HospitalInspections.org

Based on record reviews, document reviews, policy reviews, and interviews, the hospital failed to protect and promote each patient's rights. The hospital failed to ensure each patient had the right to be free from all forms of abuse or harassment and failed to conduct a thorough investigation when a patient voiced an allegation of sexual abuse for one (Patient 1) of one patient record reviewed for abuse from a sample of 14 patients.

The cumulative effects of this deficient practice resulted in an Immediate Jeopardy (IJ) (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death) situation.

The surveyor notified the hospital that an IJ existed on 01/13/21 at 1:50 PM, related to Patient Rights. The hospital submitted a credible plan of removal and the IJ was removed on 01/14/21 at 7:45 PM. The plan of removal included the following:

1. Staff A, Administrator, is ultimately responsible for the removal plan.
2. The hospital will protect and promote patients' rights and ensure they are free from harm by following the "NSG 02 Abuse and Neglect" policy.
3. On 01/14/21 after 3:00 PM, "30% [per cent] of the total employee population will be educated immediately. Employees that have not been educated on newest policy change approved by the Governing Board on 1/14/2021 [01/14/21] at 6:30 PM will be educated before next shift worked. At the beginning of each shift, employees that have not been educated on abuse and neglect policy will receive education on the abuse and neglect policy. 100% of staff will be educated by January 20, 2021. Any staff that are not available during this time (FMLA [Family Medical Leave Act], vacation, PRN [as needed], etc.) will be educated prior to the start of their first shift either in person or via telephone. Staff will not be permitted to work without education.
4. The hospital CEO [Staff A, Administrator], CNO [Staff C, Chief Nursing Officer (CNO)], and DQM [Staff B, Director of Quality management (DQM)] have educated the leadership team and hospital staff on "NSG 02 Abuse and Neglect" policy. Any incident report related to abuse or neglect will be reviewed by the on call hospital representative prior to the end of the shift.
5. The investigation was started on 1-13-2021 [01/13/21] and is ongoing. The alleged perpetrator has been suspended indefinitely until investigation is final. Police have been notified of the investigation 1-14-2021 [01/14/21] at 1700 [5:00 PM].
6. The Director of Quality management will audit all incident reports to ensure if any occurrence of abuse or neglect has been identified that the policy has been followed. Monitoring will continue for one (1) consecutive quarter until compliance has been demonstrated. Once compliance is demonstrated, monitoring will occur for two (2) more weeks to determine sustainability. If sustainability is not demonstrated monitoring will continue for one (1) more consecutive week. Data will be reported through QAPI [quality assessment and performance improvement], MEC [medical executive committee], and Governing Board. Non-compliance will be addressed immediately; re-education will be instituted; if non-compliance by an employee remains the discipline process will be instituted.
7. The "Abuse and Neglect- Internal and External" policy was revised and approved by the Governing Board with the following revisions:
a. "The first employee who first becomes aware of a patient who is said to be abused, neglected, mistreated and/or exploited must take all appropriate steps necessary to protect the patient. This would include assignment changes, and restriction of visitors if applicable."
b. "The DQM shall be notified immediately in any case of suspected adult elder abuse, neglect, mistreatment, exploitation or child abuse, the DQM or designee, after consultation with the Chief Legal Officer and Vice-President of Safety and security, will notify law enforcement."
c. "The Report of the Findings will be sent to the KDHE [Kansas Department of Health and Environment] within 5 (five) working days of the alleged notification . . . In the case of sexual assault, do not allow the victim or perpetrator to shower or bathe, rinse mouth, brush teeth, use toilet paper or moistened towelettes after elimination, or change clothes."
d. The number for the Kansas Department of Aging and Disability Services (KDADS)/Kansas Department of health & [and] Environment (KDHE) was corrected with the current phone number.

Findings Include:

1. The hospital failed to ensure each patient had the right to be free from all forms of abuse or harassment and failed to conduct a thorough investigation when one patient (Patient 1) who voiced an allegation of sexual abuse. One of one patient's record was reviewed for abuse from a sample of 14 patients. This failure put the 39 patients receiving care in the hospital and any future patients at risk for abuse, (see findings in tag A0145).

