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Based on observation, interview, and record review, the facility failed to correctly and safely apply non-violent ankle restraints (soft restraint [any physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move freely] used to manage behaviors which interfere with medical care) for one of 30 sampled patients (Patient 11), in accordance with the facility's policy and procedures regarding restraints use.

This deficient practice had the potential to cause injury or death to Patient 11 such as skin tear, etc.

Findings:

During a review of Patient 11's Face Sheet (a document that gives a patient's information at a quick glance), dated 2/19/2024, the Face Sheet indicated Patient 11 was admitted to the facility on 2/19/2024 at 11:56 a.m. with diagnoses of alcohol withdrawal (reduction in alcohol use after a period of excessive use) and seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain).

During a concurrent observation and interview on 2/21/2024 at 11:25 a.m. with Nurse Manager 3 (NM 3), Patient 11 was observed in non-violent ankle restraints (soft restraint [any physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move freely] used to manage behaviors which interfere with medical care) to both ankles, a roll belt restraint (belt applied around the torso to protect the patient from rolling out of bed and falling to the floor), and a patient sitter, while lying flat on his (Patient 11's) back. NM 3 said that ankle restraints were applied to Patient 11's ankles because the patient kicked facility staff. When Patient 11's blanket was removed by NM 3, observed Patient 11's ankle restraint straps attached and clipped together. NM 3 stated that this is not the correct way to apply ankle restraints and that the restraints should be individually applied to the patient and not clipped or tied together. Observed NM 3 unclip Patient 11's ankle restraints and apply the straps individually to each ankle restraint, so each leg was restrained individually. NM 3 checked each ankle restraint strap which was tied to the bed frame with a slipknot (knot that is secured, but can be easily released in an emergency, using one hand). NM 3 stated that the ankle restraints should be tied to the bed individually so the patient can move freely.

During an observation on 2/21/2024 at 11:37 a.m. with Patient 11, observed Patient 11 reposition himself to lay on his (Patient 11's) right side following ankle restraint readjustment by NM 3.

During a concurrent observation and interview on 2/21/2024 at 11:32 a.m. with Registered Nurse 10 (RN 10), RN 10 stated that she (RN 10) was the primary nurse assigned to Patient 11. RN 10 was made aware NM 3 adjusted Patient 11's ankle restraints because they were applied incorrectly, with the straps clipped together. RN 10 said that she (RN 10) was unaware Patient 11's restraints were previously incorrectly applied, with the restraints clipped together, and she was unaware who applied them incorrectly. RN 10 stated that she (RN 10) last checked Patient 11's restraints at 10 a.m., and that Patient 11's ankle restraints were applied individually during her last assessment. Observed RN 10 demonstrate the application of ankle restraints with the restraints individually applied and strap tied to the bed frame with a slipknot. RN 10 said that if restraints were not applied correctly, there is not enough room for the patient to do range of motion (ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point) and movement was restricted.

During an interview on 2/21/2024 at 10:11 a.m. with Nursing Professional Development Specialist (EDU), EDU stated that if ankle restraints were incorrectly applied, this was a safety issue, and the patient can have problems with ROM.

During a concurrent interview and record review on 2/23/2024 at 12:30 p.m. with Nurse Manager of Medical-Surgical (NM 2), RN10's skilled validation checklist titled, "Restraints Application: Acute Care and Emergency Department," dated 4/13/2023, was reviewed. NM 2 verified that there were no ankle restraints included in the skills validation checklist. NM 2 stated ankle restraints should have been included in the skills validation checklist because it was important for staff to know how to use and apply ankle restraints correctly, otherwise it could lead to patient injury.

During a review of the facility's Policy and Procedure (P&P), dated 2/2022, titled "Restraints and Seclusion (involuntary confinement of a patient alone in a room or area from which the patient was physically prevented from leaving)," the P&P indicated: "Purpose: To guide the appropriate and safe management of adult and pediatric patients who are restrained and/or in seclusion. To guide on appropriate utilization of alternatives to restraint and/or seclusion, as well as nonphysical interventions ... V. Restraint Category A. Non-Violent or Non-Self Destructive 1. Used to promote healing and improve the patient's well-being ... II. Selecting the Least Restrictive Type: The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm ... G. Limb Holder (soft), wrist and/or ankle (1-4) points ... Safe Application of Restraints A. Restraints will be applied correctly and appropriately according to the manufacturer's recommendation by competent, trained staff ... C. Soft restraint straps will be secured to the bed frame (not to side rails) using a quick-release buckle supplied with the restraint, or tied such that they can be released quickly and easily in an emergency ..."

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.a. The facility failed to follow State and Federal regulatory standards regarding nurse-to-patient ratios (number of patients a registered nurse can care for at one time) and safe patient care assignments when Registered Nurses (RNs) cover each other for meal breaks (30 minutes lunch break) in three (3) of three sampled units (Cardio- Thoracic unit [CTU, a unit that specializes in the care of patient with heart, lungs, and chest conditions], Surgical-Trauma unit [STU, 32 bed unit, specializing in the delivery of care to the general surgical patients and post-operatively], and the Direct Observation Unit [DOU, unit that provides the second-highest level of care]). The nurse-to-patient ratio in CTU and STU was either 1: 4 or 1: 5 (one nurse to 4 or 5 patients) while DOU was 1: 3 (one nurse to 3 patients). When covering meal breaks, each RN assumed the care of additional 3 or 4 patients aside from their own assigned 3, 4 or 5 patients.

This deficient practice had the potential to result in patient needs not being met (Refer to A-0392)

1.b. The facility failed to ensure Patient Flow Coordinators (Charge Nurses) remained free of direct patient care duties that prevented charge nurses from fulfilling the functions of the Patient Flow Coordinator (PFC) or (Charge Nurse) role, when charge nurses were assigned as the PFC (PFC or Charge Nurse, oversee the operations of their specific nursing unit during a set period while working alongside the team) and had patient assignments of their own concurrently for one of 3 sampled Charge Nurses (CN 3).

This deficient practice resulted in CN 3 being unable to fulfill assigned Charge Nurse duties and also had the potential to compromise the quality of care provided to patients. (Refer to A-0392)

2. The facility failed to ensure the registered nurse (RN 20) provided oversight over licensed vocational nurse's (LVN1) assessments for one of 30 sampled patients (Patient 24), in accordance with the facility's policy and procedure regarding assessment (in depth evaluation conducted by a registered nurse that evaluates a patient's current physical, mental and emotional state) and reassessment and professional standards of practice.

This deficient practice resulted in assessments documented by LVN1 without RN 20's oversight and had the potential for an inaccurate assessment of Patient 24's condition which may result in Patient 24's care needs not being addressed. (Refer to A-0395)

3.a. The facility failed to ensure Nursing staff developed, maintained and nursing updated care plans (provides a framework for evaluating and providing patient care needs related to the nursing process) specific to infection control and diarrhea (frequent watery stools) for one of 30 sampled patients (Patient 8).

This deficient practice had the potential to result in the delay of treatment by not identifying the patient's (Patient 8) needs and risks, which may result in worsening of the patient's (Patient 8) condition and prolonged hospitalization. (Refer to A-0396)

3.b. The facility failed to ensure nursing staff develop the nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for hemodialysis (a machine filters wastes, salts and fluid from the blood when kidneys are no longer functioning) management for one of 30 sampled patients (Patient 22). This deficient practice had the potential to result in Patient 22 not knowing how to manage hemodialysis including how to manage new dialysis catheter (device used during hemodialysis). (Refer to A - 0396)

4.a. The facility failed to ensure the dialysis nurse had dialysis (dialysis machine cleans blood and moves it back into the body) vascular access (an access point for the dialysis machine to connect to the blood stream) site and the blood line connections continuously visible throughout the dialysis treatment for one of 30 sampled patients (Patient 1) in accordance with the facility's policy and procedure regarding dialysis monitoring. This deficient practice had the potential to compromise Patient 1's well-being if an accidental disconnection of a line went undetected which may result in complications such as bleeding, etc. (Refer to A-0398)

4.b. The facility failed to ensure nursing staff followed infection precautions guidelines (example: hand hygiene, use of gloves and masks) for one of 30 sampled patients (Patient 8), when one of one Registered Nurse (RN 18) used a hand sanitizer (alcohol based gel or liquid used to kill some forms of germs or infectious bacteria) after coming out of an isolation precaution (used to reduce transmission of microorganisms in the healthcare setting) patient room (Patient 18) instead of washing hands with soap and water in accordance with the facility's policy and procedure on infection control.

