #1, #2, #3, #4, #5, and #6)

Findings include:

Facility policies:

The Medication Administration policy read, medications are administered at scheduled times. Only competent Registered Nurses (RN) and Licensed Practical Nurses (LPN) may administer medication. Medication administration education and training is included in hospital orientation. Licensed nursing staff must know the correct medication and appropriate time.

The Content of All Medical Records policy read, all entries must be signed, credentials recorded, and the date and time of the entry must be documented.

Reference:

A New Hire Orientation poster board titled Medication Administration Records (MARs) read MARs should be noted at the time of medication administration.

1. The facility failed to ensure RN and LPN staff members documented the time medication was administered to patients.

A. Medical Record Review

i. On 11/10/22 Patient #1 was admitted for alcohol detoxification treatment. Review of Patient #1's medication administration record (MAR) revealed the time of medication administration was not documented. For example:

a. On 11/10/22 a two milligram (mg) dose of Ativan (a medication used to treat symptoms of alcohol withdrawal) was scheduled for administration at 9:00 a.m. The staff member who administered the medication documented their initials however did not document the actual time of administration.

b. On 11/11/22 a two mg PRN (as needed) dose of Ativan was administered by a staff member, however, the time the medication was administered was not documented on the MAR. On 11/12/22, a similar instance occurred where one mg of Ativan PRN was administered however a time was not documented for when the medication was administered.

ii. On 11/8/22 Patient #2 was admitted for opioid detoxification. Review of Patient #2's MAR revealed the time of medication administration was not documented. For example:

a. On 11/11/22, two mg of Subutex (a narcotic medication used to treat opioid addiction) and 875 mg of Augmentin (a type of antibiotic) was scheduled to be administered at 9:00 a.m. The staff member who administered the medication noted their initials, however the actual time of medication administration was not documented on the MAR.

iii. Similar findings were discovered on the MARs for Patient's #3, #4, #5 and #6.

B. Interviews

i. On 11/28/22 at 2:37 p.m., an interview was conducted with registered nurse (RN) #1. RN #1 stated the process for documenting medication administration was to document the time the medication was administered. RN #1 stated most medications were time sensitive so it was important to know the exact time a medication was administered.

ii. On 11/28/22 at 3:44 p.m., an interview was conducted with RN #3. RN #3 stated when medication was administered, RNs and LPNs were expected to document on the MAR the actual time the medication was administered. RN #3 stated if the times were not documented accurately, there was a risk the patient could receive medication too soon and have too high of levels in their blood.

iii. On 11/29/22 an interview was conducted with chief nursing officer (CNO) #4. CNO #4 stated when a RN or LPN administered medications, the staff member was to date, time, and initial the MAR at the time the medication was administered. CNO #4 stated it was important to document the accurate time medication was administered in order to ensure the patient did not receive too much of a medication.