2. The hospital failed to ensure the grievance process was implemented for three (Patient 1, Patient 2, Patient 3) of three patient records/incident reports reviewed for grievances and two (Patient 13, Patient 14) of five grievances listed on the "Grievance Log" from a sample of 14 patients. This failure had the potential to cause serious harm or injury to the 39 patients receiving care in the hospital and any future patient admitted to the hospital. (see findings in tag A0118).

Based on record reviews, policy reviews, document reviews, and interviews, the hospital failed to ensure the grievance process was implemented for three (Patient 1, Patient 2, Patient 3) of three patient records/incident reports reviewed for grievances and two (Patient 13, Patient 14) of five grievances listed on the "Grievance Log" from a sample of 14 patients. This failure had the potential to cause serious harm or injury to the 39 patients receiving care in the hospital and any future patient admitted to the hospital.

Findings Include:

Review of the policy titled "Grievance Resolution Process," revised 10/09/20, showed "All patients have the right to initiate the grievance resolution process. . . Grievance - Written or verbal complaint made to the hospital by patient or representative related to: Patient care (when not resolved at the time) Abuse or Neglect Noncompliance with CoP's [Conditions of Participation] Medicare beneficiary complaint Any written complaint Any complaint asked to be treated as a grievance AMA [Against Medical Advice] . . . The Director of Quality Management will meet with the patient to discuss their complaint and resolve the issue if possible. If it is necessary to initiate the grievance resolution process, the patient will be provided with a written response. Should the grievance involve more than one specific concern, each concern will be addressed individually within the written response. The Director of Quality Management refers the grievance to the Grievance Review Committee which will meet and provide written documentation to the patient within seven calendar days on average from the date the grievance request was received. The hospital must attempt to resolve all grievances as soon as possible and must demonstrate the capability to resolve almost all grievances within the 7 day calendar timeframe. If unable to complete the investigation within 7 business days, the hospital will notify the patient in writing of ongoing investigation with completion of investigation and written notification in 30 days. The Grievance review Committee . . . provides in writing to the patient who filed the grievance: Name of the hospital contact person, The steps taken on behalf of the patient to investigate the grievance, The results of the grievance process, and The date of completion of the grievance process. After conferring with the hospital CEO [ Chief Executive Officer], the Grievance review Committee chairperson will provide the written response to the patient. . ."

1. Review of an incident report dated 10/03/20 by Staff E, Registered Nurse (RN), of a complaint by Patient 1 showed "Staff F, Certified Nursing Assistant (CNA), asked charge nurse to come help him clean up patient who was being combative. When she entered the room, neither staff member was able to get close to the bed because patient was swinging his fist and kicking at staff. Patient shouted that Staff F, CNA, tried to "butt f - - -" him and that he (the patient) was going to kill Staff F, CNA. Nurse told Staff F, CNA, to leave the room. Patient calmed down slightly and allowed charge nurse to clean him up and get a clean brief on him. Patient continued to rant about wanting to kill the CNA and asked what was going to be done about it. Charge nurse took Staff F, CNA, off the assignment and replaced him with a female CNA. Patient continued to make the accusation several times to multiple staff members, asking several for weapons."

Further review showed "corrective action was taken, environment reviewed, family notified, informed staff, and manager/director notified." Further review showed on 10/06/20 at 9:44 AM Staff B, Director of Quality Management (DQM) documented "Staff B, DQM, spoke with Staff F, CNA, regarding this incident and he said that patient had been appropriate with him the whole time he was caring for him and it was that one time incident that he snapped. The patient assignment has been changed to manage the situation and tech stated that there was no more incident with him and the patient since then.

Staff C, Chief Nursing Officer (CNO), also followed this incident and has been resolved." Review showed "Additional Information by Staff C, CNO, on Tuesday, October 06, 2020 at 5:15 pm Description: Reviewed this report and the staff followed proper protocol."

There was no documented evidence presented that showed facility staff documented this incident as a grievance or that the facility conducted a thorough investigation of Patient 1's allegation of sexual abuse.