This deficient practice had the potential to cross-contaminating (when bacteria or other microorganisms are unintentionally transferred from one object to another) other patients and staff with infectious micro-organisms, which may cause patients and staff to get sick. (Refer to A-0398)

4.c. The facility failed to label the administration set for Intravenous (IV) infusion (a method of putting fluids, including drugs, into the bloodstream) with the date, time hung, and personnel's initials for one of 30 sampled patients (Patient 6) in accordance with the facility's policy and procedure regarding labeling administration set for IV infusions after 72 hours from the time the IV tubing was used.

This deficient practice had the potential to place Patient 6 at risk for phlebitis (inflammation of the walls of a vein) or contamination (growing microorganisms, that may cause infections) associated with catheter (a device used to draw blood and give treatments) related bloodstream complications. (Refer to A-0398)

4.d. The facility failed to discontinue an order for physical restraints (any physical or mechanical device material or equipment that immobilizes or reduces the ability of the patient to move his or her arms, legs, body or head freely, or prevent the patient from voluntary exiting the bed) and remove restraints from the room of one of 30 sampled patients (Patient 10) in accordance with the facility's policy and procedure regarding the use of restraints.

This deficient practice had the potential to compromise Patient 10's safety due to unnecessary use of restraints, which may result in complications such as skin tear, etc. (Refer to A-0398)

4.e. The facility failed to complete a pain reassessment (a process where a nurse reevaluates a patient's health information for new information or changes) for one of 30 sampled patients (Patient 13) after pain medications were given. This deficient practice had the potential for delayed medical care and treatment to Patient 13, when Patient 13's response to medication is not reassessed on time thus preventing the use of other alternative methods to relieve Patient 13's pain. (Refer to A-0398)

4.f. The facility failed to provide an interpreter and consent forms in a language the patient can understand for one of 30 sampled patients (Patient 14), during the informed consent (the process in which a healthcare provider educates a patient about the risks, benefits and alternatives, of a given procedure or intervention) process in accordance with the facility's policy and procedure regarding the use of translator/interpreter services (facilitates communication between healthcare providers and non-English speaking patients to provide the best possible quality of care).

This deficient practice had the potential for Patient 14 to not understand the medical care and procedures Patient 14 was consenting to and may lead to unwanted medical care and procedures. (Refer to A-0398)

4.g. The facility failed to ensure staff followed the facility's policy and procedure on proper intravenous tubing (IV tubing, used to deliver medications to the vein via a machine pump) labeling and handling for one of 30 sampled patients (Patient 25) as the IV tubing was not labeled and covered with sterile cap (cap to cover endling of the IV tubing to prevent infection). This deficient practice had to potential for Patient 25 to develop infection due to contaminated IV line. (Refer to A-0398)

4.h. The facility failed to ensure staff to use translator service (facilitates communication between healthcare providers and non-English speaking patients to provide the best possible quality of care) based on patient's language preference in Spanish when obtaining for informed consent (the process in which a healthcare provider educates a patient about the risks, benefits and alternatives, of a given procedure or intervention) for one of 30 sampled patients (Patient 22) in accordance with the facility's policy and procedure regarding the use of translator/interpreter services.

This deficient practice had the potential for Patient 22 not receiving accurate and current information in the language Patient 22 could understand which might result in Patient 22 not understanding information regarding his (Patient 22) treatment plan. (Refer to A-0398)

4.i. The facility failed to ensure nursing staff documented date and time when obtaining telephone informed consent (the process in which a healthcare provider educates a patient about the risks, benefits and alternatives, of a given procedure or intervention) from the emergency contact for one of 30 sampled patients (Patient 27) in accordance with the facility's policy and procedure regarding informed consents. This deficient practice had the potential to result in causing confusion and violate Patient 27's rights as it was unknown if the informed consent obtained was before or after the procedure. (Refer to A-0398)

4.j. The facility failed to ensure nursing staff documented the type of restraints (a physical restraint is any manual method, material or equipment that is attached to patient's body that cannot be easily removed and restricts freedom of movement) use and alternative interventions for one of 30 sampled patients (Patient 26) from 2/16/2024 to 2/18/2024, in accordance with the facility's policy and procedure regarding restraints use and documentation.

This deficient practice had the potential to result in unnecessary use of restraints on Patient 26 as it was lacking alternative intervention attempt and unclear what type of restraints being used on Patient 26 putting Patient 26 at risk for injury and delaying removal of restraints. (Refer to A-0398)

5. The facility failed to ensure nursing staff gave medications only ordered by a physician when a Registered Nurse (RN 17) gave insulin Lispro (insulin to treat control blood sugar) to one of 30 sampled patients (Patient 21) without a physician order.

This deficient practice had the potential for Patient 21 not getting appropriate insulin (medication used to lower blood sugar via injection) dosage to manage the elevated blood glucose (blood sugar), which may result in complications such as excessively low blood sugar, coma (state of prolonged loss of consciousness) or death. (Refer to A-405)

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:

1. Follow State and Federal regulatory standards regarding nurse-to-patient ratios (number of patients a registered nurse can care for at one time) and safe patient care assignments when Registered Nurses (RNs) cover each other for meal breaks (30 minutes lunch break) in three (3) of three sampled units (Cardio- Thoracic unit [CTU, a unit that specializes in the care of patient with heart, lungs, and chest conditions], Surgical-Trauma unit [STU, 32 bed unit, specializing in the delivery of care to the general surgical patients and post-operatively], and the Direct Observation Unit [DOU, unit that provides the second-highest level of care]). The nurse-to-patient ratio in CTU and STU was either 1: 4 or 1: 5 (one nurse to 4 or 5 patients) while DOU was 1: 3 (one nurse to 3 patients). When covering meal breaks, each RN assumed the care of additional 3 or 4 patients aside from their own assigned 3, 4 or 5 patients.

This deficient practice had the potential to result in patient needs not being met.

2. Ensure Patient Flow Coordinators (Charge Nurses) remained free of direct patient care duties that prevented charge nurses from fulfilling the functions of the Patient Flow Coordinator (PFC) or (Charge Nurse) role, when charge nurses were assigned as the PFC (PFC or Charge Nurse, oversee the operations of their specific nursing unit during a set period while working alongside the team) and had patient assignments of their own concurrently for one of 3 sampled Charge Nurses (CN 3).

This deficient practice resulted in CN 3 being unable to fulfill assigned Charge Nurse duties and also had the potential to compromise the quality of medical care delivered to patients.

Findings:

1. During an interview on 2/22/2024 at 8:00 p.m. with the patient flow coordinator (charge nurse- CN 12) working at the Cardio-Thoracic Unit (CTU- a unit that specializes in the care of patients with heart, lungs, and chest conditions), CN 12 stated, the facility staffing grid (planning tools that assign the appropriate amount of staff to care for the number of patients in the unit) for the CTU required the Registered Nurses (RNs) are staffed at 1:5 or 1:4 (1 RN to 4 or 5 patient) ratios (number of patients a registered nurse can care for at one time), and should have a charge nurse, 8 nurses, 4 CNAs and a break nurse. CN 12 stated, when there was no break relief nurse (covers the 15 minutes and the 30 minutes meal break) on duty, if charge nurse was unable to cover staff RN for their breaks, nurses cover each other for break relief, and are forced to go out of ratio (when 1 RN who had 4 or 5 patients assumes the care of additional 4 or patients from another RN going on break) which may diminish the quality of patient care making it difficult to meet patient needs.

During an interview on 2/22/2024 at 8:10 p.m. with Patient Flow Coordinator (Charge Nurse -CN 11) working at the Surgical Trauma Unit (STU- a 32 bed unit, specializing in the delivery of care to the general surgical patients and post-operatively), CN 11 stated, the STU assignments were made based on State Regulations, and Registered Nurses (RNs) are staffed at 1:5 (1 RN to 5 patients) for medical surgical patients and 1:4 (1 RN to 4 patients) for patients with telemetry (patients undergo continuous cardiac [heart] monitoring). CN 11 further stated, per facility's staffing grid requirements, the unit should have a charge nurse, 8 RNs, 4 Certified Nursing Assistants or Patient Care Providers (PCPs), and ideally a break nurse to cover nurses for rest breaks and lunches. CN 11 further said, there were numerous shifts the facility did not provide a break nurse to cover breaks and lunches and nurses had to cover each other for their breaks, which forces them out of ratio when they cover each other during their 30 minutes lunch breaks and two 10-minute rest breaks. CN 11 further stated, when the unit was not sufficiently staffed, patient care delivery was compromised.

