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Based on observation, interview and record review, the facility failed to ensure the Condition of Participation (CoP) for Patient Rights was met as evidenced by:

1. The facility failed to ensure that a patient's rights requirement pertaining to care and treatment was met when the facility failed to obtain and verify an accurate past medical history (a comprehensive record of a patient's previous health conditions, treatments, and diagnoses) regarding seizures (a sudden, uncontrolled electrical disturbance in the brain that can cause changes in behavior, movements, feelings, or consciousness), for one of 34 sampled patients (Patient 2), despite being documented that family was at the bedside to provide information and contact information being charted in Patient 2's medical record in the ED (Emergency Department, a specialized hospital unit providing acute [sudden and severe] care for patients with severe or urgent medical conditions) on 7/1/2024 (date of Patient 2's ED arrival).

This deficient practice resulted in Patient 2's past medical history not to be timely verified, potentially causing a delay in the implementation of a timely and appropriate treatment and care plan to address Patient 2's stroke (a medical emergency that occurs when blood flow to a part of the brain is interrupted or reduced, preventing brain tissue from receiving oxygen and nutrients), which was later confirmed on 7/2/2024 (Patient 2 arrived at the ED on 7/1/2024). (Refer to A-0129)

2. The facility failed to ensure for one of 34 sampled patients (Patient 19), Patient 19's conservatorship (a court-ordered arrangement where a judge appoints a person to manage the affairs of another person who is unable to do so themselves) was verified for its existence upon admission to the facility.

This deficient practice had the potential to result in Patient 19 or the patient's conservator (the person or organization appointed by the court who would be responsible of one person's physical health and medical care) rights to not be exercised by not knowing who is legally able to make medical decision for Patient 19. This deficient practice also had the potential to impede the conservator's involvement to work with the healthcare team to achieve recovery for Patient 19. (Refer to A-0129)

3. The facility failed to ensure safety precautions were in place for two of 34 sampled patients (Patients 4 and 34), when safety straps (immobilizes patients on a table to prevent falls [unplanned descent to the floor with or without injury to the patient]) were not utilized, in accordance with the manufacturer's instructions, for Patients 4 and 34 while on the cardiac catheterization laboratory (cath lab, a hospital room where doctors perform procedures and tests to diagnose and treat heart and blood vessel conditions) table, and Patients 4 and 34 fell off the cath lab table.

This deficient practice had the potential for Patients 4 and 34 to suffer bodily injury, including but not limited to head trauma, broken bones, and skin injuries. (Refer to A-0144)

4. The facility failed to ensure for one of 34 sampled patients (Patient 19), a code green (the facility's notification of emergency to the staff indicating a missing/eloping patient who is determined to be a danger to themselves or has been identified as a safety risk) was activated, in accordance with the facility's policy and procedure regarding "Emergency Management," when Patient 19 eloped (the act of leaving a facility unsupervised and without prior authorization) from the facility on 11/12/2024 at 1:40 p.m.

This deficient practice resulted in Patient 19 leaving the facility unsupervised and may have the potential to result in Patient 19 harming self and could cause injury and/or death to the patient. (Refer to A-0144)

5. The facility failed to ensure one of 34 sampled patients (Patient 22), was free from restraint (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) when, Patients 22's four siderails of the bed were observed raised without a physician's order and in accordance with the facility's policy and procedure regarding use of restraints.
This deficient practice resulted in inappropriate, unnecessary use of restraints, and had violated Patient 22's rights regarding being free from inappropriate restraints use. In addition, this deficient practice had the potential for Patient 22 to suffer from physical harm such as strangulation (obstruction of blood vessels and/or airflow in the neck resulting in asphyxia [lack of oxygen]), skin tear, loss of consciousness, broken skull, bleeding in the brain, etc. (Refer to A-0154)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments.

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

1. Ensure that a patient's rights requirement pertaining to care and treatment was met when the facility failed to obtain and verify an accurate past medical history (a comprehensive record of a patient's previous health conditions, treatments, and diagnoses) regarding seizures (a sudden, uncontrolled electrical disturbance in the brain that can cause changes in behavior, movements, feelings, or consciousness), for one of 34 sampled patients (Patient 2), despite being documented that family was at the bedside to provide information and contact information being charted in Patient 2's medical record in the ED (Emergency Department, a specialized hospital unit providing acute [sudden and severe] care for patients with severe or urgent medical conditions) on 7/1/2024 (date of Patient 2's ED arrival).

This deficient practice resulted in Patient 2's past medical history not to be timely verified, potentially causing a delay in the implementation of a timely and appropriate treatment and care plan to address Patient 2's stroke (a medical emergency that occurs when blood flow to a part of the brain is interrupted or reduced, preventing brain tissue from receiving oxygen and nutrients), which was later confirmed on 7/2/2024 (Patient 2 arrived at the ED on 7/1/2024).

2. Ensure for one of 34 sampled patients (Patient 19), Patient 19's conservatorship (a court-ordered arrangement where a judge appoints a person to manage the affairs of another person who is unable to do so themselves) was verified for its existence upon admission to the facility.