During an interview on 01/11/21 at 2:15 PM, Staff B, Director of Quality Management (DQM), stated she didn't handle the complaint as an alleged sexual abuse or as a grievance. She stated she was responsible for the hospital's grievance process.


2. Review of documentation a hand-written list of complaints, voiced by Patient 2's daughter, provided by Staff R, Patient Assessment Coordinator (PAC), showed "on the morning of 12/9 [12/09/20] [first name of Patient 2's daughter] received text from (approx.. [approximately] 0530am) [5:30 AM] the patient stating she couldn't stay here during the night she had to use restroom she stated the person who helped her "shoved her." Approx.. 0700am [7:00 AM] (12/9) [12/09/20] [first name of Patient 2's daughter] rcvd [received] test reading "help me" Daughter spoke w/ [with] patient pt [patient] told daughter "the owner's daughter" "shoved her" into bathroom wouldn't let her wash her hands, told her "No" when she asked. Pt stated she asked for a wipe then to wipe her hands, the staff again told her "No" that she just needed to go back to sleep, turned lights off on her and left room. [first name of Patient 2's daughter] said she tried to get hold of someone to address this yesterday but no one called her back."

Review of the hospital's incident reports and grievances showed the facility failed to document evidence of Patient 2's daughter's complaints or that the facility conducted a thorough investigation of the concerns.

During an interview on 01/12/21 at 3:12 PM, Staff R, PAC, stated he's a patient partner for some of the patients. He stated he covered the patient partner role by asking Patient 2 if she's being taken care of and if she's meeting her therapy goals. He stated Patient 2 didn't express any concerns except that she missed her dog. He stated the next day Staff C, Chief Nursing Officer (CNO), gave him a list of concerns Patient 2's daughter had voiced. He stated he called Patient 2's daughter to get more information and spoke with Patient 2. After team conference was conducted, Staff R, PAC, stated they were able to say Patient 2 was at a "pretty functional level" not needing maximum assistance to the bathroom. He stated he didn't remember if a complaint was entered related to the documented complaint presented to him. Staff B, Director of Quality Management (DQM), who was present during the interview, checked the complaint report system, she stated no complaint was documented.

During an interview on 01/12/21 at 4:20 PM, Staff C, CNO, stated she didn't handle Patient 2's daughter's concerns as a grievance and so they did not conduct a thorough investigation.


3. Review of an incident report dated 10/07/20, documented by Staff B, DQM, at 4:52 PM on 10/07/20, showed "During patient partner rounding, with spouse present in the room, patient reported that she pressed the call light 3 x [times] this morning at around 3 or 3:30 am [3:30 AM] and asked to be changed as she had an accident in her brief. The patient reported that the staff would go to her room and told her that they will be right back but staff never came in again to clean her up. The patient reported that it was not until this morning at around 6:30 am or 7 that she was cleaned up and she reported that she was soaked in urine and even the top of her sheets were soaked. DQM apologized for this incident and told patient and spouse that this will be reported and investigated."

Follow up documentation by Staff B, DQM, on 10/07/20 at 5:08 PM showed "After speaking with patient and spouse, DQM spoke with Staff W, CNA, for the patient today. C.N.A. said that she did not receive any report this morning about this patient. She recalled that the NP who saw this patient in the morning had told her that this patient "needed attention." CNA reported that when she came in the patient's room, at around 7:30 am, she concurred that the whole bedding, the top sheets, the patient's clothing, and even the pillows were saturated with urine and some areas looked like they were dried up and stained and that it looked like she had been saturated with urine for a few hours. The CNA cleaned her up, changed her clothing, changed the bed linens and pillows as well."

Additional information documented by Staff C, CNO, on 10/18/20 at 2:50 PM showed "Reviewed report. Followed up with issue. This patient requested only female care so the night tech who was male asked for another tech to assist this patient. Spoke to both night techs [names of techs not documented] in regards to this issue."

The facility did not provide any documented evidence of an investigation including a lack of interviews with each staff person involved with the incident.