During an interview on 2/22/2024 at 8:20 p.m. with the Patient Flow Coordinator (Charge Nurse- CN 13) working nights at the Direct Observation unit (DOU, a unit that provides the second-highest level of care), CN 13 stated, the facility's DOU unit specializes in caring for very sick patients. CN 13 said, the facility's staffing grid requires the DOU to be staffed with 11 RNs, 3 CNAs, and ideally there should be a break nurse provided. CN 13 further stated, "Lately, the facility is unable to provide break relief nurses for the unit." CN 13 stated, when there was no break nurse relief to cover nurses on their breaks, nurses have to go out of ratio (DOU staffed at 1:3 (1 RN to 3 patients) when covering each other for breaks. CN 13 stated, the DOU unit had high acuity (means that patients' condition is severe and imminently dangerous) patients and when the staffing grid was not met for the unit, patients may not be receiving the best quality care as they should.

During an interview on 2/23/2024 at 11:53 a.m. with the Director of Clinical Resource (DCR), DCR stated, the facility provided staffing budget for break nurses but at times staffing the floors with break nurses can be difficult. DCR further stated, for the facility to meet the staffing grid requirements and supplement for adequate staffing, the facility brings registry nurses and hires traveler nurses, but staffing was not an easy task in the last couple of months. DCR also stated, charge nurses occasionally must take on patient assignments while also continuing to perform charge nurse's duties on the assigned unit and nurses cover each other on their 30 minutes rest periods which places them briefly out of ratio while caring for their patients.

During a concurrent interview and record review on 2/23/2024 at 11:58 a.m. with DCR, the Cardio-Thoracic unit's Break Assignment Sheet (BAS) for the night shift (7 p.m.-7 a.m.), dated 2/18/2024, was reviewed. The BAS indicated, PFC (Charge Nurse) had 4 assigned patients while being assigned charge nurse (PFC) duties; all licensed nurses had 4 patients assigned to them, and all licensed nurses had to cover each other for breaks (two 15 min breaks, and 30-minute lunch). DCR stated, when nurses cover each other for their breaks, they are going out of ratio, because they must cover additional 4 patients during the entire break period. DCR further stated, when nurses are under- staffed, patients may not receive the proper care and may not be properly monitored.

During an interview on 2/23/2024 at 12:23 p.m. with the nurse manager (NM 4) of the Surgical Trauma Unit (STU), NM 4 stated, nursing core staffing for the STU required 8 to 9 nurses to be scheduled daily. NM 4 also stated, nurses should not be covering each other for meal breaks, and should not take meal breaks if unable to, because the facility reimburses nurses for their missed meal breaks.

During an interview on 2/23/2024 at 1:24 p.m. with Registered Nurse (RN) 11, working in DOU, RN 11 stated, the facility often was unable to staff the floor with a break nurse and nurses cover each other for lunches and rest breaks. RN 11 said, the RN's staffing ratio in this unit was 1:3 (1 RN to 3 patients), and when nurses cover each other for their meal relief breaks, nurses go out of ratio, often overseeing 6 patients at a time.

During an interview on 2/23/2024 at 1:35 p.m. with Registered Nurse (RN) 12, working in DOU, RN 12 stated, nurses do not have an option to miss their meal breaks, and when there was no break relief nurse, nurses cover each other for their breaks, caring for 6 patients while covering.

During a review of the facility's STU Unit Assignment Sheets (UAS), dated 2/17/2024 and 2/18/2024, night shift, the UAS indicated, on both dates, charge nurse was assigned charge nurse duties, while taking care of 4 patients.
During a review of the facility's CTU Unit Assignment Sheets (UAS), dated 2/16/2024, 2/17/2024, and 2/21/2024, night shift, nurses covered each other for break relief.

During a review of the facility's 5 CTU Unit Assignment Sheet (UAS), dated 2/20/2024, day shift, the assignment indicated, nurses covered each other for their meal breaks.

During a review of the facility's policy and procedure (P&P) titled, "Hospital Plan for the Provision of Patient Care Services," dated 9/1/2020, the P&P indicated, "Patient care is directed, organized, and staffed on the basis of the identified needs of the patient. Staffing a patient care unit with patient care personnel is guided by a patient classification system, patient acuity (measure of a patient's severity of illness), and mandated staffing ratios (the maximum number of patients a nurse can be responsible for in a shift)."

During a review of the facility's policy and procedure (P&P) titled, "Hospital Plan for the Provision of Patient Care Services," dated 9/1/2020, the P&P indicated, "Staffing is assessed and adjusted on an ongoing basis to provide optimal patient care. Schedules are adjusted on an ongoing basis to meet patient care demands and may include adding additional staff, re-assignment of staff, or modification of the care delivery model."

During a review of the facility's policy and procedure (P&P) titled, "Meal and Rest Periods," dated 1/22/23, the P&P indicated, "Managers are responsible for providing meal periods and authorizing and permitting rest periods to the staff in accordance with the policy. Managers and their designees may not impede or discourage employees from taking meal and or rest periods in accordance with the policy."

2. During an interview on 2/22/2024, at 8:00 p.m., with patient flow coordinator (Charge Nurse- CN 12) working at the Cardio-Thoracic Unit (CTU, a unit that specializes in the care of patients with heart, lungs, and chest conditions), CN 12 stated, the facility staffing grid (planning tools that assign the appropriate amount of staff to care for the number of patients in the unit) for the unit required the Registered Nurses (RNs) are staffed at 1:5 or 1:4 (1 RN to 4 or 5 patients) ratios, and should have a charge nurse, 8 nurses, 4 CNAs and a meal break nurse. CN 12 stated, typically, the floor should have a charge nurse on duty, but often, the charge nurse must take on patients' assignments while they continue performing charge nurse duties.

During an interview on 2/22/2024 at 8:10 p.m. with the Patient Flow Coordinator (Charge Nurse -CN 11) working at the Surgical Trauma Unit (STU -32 bed unit, specializing in the delivery of care to the general surgical patients and post-operatively), CN 11 stated, the unit assignments were made based on State Regulations, and Registered Nurses (RNs) were staffed at 1:5 (1 RN to 5 patients) for medical surgical patients and 1:4 (1 RN to 4 patients) for patients with telemetry (patients undergo continuous cardiac [heart] monitoring). CN 11 further stated, per facility's staffing grid requirements, the unit should have a charge nurse. CN 11 further stated, lately, the unit charge nurses working night shifts had to take on patient assignments in addition to performing charge nurse duties due to insufficient staffing.

During an interview on 2/22/2024 at 8:20 p.m. with the Patient Flow Coordinator (Charge Nurse- CN 13) working nights at the Direct Observation unit (DOU- a unit that provides the second-highest level of care), CN 13 stated, the facility's DOU specializes in caring for very sick patients. CN 13 said, the facility's staffing grid required the DOU to be staffed with 11 RNs, 3 CNAs, and ideally there should be a break nurse provided. CN 13 further stated, "Lately, the facility is unable to provide break relief nurses for the unit and as a charge nurse, I often go into care myself, while continuously providing support for the unit as a charge nurse, carrying on the charge nurse's duties because we have registry nurses, that often need help, we have nurses that need guidance, and we have orientees."

During an interview on 2/23/2024 at 11:53 a.m. with the Director of Clinical Resource (DCR), DCR stated, charge nurses occasionally must take on patient assignments while also continuing to perform charge nurse's duties on their assigned units.