During an interview on 01/12/21 at 11:00 AM, Staff B, DQM, stated Patient 3 and her husband was present when she made rounds on 10/07/20, and this is when they reported the incident about not being cleaned up the morning of 10/07/20.

During an interview on 01/13/21 at 7:08 AM, Staff B, DQM, stated she is responsible for the grievance process. She stated her understanding was that if a complaint wasn't handled to resolution, it would become a grievance. When the policy was reviewed with Staff B, DQM, that states if a complaint needs to be investigated it becomes a grievance, she stated she read the policy but didn't interpret it that way. She stated Staff J, CNA (a male), was assigned at the beginning of the shift, and Patient 3 was changed to Staff U, CNA, since Patient 3 requested a female CNA. Staff B, DQM, confirmed the incident on 10/07/20 related to Patient 3 was not handled as a grievance but should have been.

During an interview on 01/13/21 at 9:13 AM, Staff L, LPN, stated she usually goes in the room with Staff W, CNA, to help her clean a patient. She stated she didn't remember Patient 3. She stated if she found the incident as documented in the incident report, she would have documented those details in the patient's record.


4. Review of a grievance documented for Patient 13 on 12/03/20 by Staff Z, Licensed Practical Nurse (LPN), showed Patient 13's wife called at approximately 9:30 AM insisting that Patient 13 be "discharged to home today. This writer informed charge nurse and NP (nurse practitioner) or [name of attending physician]. After wife discussed with NP, Casemanger [sic], wife continued to insist that patient will be discharged home today even if that means leaving AMA [against medical advice]. After signed AMA papers, patient left with wife." "Followup list" documented by Staff B, DQM, on 12/04/20 at 12:12 PM showed "DQM reviewed incident and was made aware. Patient and wife insisted on leaving AMA despite multiple communication to them by nursing, providers, and case manager. . . Patient was picked up by spouse in stable condition. No further follow up needed from this incident at this time and will be closed.

Staff B, DQM did not present any documented evidence during the survey of a thorough investigation related to the AMA discharge of Patient 13.

During an interview on 01/14/21 at 10:46 AM, Staff B, DQM, confirmed that they had not conducted a thorough investigation of Patient 13's grievance including interviews with staff involved in Patient 13's care. She stated she was responsible for the hospital's grievance process.


5. Review of a grievance documented for Patient 14 on 09/03/20 at 4:53 PM by Staff B, DQM, showed the daughter of Patient 14 "submitted a negative Google review about the facility. . . Areas of complaint were communication from nursing staff to family and in between staff, call light responses, nurse's courtesy to family, nursing management follow up, and request for itemized bill for insurance not being provided." Additional information documented by Staff C< CNO, on 09/08/20 at 3:51 PM showed "I was called by the daughter late in the evening regarding her concerns about the care of the patient Patient 14. Daughter shared that she felt our food was not of good quality and brought her mother dinner from Longhorn steakhouse. Shortly after eating the daughter reported that her mother started to have what she thought might be chest pain. She pushed the call light and after a few minutes decided to go to the nurses station to report mother pain. She spoke to Staff BB, Licensed Practical Nurse (LPN), and [first name and initial of last name of other nurse] Daughter shared that Staff BB, LPN, was rude and said she would come see her in a moment, [first name and initial of last name of other nurse] was at the desk and went to access [sic] patient. . . Daughter didn't want Staff BB, LPN, to be her mothers [sic] nurse. I reassured her that we can make changes to the assignment and her mother would be well cared for. Daughter agreed to new nurse. I then called charge nurse and had assignments switched. No further issues. Checked on patient next morning and no concerns noted."

The facility failed to provide any documented evidence of a thorough investigation including interviews with Staff BB, LPN, and [other nurse who assessed Patient 14 - name not listed on staff roster provided by facility]

During an interview on 01/14/21 at 12:12 PM, Staff C, CNO, confirmed she did not interview the nurse who assessed Patient 14 and Staff BB, LPN, regarding the complaints voiced by Patient 14's daughter. She confirmed she did not have documented evidence of a thorough investigation.

Based on policy review, document review, patient medical record review, and interviews, the hospital failed to ensure each patient had the right to be free from all forms of abuse or harassment and failed to conduct a thorough investigation when a patient voiced an allegation of sexual abuse for one (Patient 1) of one patient record reviewed for abuse from a sample of 14 patients.

Findings Include:

On 01/13/21 at 1:50 PM the surveyor notified the hospital an Immediate Jeopardy (IJ) (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death) existed related to Patient Rights. (See findings in tag A-0115)

On 01/14/21 at 7:45 PM, the hospital was notified that the IJ was removed with the submission of an acceptable plan of removal, prior to survey exit. (See findings in tag A-0115)

Review of the policy titled "Abuse and Neglect- Internal and External," revised 11/06/20 showed "Patient Abuse, Neglect, and/or Mistreatment is defined as any incident of physical, sexual, or verbal abuse, neglect, and/or mistreatment that is reported by the patient or family; or is witnessed reported, or suspected by an employee. . . The employee who first becomes aware of a patient who is said to be abused, neglected, mistreated and/or exploited must take all appropriate steps necessary to protect the patient, including but not limited to, reassignment of staff, removal of staff from patient care, and restriction of visitors. . . Notify the CEO [Chief Executive Officer] or designee (Administrator on Call) immediately in any instance of reported, observed, or suspected patient abuse, neglect, mistreatment and/or exploitation. Notify the patient's attending physician. Document the allegations in the incident reporting system. . . Investigation and Reporting Guidelines Once incident is identified the Incident will be reported to CEO, DON [Director of Nursing], and DQM [Director of Quality Management]. The hospital will report the incident to the Divisional President, Chief Legal Officer, and Chief Clinical Officer. The hospital will follow their state guidelines for reporting, filing and follow-up guidelines. Investigation of the incident and allegations will be conducted in a timely manner. Nursing assessment within 24 hrs. [hours] to identify any signs of physical injury. Findings, including the absence of any signs of physical injury, emotional status and comfort level of the patient will be recorded in the clinical notes section of the chart. Notify patient's physician immediately of any alleged, suspected or witnessed abuse or neglect and suggest physician examines the patient and documents assessment as soon as possible. . . Identify and interview all involved persons including others with any knowledge of the allegations. . . Documentation should be complete and thorough including every step of the investigation. Patient should include description of initial complaint, assessment findings, . . . interventions in response to findings, and physician notification - do not include details of investigation. . . If the alleged offender is an employee, he/she will be removed from all cases immediately pending investigation. . . The hospital will report allegations, incidents, investigations and outcomes to the appropriate agency based on state mandated reporting requirements. . ."

The hospital staff failed to follow the facility's abuse and neglect policy as evidenced by:
1. The RN failed to immediately report the allegation of sexual abuse to the Administrator, Director of Quality management, and attending physician.
2. The hospital did not report the incident to the Divisional President, Chief Legal Officer, and Chief Clinical Officer.
3. The RN did not document in Patient 1's medical record a nursing assessment within 24 hours to identify signs of physical injury.
4. The RN did not remove Staff F, certified Nursing Assistant (CNA), from providing direct patient care.
5. The hospital had no documented evidence that an investigation had been conducted.
6. The hospital failed to report the allegation of abuse to the Kansas Department for Aging and Disability Services / Kansas Department of Health and Environment's Abuse, Neglect, and Exploitation Hotline.

Review of the policy titled "Incident Reports," revised 10/09/20, showed ". . . An incident report will be completed on any incident deemed to be inconsistent with the desired operation of the hospital or the care of patients. The incident will be submitted through the incident reporting system. . . Reference to the report should not be made in the medical record. Patients and/or family members should not be told an incident report has been completed. Details of any incident involving a patient will be documented in the medical record as per applicable documentation policies and procedures. . ."