During a concurrent interview and record review on 2/23/2024 at 11:58 a.m. with DCR, the Cardio-Thoracic Unit Break Assignment Sheet (BAS) for the night shift (7 p.m.-7 a.m.), dated 2/18/2024, was reviewed. The BAS indicated, PFC or Charge Nurse (CN 3) had 4 assigned patients while being assigned charge nurse (PFC) duties.
During an interview on 2/23/2024 at 12:23 p.m. with the nurse manager (NM 4) of the STU, NM 4 stated, nursing core staffing for the unit required 8 to 9 nurses to be scheduled daily. NM 4 further stated, the goal was to always have a charge nurse (or also called Patient Flow Coordinator, PFC) present in the unit, but occasionally, PFCs needed to take patient assignments to maintain nurses in the ratio (Ratio of 1 RN to4 Patients or 1 RN to 5 Patients).

During a review of the facility's STU Unit Assignment Sheets (UAS), dated 2/17/2024 and 2/18/2024, night shift, the UAS indicated, on both dates, charge nurse was assigned charge nurse duties, while taking care of 4 patients.
During an interview on 2/23/2024 at 1:24 p.m. with Registered Nurse (RN) 11, working in DOU, RN 11 stated charge nurses were expected to take patients assignments if necessary while continue performing charge nurse's duties.

During a review of a document titled, "Patient Flow Coordinator-Job description," dated, 5/2023, the document indicated, " Position of a Patient Flow Coordinator (PFC) entails the following responsibilities: coordination and management of patient flow operatives to meet department needs to ensure an efficient operation of the department by directing functions and activities: interpreting policies and procedures, standards, and regulation as applicable, provides clinical leadership of the unit's patient care team; plans for the timely completion of intake and discharge care processes and utilizes the nursing process to provide population specific patient care; Initiation and supervision of discharge planning with the RN; ensures patients safety, performs all the responsibilities and duties required by the assigned Unit/Division to ensure that the unique needs of the patient are addressed; actively participates in the Code Blue Response Team"

During a review of the facility's policy and procedure (P&P) titled, "Hospital Plan for the Provision of Patient Care Services," dated 9/1/2020, the P&P indicated, "Patient care is directed, organized, and staffed on the basis of the identified needs of the patient. Staffing a patient care unit with patient care personnel is guided by a patient classification system, patient acuity (measure of a patient's severity of illness), and mandated staffing ratios (the maximum number of patients a nurse can be responsible for in a shift)."

Based on interview and record review, the facility failed to ensure the registered nurse (RN 20) provided oversight over licensed vocational nurse's (LVN1) assessments for one of 30 sampled patients (Patient 24), in accordance with the facility's policy and procedure regarding assessment (in depth evaluation conducted by a registered nurse that evaluates a patient's current physical, mental and emotional state) and reassessment and professional standards of practice.

This deficient practice resulted in assessments documented by LVN1 without RN 20 oversight and had the potential for an inaccurate assessment of Patient 24's condition which may result in Patient 24's care needs not being addressed.

Findings:

During a review of Patient 24's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/16/2024, the H&P indicated, Patient 24 was admitted to the facility's rehabilitation unit (assists patients recovering from a serious injury, illness or surgery to regain strength) for physical therapy (helps manage movement and reduce pain in people with various conditions) and occupational therapy (assists patients to improve the skills that are needed to live life as independently as possible) after sustaining a fall (an unplanned descent to the floor with or without injury to the patient) with multiple fractures (broken bones) at left leg and left hip.

During an interview on 2/23/2024 at 1:10 p.m. with nurse manager (NM2) of the Medical-Surgical Unit (serves the general population hospitalized for various cases such as surgery, etc.), NM2 stated registered nurses in the rehabilitation unit were responsible to oversee licensed vocational nurse's patients as assigned. The covering RN was required to co-sign and validate the findings documented by the LVN.
During a review of the Rehabilitation unit's Patient assignment sheet dated 2/19/2024, the Patient assignment sheet indicated LVN1 was the assigned primary nurse for Patient 24, while RN 20 would cover (to co-sign and validate assessments) LVN1 for Patient 24.

During a concurrent interview and record review on 2/23/2024 at 2:38 p.m. with the nurse manager (NM2) of Medical-Surgical Unit, Patient 24's "Shift Assessment (nursing assessment, documentation of nursing assessment for patient in Rehab)," dated 2/19/2024 was reviewed. The nursing assessment indicated LVN1 recorded the nursing assessment on 2/19/2024 at 8 a.m. NM2 verified that there was no RN sign off on the nursing assessment recorded by LVN1. NM2 stated assessment was considered not done if it was not signed off and validated by a RN. NM2 also said RN 20 should have co-signed and validated LVN1's findings in the shift assessment for Patient 24 to ensure it was correct in order to identify patient's change of condition and modify plan of care.

During a review of the facility's policy and procedure (P&P) titled, "Scope of Service," dated 1/2024, the P&P indicated, "Patient Monitoring: Assessments are done every shift and as needed based on the patient's medical status."

During a review of the facility's job description for Licensed Vocational Nurse at Physical Rehab Care with no date, the job description indicated, "[LVN] are responsible for performing nursing services requiring technical and manual skills under the direction of the Registered Nurse or Physician."

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

1. Nursing staff developed, maintained and nursing updated care plans (provides a framework for evaluating and providing patient care needs related to the nursing process) specific to infection control and diarrhea (frequent watery stools) for one of 30 sampled patients (Patient 8).

This deficient practice had the potential to result in the delay of treatment by not identifying the patient's (Patient 8) needs and risks, which may result in worsening of the patient's (Patient 8) condition and prolonged hospitalization.

2. Nursing staff developed the nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for hemodialysis (a machine filters wastes, salts and fluid from the blood when kidneys are no longer functioning) management for one of 30 sampled patients (Patient 22).

This deficient practice had the potential to result in Patient 22 not knowing how to manage hemodialysis including how to manage newl dialysis catheter (device used during hemodialysis).

Findings:

1. During a review of Patient 8's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 2/18/2024, the H&P indicated, Patient 8 was admitted after a syncopal (fainting or passing out) episode and fall (an unplanned descent to the floor with or without injury to the patient). The H&P further indicated, Patient 8's Past Medical History (PMH, the total sum of a patient's health status prior to the presenting problem) included abdominal infections leading to multiple surgeries and a colostomy (an operation that creates an opening for the colon, or large intestine, through the abdomen) and ileostomy (an opening in the abdomen that's made during surgery to divert a piece of the small intestines), diabetes mellitus (a disease of inadequate control of blood levels of sugar), hypertension (the pressure in the blood vessels is above normal limits; normal BP 120/90 millimeters of Mercury [mmHg- a unit of measurement]) and chronic anemia (a condition in which the body does not have enough healthy red blood cells to carry oxygen).

During a review of Patient 8's medical record (MR) titled, "Infectious Disease Consultation Note," dated 2/20/2024, the MR indicated, Patient 8 had had diarrhea (a lot of loose stool output) and was ordered to have stool tested for the presence of gastrointestinal (GI, relating to the stomach and the intestines) pathogens (microorganism that can cause disease.)and C. difficile (Clostridioides difficile or C. difficile is a germ (bacterium) that causes diarrhea and inflammation of the colon).

During a review of Patient 8's medical record (MR) titled, "Order History," dated 2/20/2024, the MR indicated, the physician placed a continuous (until specified otherwise) order for isolation for "Contact Plus Precautions (Contact precautions isolation is intended to prevent transmission of infectious agents, which are spread by direct and indirect contact with the patient or the patient's environment and requires all staff interacting with the patient to wash hands with soap and water upon exiting the room instead of using alcohol rub because specific infectious organisms are not affected by the alcohol)."

During a concurrent interview and record review on 2/22/2024 at 3:35 p.m. with informatics nurse specialist (INS), Patient 8's medical record (MR) titled, "Care Plans-Encounter Problems," dated 2/18/2024, last updated 2/22/2024, was reviewed. The MR indicated, nursing developed three care plans for Patient 8 to address risk for falls, pain, and impaired skin integrity. INS stated, no infection control and diarrhea care plans were developed, maintained, and updated by nursing for Patient 8.

During an interview on 2/23/2024 at 12:18 p.m. with nurse manager (NM 4), NM 4 stated, nursing staff should develop and update care plans for their patients. NM 4 further stated, each patient care plan must be individualized, based on patients' specific needs, because it allows nurses to plan for meeting patients' goals and monitoring the progress toward achieving goals. NM 4 further stated, if a patient is in "Isolation" status, there should be a care plan for isolation precautions (used to reduce transmission of microorganisms in healthcare settings).

During an interview on 2/23/2024 at 1:24 p.m, with Registered Nurse (RN 11), RN 11 stated, a patient's care plan should be specific to the patient's diagnosis and is developed upon admission with specific goals and should be updated every shift to be able to track patient's progress toward meeting the goals.

During an interview on 2/23/2024 at 1:35 p.m. with Registered Nurse (RN 12), RN 12 stated, patient care plan should be specific to the patient's diagnosis. The RN 12 further stated, if patient for instance had dialysis ordered, the care plan should be developed for the fluid and electrolyte imbalances, pain, and breathing pattern.

During a review of the facility's policy and procedure (P&P) titled, Interdisciplinary Plan of Care (IPOC)," dated 9/2020, the P&P indicated, "Nursing staff must develop and keep current nursing care plan for each patient. Each patient should receive care based on individualized IPOC because aspects of patient care, such as teaching, interventions, referrals, discharge planning, follow up, changes in plan are linked with the interdisciplinary plan of care."

2. During a review of Patient 22's nephrology consultation (physician examination and recommendation completed by kidney specialist), dated 2/20/2024, the consultation note indicated Patient 22 was admitted to the facility with diagnoses of hyperkalemia (high level of the electrolyte potassium in blood), and kidney failure (a condition in which kidneys are not functioning). The consultation note also indicated Patient 22 would be undergoing his first hemodialysis (a machine filters wastes, salts and fluid from the blood when kidneys are no longer functioning) on 2/21/2024 as part of the treatment plan.

During a concurrent interview and record review on 2/22/2024 at 10:35 a.m. with the Patient Safety Officer (PSO), Patient 22's care plan (provides a framework for evaluating and providing patient care needs related to the nursing process), dated 2/20/2024, was reviewed. The care plan indicated nursing had identified acute pain and risk for fall for Patient 22 as active problems on care plan. PSO stated the care plan was not complete because it did not address Patient 22's diagnosis and his (Patient 22) needs. PSO further stated Patient 22's care plan should have addressed fluid imbalance (occurs when you lose more fluid or water than your body can take in), electrolytes imbalance (occurs when certain mineral levels in your blood get too high or too low), and hemodialysis so that nursing staff can provide proper intervention and education for Patient 22. PSO further stated, otherwise it (lack or absence of a specific care plan) could result in difficulty in continuum of care, inconsistency in documentation and difficulty in evaluating Patient 22's response to care.

During an interview on 2/23/2024 at 11:21 a.m. with the Clinical Nurse Specialist (CNS), CNS stated the care plan should address Patient 22's diagnoses and chief complaint and identify problems by talking to Patient 22. Patient 22's care plan should have at least addressed knowledge deficit related to hemodialysis because he (Patient 22) was new to hemodialysis so that nursing staff can provide teaching on what to expect during hemodialysis and how to take care of the new dialysis catheter (device used during hemodialysis).

During a review of the facility's policy and procedure (P&P) titled, "Interdisciplinary Plan of Care," dated 9/2020, the P&P indicated, "Each patient will receive care based on an individualized IPOC (interdisciplinary plan of care) in collaboration with the interdisciplinary team ...Plan of care: a communication tool that identifies and prioritizes patient care and treatment needs including outcomes, interventions, indicators and goals ... A nursing IPOC is developed based on assessing the patient's needs upon admission from all available sources of assessment to develop a comprehensive picture of the patients' condition."

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

1. Ensure the dialysis nurse had dialysis (dialysis machine cleans blood and moves it back into the body) vascular access (an access point for the dialysis machine to connect to the blood stream) site and the blood line connections continuously visible throughout the dialysis treatment for one of 30 sampled patients (Patient 1) in accordance with the facility's policy and procedure regarding dialysis monitoring. This deficient practice had the potential to compromise Patient 1's well-being if an accidental disconnection of a line went undetected which may result in complications such as bleeding, etc.

2. Ensure nursing staff followed infection precautions guidelines (example: hand hygiene, use of gloves and masks) for one of 30 sampled patients (Patient 8), when one of one Registered Nurse (RN 18) used a hand sanitizer (alcohol based gel or liquid used to kill some forms of germs or infectious bacteria) after coming out of an isolation precaution (used to reduce transmission of microorganisms in the healthcare setting) patient room (Patient 18) instead of washing hands with soap and water in accordance with the facility's policy and procedure on infection control. This deficient practice had the potential to cross-contaminating (when bacteria or other microorganisms are unintentionally transferred from one object to another) other patients and staff with infectious micro-organisms, which may cause patients and staff to get sick.

3. Label the administration set for Intravenous (IV) infusion (a method of putting fluids, including drugs, into the bloodstream) with the date, time hung, and personnel's initials for one of 30 sampled patients (Patient 6) in accordance with the facility's policy and procedure regarding labeling administration set for IV infusions after 72 hours from the time the IV tubing was used. This deficient practice had the potential to place Patient 6 at risk for phlebitis (inflammation of the walls of a vein) or contamination (growing microorganisms, that may cause infections) associated with catheter (a device used to draw blood and give treatments) related bloodstream complications.

4. Discontinue an order for physical restraints (any physical or mechanical device material or equipment that immobilizes or reduces the ability of the patient to move his or her arms, legs, body or head freely, or prevent the patient from voluntary exiting the bed) and remove restraints from the room of one of 30 sampled patients (Patient 10) in accordance with the facility's policy and procedure regarding the use of restraints. This deficient practice had the potential to compromise Patient 10's safety due to unnecessary use of restraints, which may result in complications such as skin tear, etc.

5. Complete a pain reassessment (a process where a nurse reevaluates a patient's health information for new information or changes) for one of 30 sampled patients (Patient 13) after pain medications were given. This deficient practice had the potential for delayed medical care and treatment to Patient 13, when Patient 13's response to medication is not reassessed on time thus preventing the use of other alternative methods to relieve Patient 13's pain.

6. Provide an interpreter and consent forms in a language the patient can understand for one of 30 sampled patients (Patient 14), during the informed consent (the process in which a healthcare provider educates a patient about the risks, benefits and alternatives, of a given procedure or intervention) process in accordance with the facility's policy and procedure regarding the use of translator/interpreter services (facilitates communication between healthcare providers and non-English speaking patients to provide the best possible quality of care). This deficient practice had the potential for Patient 14 to not understand the medical care and procedures Patient 14 was consenting to and may lead to unwanted medical care and procedures.

7. Ensure staff followed the facility's policy and procedure on proper intravenous tubing (IV tubing, used to deliver medications to the vein via a machine pump) labeling and handling for one of 30 sampled patients (Patient 25) as the IV tubing was not labeled and covered with sterile cap (cap to cover endling of the IV tubing to prevent infection). This deficient practice had to potential for Patient 25 to develop infection due to contaminated IV line.

8. Ensure staff to use translator service (facilitates communication between healthcare providers and non-English speaking patients to provide the best possible quality of care) based on patient's language preference in Spanish when obtaining for informed consent (the process in which a healthcare provider educates a patient about the risks, benefits and alternatives, of a given procedure or intervention) for one of 30 sampled patients (Patient 22) in accordance with the facility's policy and procedure regarding the use of translator/interpreter services. This deficient practice had the potential for Patient 22 not receiving accurate and current information in the language Patient 22 could understand which might result in Patient 22 not understanding information regarding his (Patient 22) treatment plan.

9. Ensure nursing staff documented date and time when obtaining telephone informed consent (the process in which a healthcare provider educates a patient about the risks, benefits and alternatives, of a given procedure or intervention) from the emergency contact for one of 30 sampled patients (Patient 27) in accordance with the facility's policy and procedure regarding informed consents. This deficient practice had the potential to result in causing confusion and violate Patient 27's rights as it was unknown if the informed consent obtained was before or after the procedure.

10. Ensure staff documented the type of restraints (a physical restraint is any manual method, material or equipment that is attached to patient's body that cannot be easily removed and restricts freedom of movement) use and alternative interventions for one of 30 sampled patients (Patient 26) from 2/16/2024 to 2/18/2024, in accordance with the facility's policy and procedure regarding restraints use and documentation.

This deficient practice had the potential to result in unnecessary use of restraints on Patient 26 as it was lacking alternative intervention attempt and unclear what type of restraints being used on Patient 26 putting Patient 26 at risk for injury and delaying removal of restraints.