Review of an incident report dated 10/03/20 by Staff E, Registered Nurse (RN), of a complaint by Patient 1 showed "Staff F, Certified Nursing Assistant (CNA), asked charge nurse to come help him clean up patient who was being combative. When she entered the room, neither staff member was able to get close to the bed because patient was swinging his fist and kicking at staff. Patient shouted that Staff F, CNA, tried to "butt f - - -" him and that he (the patient) was going to kill Staff F, CNA. Nurse told Staff F, CNA, to leave the room. Patient calmed down slightly and allowed charge nurse to clean him up and get a clean brief on him. Patient continued to rant about wanting to kill the CNA and asked what was going to be done about it. Charge nurse took Staff F, CNA, off the assignment and replaced him with a female CNA. Patient continued to make the accusation several times to multiple staff members, asking several for weapons." Further review showed " corrective action was taken, environment reviewed, family notified, informed staff, and manager/director notified." Further review showed on 10/06/20 at 9:44 AM Staff B, Director of Quality Management (DQM) documented "Staff B, DQM, spoke with Staff F, CNA, regarding this incident and he said that patient had been appropriate with him the whole time he was caring for him and it was that one time incident that he snapped. The patient assignment has been changed to manage the situation and tech stated that there was no more incident with him and the patient since then. Staff C, Chief Nursing Officer (CNO), also followed this incident and has been resolved." Review showed "Additional Information by Staff C, CNO, on Tuesday, October 06, 2020 at 5:15 pm Description: Reviewed this report and the staff followed proper protocol."

The facility provided no documented evidence that hospital staff conducted a thorough investigation of Patient 1's allegation of sexual abuse.

During an interview on 01/11/21 at 2:15 PM, Staff B, DQM, stated she spoke only to Staff F, CNA. She stated typically the nurse leader (CNO or nurse manager) talks to the staff involved and the patient as well. She stated she didn't handle the complaint as an alleged sexual abuse or as a grievance.

During an interview on 01/12/21 at 3:25 PM, Staff E, RN, stated she wrote the incident report related to Patient 1's allegation of sexual abuse. She stated she worked the day of the incident. She stated Staff F, CNA, came from Patient 1's room to ask her for help. She stated she was the charge nurse at that time. Staff E, RN, stated she had no knowledge of how long Staff F, CNA, was in the room before he called her for help. She stated she assessed Patient 1 and looked for any redness around the anus and around the wrist (for restraint). She stated she didn't see anything like that. She confirmed she didn't document Patient 1's allegation of sexual abuse in Patient 1's medical record. Staff, E RN verified she failed to document a physical assessment was completed on Patient 1 after the allegation of an attempted sexual abuse.

During an interview on 01/12/21 at 4:20 PM, Staff C, CNO, stated when she spoke to Patient 1, he was very confused and did not mention anything about the allegation or about Staff F, CNA. She stated she didn't ask Patient 1 about the abuse allegation, because he was confused, and when you would talk to him, he wouldn't answer. Staff C, CNO, confirmed she didn't report the allegation of abuse to the State.

During a telephone interview on 01/13/21 at 8:05 AM, Staff F, CNA, stated he remembered Patient 1 being combative but didn't remember Patient 1 saying Staff F, CNA tried to "butt f - - -" him. He stated he didn't remember that, but he remembered telling a nurse he couldn't care for Patient 1, because the patient tried to "physically abuse me while changing him." He stated he told Staff E, RN, the day charge nurse, that he couldn't work with Patient 1. He stated Patient 1 physically abused him by trying to swing at him. Staff F, CNA, stated he had begun to try to change Patient 1's brief and was in Patient 1's room less than 10 minutes before he went to get Staff E, RN, to assist him.

During an interview on 01/13/21 at 9:19 AM, Staff E, RN, when asked why she did not document the allegation of sexual abuse in Patient 1's medical record, she stated she felt she had documented it by documenting the incident report. When told by the surveyor there was no documentation of an assessment for injury in the incident report, Staff E, RN, stated she didn't document it but should have. She stated "I don't know why I didn't document it. I guess if there was something [abnormal finding] I would have documented it." She stated she didn't realize the incident report did not become a part of the medical report. She stated she "wasn't aware of it [the incident report policy] at the time" when the policy was reviewed. Staff E, RN, stated she didn't recall Staff F, CNA, saying he didn't want to care for Patient 1. She stated she notified the CNO at the time of the allegation and Patient 1's son who had visited after the incident. After reviewing the hospital's abuse policy, Staff E, RN, confirmed she did not follow the abuse policy.