Findings:

1. During a review of Patient 1's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 2/15/2024, the H&P indicated, Patient 1 had past medical history (PMH, a record of information about a person's health) of End-stage renal disease (ESRD the final, permanent stage of chronic kidney disease), dialysis (the clinical filtering of blood as a substitute for the normal function of the kidney), and diabetes (elevated levels of blood glucose (or blood sugar) and was admitted due to increased shortness of breath (not being able to get enough air).

During a further review of Patient 1's medical record (MR) titled, "Physician's Progress Note," dated 2/20/2024, the MR indicated, Patient 1 required hemodialysis (kidney dialysis) treatment on 2/20/2024.

During an observation on 2/20/2024 at 11:07 a.m. Patient 1 was observed in Patient 1's room, alone, with dialysis machine performing hemodialysis treatment. The dialysis nurse was not in the room.

During a concurrent observation and interview on 2/20/2024 at 11:07 a.m. with dialysis registered nurse (RN 1), in the hallway, RN 1 was observed charting at the nurse station, across from Patient 1's room. Patient 1 and Patient 1's dialysis access site was not within the view from the nurse's station, and only the dialysis machine was observed from the nurse station where RN 1 was charting. RN 1 stated, "Patient 1 is in the room being dialyzed (treat [a patient] by means of dialysis) and the dialysis machine is within the RN 1's view and the alarm can be heard from the nurse station and Patient 1 can be attended immediately if needed."

During an interview on 2/20/2024 at 11:19 a.m. with dialysis RN (RN 1), RN 1 stated, dialysis nurses should stay inside the room with patients during dialysis treatment to monitor the patient while receiving treatment.

During an interview on 2/20/2024 at 12:35 p.m. with dialysis RN (RN 7), RN 7 stated, dialysis nurses should stay inside the room or right outside of the door to be able to always see patient and the dialysis machine because treatment changes may require an immediate action from the nurse at any time during the treatment.

During an interview on 2/23/2024 at 2:56 p.m. with dialysis charge nurse (CN 10), CN 10 stated, dialysis nurses should stay inside the room with the patient, overseeing the treatment and the patient's access sites and line connections, monitoring and obtaining vital signs (pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions every at 15 minutes intervals, monitoring level of consciousness [a person's awareness and understanding of what is happening in his or her surroundings]) and response to dialysis treatment.

During a review of the facility's policy and procedure (P&P) titled, "Intradialytic Treatment Monitoring," dated 10/2023, the P&P indicated, "The patient's vascular access site and the blood line connections needs to be continuously visible throughout the dialysis treatment. Allowing patients to cover access sites and line connections provides an opportunity for accidental needle dislodgement or a line disconnection to go undetected. The arterial and venous drip chamber levels should be observed and adjusted as needed."

2. During an observation on 2/21/2024 at 11:41 a.m. in Station 31, a registered nurse (RN 18) was observed using hand sanitizer (alcohol hand rub) before leaving Patient 8's room. The signage posted at the entry to Patient 8's room indicated, "Contact Plus Precautions," which read, "Wash hands with soap and water upon exiting the room; alcohol hand rub may be used upon entry."
During an interview on 2/21/2024 at 11:45 a.m. with registered nurse (RN 18), RN 18 stated, Patient 8 was placed in "Contact Plus Precautions," isolation due to a suspected case of unexplained/infectious diarrhea (loose stools). RN 18 further admitted using hand sanitizer before leaving Patient 8's room instead of washing hands with soap and water as per infection control policy.

During a review of Patient 8's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 2/18/2024, the H&P indicated, Patient 8 was admitted status post (after) syncopal (fainting) episode and fall (an unplanned descent to the floor with or without injury to the patient).

During a review of Patient 8's medical record (MR) titled, "Infectious Disease Consultation Note," dated 2/20/2024, the MR indicated, Patient 8 had past medical history (PMH, a record of information about a person's health) of partial colectomy (surgical procedure to remove part of the colon) and small bowel resection (a surgery to remove part of the small intestine, large intestine or both) with creation of left ileostomy (a procedure in which the lumen of the ileum, part of the small bowel, is brought through the abdominal wall via a surgically-created opening) and a colostomy (an opening into the colon from the outside of the body). The MR further indicated, Patient 8 had a lot of loose stool output and was ordered to have stool tested for gastrointestinal pathogens (a variety of viruses, bacteria, and parasites can cause infections of the digestive system and C. difficile (Clostridioides difficile or C. difficile is a germ that causes diarrhea and inflammation of the colon).

During a review of Patient 8's medical record (MR) titled, "Order History," dated 2/20/2024, the MR indicated, the physician placed a continuous (until specified otherwise) order for isolation with "Contact Plus Precautions (Contact precautions isolation is intended to prevent transmission of infectious agents, which are spread by direct and indirect contact with the patient or the patient's environment and requires all staff interacting with the patient to wash hands with soap and water upon exiting the room instead of using alcohol rub because specific infectious organisms are not affected by the alcohol)."

During a review of Patient 8's medica record (MR) titled, "Progress Note-Infectious Disease Specialist," dated 2/22/2024, the note indicated, Patient 8 continued to have persistent stool output; stool was positive for Yersenia enterecolitica (an infectious agent).

During an interview on 2/22/2024 at 10:30 a.m. with Infection Prevention Director (IPD), the IPD stated, nurses should perform handwashing with soap and water to rub-off pathogens because alcohol is not effective against specific infectious agents such as C. Difficille or others. The IPD further stated, nursing should follow infection control policies and procedures to prevent spread of infectious micro-organisms and cross-contamination (bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect).

During a review of the facility's policy and procedure (P&P) titled, "Infection Prevention and Control," dated 11/2022, the P&P indicated, "Any patient presenting with Candida auris, Clostridium difficile and Yersinia enterocolitica should be placed in Contact Plus Precautions which requires handwashing with soap and water upon exiting the room, wearing gloves and gown upon entering the room, and using bleach wipes for cleaning of equipment in between use."

3. During a review of Patient 6's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 2/11/2024, the H&P indicated, Patient 6 was admitted on 2/10/2024 with a diagnosis of pulmonary embolism (when a blood clot gets stuck in an artery in the lung, blocking blood flow to part of the lung), pulmonary infarct (the portions of lung served by each blocked artery can't get blood and may die), and pneumonia (lung inflammation caused by bacterial or viral infection).

During a review of Patient 6's electronic Medication Administration Record (eMAR, record of medications administered to the patient), dated 2/11/2024-2/22/2024, the eMAR indicated, Patient 6 last received intravenous (IV, medication delivered to bloodstream directly) linezolid (antibiotic, a medicine to destroy micro-organisms) on 2/21/2023.

During a concurrent observation and interview on 2/21/2024 at 11:01 a.m., with the Clinical Director of Medical Surgical unit (DMS), at the Direct Observation Unit (DOU, a hospital unit provide second-highest level of care), inside Patient 6's room, Patient 6's linezolid IV administration set was observed to be infusing. The IV tubing set contained no label, with the date, time hung, and personnel's initials when initiated. DMS stated, nursing should label all IV tubing with the date and time when initially hung, and the tubing should be changed in 72 hours per facility's policy.

During an interview on 2/21/2024 at 12:29 p.m. with charge nurse (CN3), CN 3 stated, nursing should change the IV tubing every 72 hours to prevent infection or other complications associated with IV catheter. CN 3 further stated, nursing should label the IV tubing with date and time hung, and initials of the registered nurse (RN) who hung the IV antibiotic.

During a review of the facility's policy and procedure (P&P) titled, "Medication Use, Administration, Routes and High Alert Medications," dated 8/2023, the P&P indicated "Any tubing intermittently connected to/disconnected from the patient is changed every 24 hours. This includes practices such as IVPB (intravenous piggy bag, a small bag of solution attached to a primary infusion line or intermittent venous access device to deliver medication over a specified period of time) that are not left continuously connected to the patient's primary IV tubing. Intermittent infusion sets are capped with a new sterile tubing cap after each use. If IV tubing is found without the sterile cap, or looped back onto one of its ports, it is discarded immediately and replaced. Secondary tubing connected continuously to another tubing in use continuously are changed every 7 days. If they are connected and disconnected from the patient, they are replaced every 24 hours."

4. During an observation on 2/21/2024, at 1:17 p.m., in the Emergency Department (ED responsible for providing treatment to patients arriving in the facility who are in need of immediate care), Patient 10 was observed sleeping in the room. Four-point restraints (devices that limit a patient's movement, and which restrain both arms and both legs) were observed to be attached to each corner of the bed, while Patient 10 was not physically restrained.

During a review of Patient 10's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 2/20/2024, the H&P indicated, Patient 10 was brought in by the police due to suicidal behavior (self-injurious behavior) and possible opiate (narcotic) intoxication (a temporary and reversible condition that affects the central nervous system after a person ingests certain substances, such as alcohol or drugs) and was placed on a 5150 Hold (involuntarily detention for a 72- hour psychiatric (mental, emotional, and behavioral conditions) hospitalization when evaluated to be a danger to others, or self or gravely disabled [a condition in which a person, as a result of a mental disorder, is unable to provide for his or her personal care needs such as hygiene, etc.]) in the ED.

During a review of Patient 10's medical record (MR) titled, "Psychiatric Consult," dated 2/21/2023, the MR indicated, Patient 10 was admitted to the ED on 2/20/2024, and placed on a 5150 Hold. The MR further indicated, Patient 10 became agitated in the ED, started punching windows and became aggressive with staff requiring Intramuscular (IM, administered into, a muscle) medication and physical restraints on 2/20/2024, until he calmed down and was released from restraints without injury. The MR indicated, Patient 10 continued to remain paranoid (obsessively anxious, suspicious, or mistrustful) with suicidal thoughts, and had to be hospitalized.

During an interview on 2/21/2024, at 1:19 p.m., with Emergency Department Manager (EDM), EDM stated, Patient 10 was placed in four-point restraints on 2/20/2024 at 6:21 p.m., but the restraints were physically removed at 6:44 p.m. after patient (patient 10) received IM sedative (calming) medications and fell asleep.

During a review of Patient 10's medical record (MR) titled, "Physician's Orders," dated 2/20/2024, the MR indicated, Patient 10 was ordered to be placed into four-point restraints due to demonstrating violent behavior, presenting with immediate and significant danger to self and or others. The MR further indicated the primary registered nurse (RN) could discontinue the order for restraints upon determination that the patient no longer meets restraint criteria.

During a concurrent interview and record review on 2/22/2024 at 4:00 p.m., with Informatics Nurse Specialist (INS), Patient 10's medical record (MR) titled, "Physician's Orders," dated 2/20/2024 was reviewed. The MR indicated, the initial order for four-point restraints was placed on 2/20/2024 at 6 :21 p.m., and expired on 2/20/2024 at 10:20 p.m. INS stated, the order for restraints remained active for four hours, and expired without being discontinued.

During a review of Patient 10's medical record (MR) titled, "Nursing ED Note," dated 2/20/2024 at 6:44 p.m., the MR indicated, primary nurse documented, Patient 10's restraints were discontinued.

During an interview on 2/23/2024 at 11:23 a.m. with Clinical Nurse Specialist (CNS 1), CNS 1 stated, as per facility's policy and procedure (P&P), if a patient no longer requires to be restrained, the restraint order should be discontinued, and the restraints should not be kept at bedside and should be removed from the room. CNS 1 further stated, nursing should discontinue an order for restraints if restraints are not in use.

During a review of the facility's policy and procedure (P&P) titled, "Restraint and Seclusion, "dated 2/2022, the P&P indicated, "All restraints orders are time limited, and restraints must be discontinued at the earliest possible time, regardless of the length of time identified in the order. Orders will not be accepted as a standing order or on an as needed basis."

During a review of the facility's policy and procedure (P&P) titled, "Restraint and Seclusion, "dated 2/2022, the P&P indicated, "Orders for Medication Administration against the patient's wishes are found under the Violent/Self Destructive orders. It is considered a type of physical restraint.

During a review of the facility's policy and procedure (P&P) titled, "Suicide Risk Assessment, Precautions and Psychiatric Holds," dated 10/2021, the P&P indicated, "When a patient has been identified as at risk for suicide ideation, all potentially harmful items, such as all detachable or unfixed equipment, must be removed from the room to deliver safe medical care."

5. During a review of Patient 13's Face Sheet (a document that gives a patient's information at a quick glance), dated 2/7/2024, the Face Sheet indicated Patient 13 was admitted to the facility on 2/7/2024 at 4:01 p.m. with a diagnosis of arm pain.
During a review of Patient 13's care plan (provides a framework for evaluating and providing patient care needs related to the nursing process), dated 2/20/2024, the care plan indicated a problem of pain. A review of care plan goals indicated a pain characteristic assessment (a pain description that includes location, radiation, mode of onset, character, exacerbating [makes worse] and relieving factors, and intensity).

During a concurrent interview and record review on 2/22/2024 at 11:10 a.m. with Process Excellence Specialist (PES), Patient 13's medical record was reviewed. The medical record indicated Patient 13 was given Norco (a combination [hydrocodone and Tylenol] opioid [class of drug] medication used to manage pain) 10 milligrams (mg, a unit of measurement)/325 mg on 2/20/2024 at 2:59 p.m. for 7/10 (severe) pain. PES stated that the indication for the Norco order (instructions a physician has written for a patient's treatment) was severe 7-10 pain. PES verified that a pain reassessment (a process where a nurse reevaluates a patient's health information for new information or changes) was not documented in Patient 13's medical record. Additionally, PES confirmed the pain assessment was missing the pain location. PES said that pain should be reassessed within 1 hour of administration to include a pain scale and location. PES said that if patient response to pain medication was not reassessed timely, it was unknown if the medication was effective and if other pain interventions were needed. PES further stated that if pain was not reassessed, the patient could have worsening pain.

During an interview on 2/23/2024 at 12:15 p.m. with Nurse Manager 4 (NM 4), NM 4 stated that a pain assessment should include documentation of a pain scale, intensity, and location. NM 4 said pain scale of 7-10 indicates severe pain and pain should be reassessed within 75 minutes per policy. NM 4 stated that pain should be reassessed to identify if the patient got relief from medications. NM 4 further stated that if pain was not reassessed, the patient can suffer in pain affecting sleep.

During a review of the facility's Policy and Procedure (P&P), dated 2/2022, titled "Pain Management," the P&P indicated: "Purpose: Pain is highly individual and variable and is one of the most feared aspects of illness, and one of the most common reasons for seeking healthcare interventions. The purpose of this policy is to provide guidelines for a collaborative interdisciplinary approach to pain management. The goals of pain management are: 1. Relief from physical suffering 2. Preservation or restoration of function 3. Sustained quality of life 4. Prevention of addiction
Policy: Pain management is a shared responsibility between the patient, providers and nursing. Opioid sparing strategies including multimodal analgesia and non-pharmacologic therapies should be considered when it is reasonable to do so.
Procedure: [the facility] Standard Pain ranges and relationship to functional ability) ... C. Severe: Pain levels 7-10: Unable to do normal activities (for this patient). Hard or unable to think, talk or move or do ADLs. Hard or unable to enjoy life because of pain ...
C. Continuing Pain Assessment (after Admission/Arrival Pain Assessment): 1. Shift Assessment a. Type of Assessment (Assessment or Post-Intervention Reassessment) ...

3. Timing of reassessments ("Post-Intervention Reassessments"): a. The reassessment task fires immediately. This reassessment occurs within 75 minutes following administration. When documenting reassessment select "Post Intervention Reassessment ..."
6. During a review of Patient 14's Face Sheet (a document that gives a patient's information at a quick glance), dated 2/12/2024, the Face Sheet indicated Patient 14 was admitted to the facility on 2/12/2024 at 7:41 a.m. with a diagnosis of leg pain. Patient 14's Face Sheet further indicated Patient 14's preferred language was Spanish.

During a review of Patient 14's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 2/12/2024, indicated Patient 14 had acute left lower extremity ischemia (inadequate blood supply) with occlusion (blockage) of left external iliac artery (provides blood to the legs, pelvis, reproductive organs and other organs in the pelvic area) and everything distal (away from a particular point in the body). Patient 14's H&P further indicated Patient 14 underwent emergent revascularization (procedure that restores blood flow) and fasciotomies (procedure to relieve pressure in the muscle compartment).