During an interview on 01/13/21 at 9:59 AM, Staff C, CNO, confirmed the staff did not follow the abuse policy.

During an interview on 01/13/21 at 10:34 AM, Staff A, Administrator, stated when he read the incident report on 01/11/21 (first day of the survey), he didn't recall the report. He stated he gets all the incident reports. After reviewing the hospital's abuse policy, Staff A, Administrator confirmed staff did not take actions in accordance with the hospital's abuse policy.

During an interview on 01/13/21 at 11:31 AM, Staff A, Administrator, reviewed the abuse policy that showed the alleged perpetrator was to be removed from patient care until the incident is investigated. He confirmed that hospital staff reassigned Staff F, CNA, but failed to remove him from patient care.

Based on record reviews, policy review, and interviews, the hospital failed to ensure: the registered nurse (RN) clarified physician orders for pain medication that did not have the exact strength and specific instructions for use for two (Patient 1, Patient 2) of nine patient records reviewed for pain medication orders from a sample of 14 patients. This failure had the potential to cause serious harm or injury to the 39 patients receiving care in the hospital and any future patient admitted to the hospital.

Findings Include:

Review of the policy titled "Medication Administration Record and Medication Administration," revised 11/06/20, showed ". . . Prior to administering the medication, the nurse will verify against the Medication Administration Record (MAR): . . . the dose strength on the package or unit dose package ... Further review of the policy, "The Medication Administration record (MAR) will: Provide a legible record on a daily basis of medications ordered and administered to hospitalized patients. . ."

There was no documented evidence that policy addressed the order should include the exact strength and specific instructions for use related to the pain scale and the need for the nurse to clarify the order if there was a discrepancy.

1. Review of Patient 1's medical record showed a physician's order, under the "Patient Experience" tab, for Tylenol 325 mg (milligrams) tabs Q (every) 4 hours prn ( as needed) for mild to moderate pain (1-6) on 09/23/20 at 4:52 PM and Hydrocodone-Acetaminophen (Norco) 5-325 mg tabs 1 tab prn Q 6 hours for moderate to severe pain (4-10). There was no documented evidence that the registered nurse (RN) clarified the order with the physician to address the overlapping pain scale.

During an interview on 01/12/21 at 8:43 AM, Staff B, Director of Quality Management (DQM), stated the nursing staff should have clarified the pain medication order with the physician to obtain the specific pain medication to administer for Patient 1's pain scale.


2. Review of Patient 2's medical record showed an order, located in the "Patient Experience" tab, on 12/08/20 at 4:42 PM for Tylenol 650 mg by mouth every 6 hours as needed for mild pain (1-3). Further review showed an order for Hydrocodone-Acetaminophen 7.5-325 mg one tab by mouth for moderate-severe pain (4-10) and severe pain (7-10). The RN failed to clarify the overlapping pain medication order.

During an interview on 01/12/21 at 8:43 AM, Staff B, Director of Quality Management (DQM), stated the nursing staff should have clarified the pain medication order with the physician to obtain the specific pain medication to administer for a specific pain level.


3. Review of Patient 8's medication administration record (MAR) showed an order for oxycodone HCL 5 mg one tab by mouth every four hours prn for moderate pain (4-6) or severe pain (7-10). Further review showed Staff P, Licensed Practical Nurse (LPN) administered oxycodone HCL 5 mg by mouth on 01/07/21 at 10:28 PM for a pain scale of 3 and on 01/08/21 at 3:00 AM for a pain scale of 3. Patient 8's MAR failed to address medication orders for a pain level of 3.

During an interview on 01/12/21 at 1:46 PM, Staff D, RN Nurse Manager, stated Staff P, LPN, is a new LPN, and she (Staff D, RN Nurse Manager) will need to re-educate her (Staff P, LPN) on an order with overlapping pain scales.