During a concurrent interview and record review on 2/22/2024 at 1:45 p.m. with Process Excellence Specialist (PES), Patient 14's medical record (a record of a patient's medical information) titled "Consent for Transfusion of Blood Components," dated 2/12/2024 at 12:49 p.m. was reviewed. The medical record indicated staff did not document the interpreter's name, identification number and language in Patient 14's medical record. PES said that when a patient does not speak English as the primary language, communication should be in the patient's primary language. PES said that the use of an interpreter should be documented by staff in the medical record. PES stated that when the patient is not consented in their primary language, the patient may not understand what they are consenting for. PES further stated that the medical care or procedure may go against the patient's wishes due to miscommunication.

During a concurrent interview and record review on 2/23/2024 at 12:15 p.m. with Patient Safety Officer (PSO) and Nurse Manager 4 (NM 4), Patient 14's medical record, dated 2/12/2024 at 12:09 p.m., titled "Authorization for and Consent to Surgery, Care, Treatment, Special Diagnostic or Therapeutic Procedures," indicated "Procedure(s): Left lower extremity thrombectomy (to remove a blood clot from inside an artery or vein), possible fasciotomy." PSO confirmed the medical record indicated the physician did not document the interpreter's name, identification number and language in Patient 14's consent form or in the medical record. NM 4 confirmed Patient 14's Face Sheet indicated the Patient's primary language was Spanish. NM 4 said that Patient 14's consent should have been in Spanish. NM 4 stated that the consent should be in a language that the patient understands so the patient knows what they are consenting for.

During a review of the facility's Policy and Procedure (P&P), titled "Patient Non-Discrimination, Rights and Responsibilities," dated 8/2021, the P&P indicated: "Purpose: To articulate the hospital's policy on patient non-discrimination, and the rights of patients and ethical obligations of Huntington Hospital (HH) to its patients and their families and visitors, community, employees, medical staff, volunteers and professional and business relationships. To articulate the responsibilities of patients to communicate their own vital health information, participate in their own care while hospitalized and respect hospital policies and property ... VII. The patient rights and responsibilities are as follows: Patient rights ... You have the right to receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery, end-of-life care options and outcomes of care (including unanticipated outcomes) in terms that you can understand ..."

During a review of the facility's Policy and Procedure (P&P), titled "Interpreter and Communication Services," dated 6/28/2023, the P&P indicated: "Purpose ... Language and communication services aid in the delivery of culturally competent care to the diverse patient population we serve. These services facilitate access to equitable healthcare by increasing the patient's ability to participate in their own care, health, and well-being fully and confidently ... N. Documentation: Documentation in the patient's EMR when an interpreter is used. Document: Interpreter's name and ID number when available, If an employee or other non-qualified interpreter was used, Patient's preferred language ..."

7. During a review of Patient 25's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 2/12/2024, the H&P indicated Patient 25 was admitted to the facility with diagnoses of acute respiratory failure (condition in which blood does not have enough oxygen causing difficulty breathing), pulmonary edema (excess fluid in the lungs), congestive heart failure (condition in which the heart does not pump blood as well as it could) and end-stage renal failure (permanent stage of chronic kidney disease where kidneys can no longer function).

During a review of Patient 25's electronic Medication Administration Record (eMAR, record of medications administered for the patient), dated from 2/13/2024 to 2/22/2024, the eMAR indicated Patient 25 last received intravenous (IV, medication deliver to bloodstream directly) Zithromax (antibiotics, type of medication to treat infection) and IV Rocephin (antibiotics, type of medication to treat infection) on 2/17/2024.

During a concurrent observation and interview on 2/20/2024 at 12:02 p.m. with the nurse manager (NM5) of Definitive Observation Unit (DOU, a hospital unit provide second-highest level of care) in Patient 25's room, there were three intravenous tubing (IV tubing, used to deliver medications to the blood stream via a machine pump) hanging without label and the ending (ending is used to connect to patient when delivering the IV fluid or medication) of the IV tubing was wrapped in an opened alcohol prep pad wrapper (individual alcohol pad used to disinfect items). NM5 stated all IV tubing should be labeled with date and time when it was first used so that it could be changed every 72 hours per facility's policy. NM5 further stated the ending of the tubing should not be covered by opened alcohol prep pad wrapper.

During an interview on 2/20/2024 at 12:11 p.m. with Patient 25's primary nurse (RN13), RN13 stated IV tubing without label should be discarded. RN13 stated the ending of IV should be covered with a sterile cap (cap to cover endling of the IV tubing to prevent infection) otherwise dirty IV ending could cause line infection for Patient 25 if it was connected to Patient 25. RN13 stated that she (RN 13) did not discard the IV tubing because she (RN 13) was too busy.

During a review of the facility's policy and procedure (P&P) titled, "Medication Use, Administration, Routes and High Alert Medications," dated 8/2023, the P&P indicated "Any tubing intermittently connected to/disconnected from the patient is changed every 24 hours. This includes practices such as IVPB (intravenous piggy bag, a small bag of solution attached to a primary infusion line or intermittent venous access device to deliver medication over a specified period of time) that are not l

Based on observation, interview and record review, the facility failed to ensure nursing staff gave medications only ordered by a physician when a Registered Nurse (RN 17) gave insulin Lispro (insulin to treat control blood sugar) to one of 30 sampled patients (Patient 21) without a physician order.

This deficient practice had the potential for Patient 21 not getting appropriate insulin (medication used to lower blood sugar via injection) dosage to manage the elevated blood glucose (blood sugar), which may result in complications such as excessively low blood sugar, coma (state of prolonged loss of consciousness) or death.

Findings:

During a review of Patient 21's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 2/17/2024, the H&P indicated Patient 21 was admitted to the facility with diagnoses of rectal (ending of the intestine) bleeding, anemia (a condition with low blood cells), and gastric outlet obstruction (mechanical obstruction or motility disorder interfering with gastric emptying).

During an observation on 2/21/2024 at 10:51 a.m. in facility's Medical Oncology (hospital unit which provides medical care for cancer patients) floor, observed Patient 21 sitting in chair receiving intravenously (IV, administered into bloodstream directly) total parenteral nutrition (TPN, IV administered nutrition for someone with impaired gastrointestinal function).

During a concurrent interview and record review on 2/22/2024 at 9:32 a.m. with the Patient Safety Officer (PSO), Patient 21's glucose (blood sugar) record on 2/20/2024 at 6:02 p.m. was reviewed. The glucose record indicated glucose level was 362 mg/dL (milligram per deciliter, normal range from 70 to 99 mg/dL [a unit of measurement]). PSO verified that glucose reading was completed by RN 17.

During a concurrent interview and record review on 2/22/2024 at 9:32 a.m. with the Patient Safety Officer (PSO), Patient 21's electronic Medication Administration Record (eMAR, record of medications administered for the patient) dated 2/20/2024 was reviewed. The eMAR indicated RN 17 administered eight (8) units (unit of measurement) of insulin Lispro (insulin to treat control blood sugar) for Patient 21 on 2/20/2024 at 6:12 p.m. The eMAR also indicated Lispro correction scale (a scale listed how much insulin would be given based on the glucose reading) initiated on 2/20/2024 at 3:30 p.m. with the following instruction:

70 - 140 mg/dL = no dose
141 - 180 mg/dL = 2 units
181 - 220 mg/dL = 4 units
221 - 260 mg/dL = 6 units
261 - 300 mg/dL = 8 units
Greater than 300 mg/dL = call physician

PSO stated that any glucose level above 300 mg/dL must be reported to the physician per correction scale in eMAR. PSO verified there was no documentation that RN 17 notified physician for glucose level of 362 mg/dL or a physician order to administer Lispro 8 units for Patient 21. PSO stated administering 8 units of Lispro was not enough based on the correction scale, RN 17 should have called the physician to obtain a one-time order for insulin coverage. PSO further stated giving insulin without physician order could lead to improper managing of Patient 21's blood glucose level.

During a review of the facility's policy and procedure (P&P) titled, "Medication Use, Administration, Routes and High Alert Medications," dated 8/2023, the P&P indicated, "An order by a [facility] credential prescriber, acting within the scope of his/her practice, is required for all medications orders. A physician must countersign a Nurse Practitioner's or a Physician's Assistant's order as specified in the Allied Health Professional Rules and Regulations."