This deficient practice had the potential to result in Patient 19 or the patient's conservator (the person or organization appointed by the court who would be responsible of one person's physical health and medical care) rights to not be exercised by not knowing who is legally able to make medical decision for Patient 19. This deficient practice also had the potential to impede the conservator's involvement to work with the healthcare team to achieve recovery for Patient 19.

Findings:

1. During a review of Patient 2's EMS (Emergency Medical Services, prehospital care provided by paramedics or emergency responders) Patient Care Report (PCR), dated 7/1/2024 at 10:47 a.m., the PCR indicated that paramedics (healthcare professionals trained to provide emergency medical care and transport patients to medical facilities) brought Patient 2 to the facility's Emergency Department (ED, a specialized hospital unit providing acute care for patients with severe or urgent medical conditions) on 7/1/2024 at 11:29 a.m. The PCR also indicated that Patient 2 was alert and oriented to none (meaning the patient was not oriented to person, place, time, or situation, typically indicating a state of confusion or altered mental status). The PCR also indicated that bystanders on scene witnessed the patient (Patient 2) come out of the bathroom, fall down, and start having full body shakes. The PCR also stated that patient (Patient 2) had a history of seizures (a sudden, uncontrolled electrical disturbance in the brain that can cause changes in behavior, movements, feelings, or consciousness), unknown if compliant with medications and that the patient (Patient 2 was possibly postictal [a state following a seizure characterized by confusion, drowsiness, or disorientation as the brain recovers]).

During a review of Patient 2's "Triage Assessment" (the initial evaluation performed upon a patient's arrival to the emergency department to prioritize care based on the severity of their condition), dated 7/1/2024, at 11:46 a.m., the record indicated that Patient 2 had a history (a documented account of a patient's past medical conditions, behaviors, or treatments that may influence their current health status) of alcoholism (a chronic disease characterized by an inability to control alcohol consumption despite negative consequences).

During an interview on 11/13/2024 at 10:12 a.m. with the Emergency Department Supervisor (EDS), regarding the documented history of alcoholism in the triage assessment and after reviewing Patient 2's EMS Patient Care Report (PCR), dated 7/1/2024, the EDS stated that the history of alcoholism was not documented in the PCR report. The EDS said that paramedics often provide additional verbal information about the patient and stated that the paramedics must have provided this information to the triage nurse upon Patient 2's admission to the ED (on 7/1/2024).

During the same interview on 11/13/2024 at 10:12 a.m. with the Emergency Department Supervisor (EDS), the EDS stated, "Triage nurses obtain patients' history directly from the patient. If the patient is unable to provide their history, triage nurses rely on paramedic's report for the information. Nurses [triage nurses and primary nurses] should verify the patient's history with family members if they are available. Taking a patient's history is an important part of the nursing assessment."

During a review of Patient 2's HPI (History of Present Illness, a detailed narrative of the patient's current health complaint, including onset, progression, and associated symptoms), dated 7/1/2024, the HPI indicated that Patient 2 presented to the Emergency Department (ED) on 7/1/2024 after experiencing a seizure. The HPI also indicated that Patient 2 had no prior visits to the facility's ED. Additionally, the HPI stated that Patient 2 had a past medical history (PMH, a record of previously diagnosed medical conditions, treatments, and surgeries) of seizures and alcoholism.

During a review of Patient 2's medical record (MR) titled, "Nurses Notes," dated 7/1/2024, at 11:55 a.m., the primary nurse documented that the patient (Patient 2) "had seizure at home, unreliable witnesses and narrator ..."

During a review of Patient 2's medical record (MR) titled, "Nurses Notes," dated 7/1/2024 at 3:43 p.m., the primary nurse documented the following: "Family at bedside."

During a review of Patient 2's medical record (MR) titled, "Nurses Notes," dated 7/1/2024 at 4:28 p.m., the MR indicated the following: "Family contact is at bedside, phone number also documented."

During a review of Patient 2's medical record (MR) titled, "Nurses Notes," dated 7/1/2024 at 6:06 p.m., the MR indicated the following: "Patient (Patient 2) is alert and oriented to none (not oriented to time, person, place, and situation), responds to pain, making noise, no words. Patient's (Patient 2) family member is at bedside."

During a review of Patient 2's MR titled, Nurses Notes," dated 7/1/2024, at 7:05 p.m., the MR indicated the following: " ...Patient's (Patient 2) family is at bedside ..."

During a review of Patient 2's MR titled, "Nurses Notes," dated 7/1/2024, at 8:33 p.m., the MR indicated the following: " ...Family member at bedside ..."

During a concurrent interview and record review on 11/13/2024 at 11:30 a.m. with the Quality Assurance Nurse (QAN), Patient 2's ED Visit Records (EVR, documentation of care and services provided during an Emergency Department visit), dated 7/1/2024, were reviewed. The QAN reviewed Patient 2's medication reconciliation record (a process of creating an accurate list of all medications a patient is taking to ensure safe and effective care) and stated that no medication reconciliation was completed for Patient 2 on 7/1/2024. The QAN then reviewed the documentation of Patient 2's past medical history (PMH) documentation and stated that no PMH was recorded for Patient 2 on 7/1/2024 or 7 2/2024.

During a review of Patient 2's History and Physical (H&P, a detailed medical record documenting the patient's current health complaint, medical history, physical examination findings, and initial diagnosis or treatment plan), dated 7/1/2024, at 5:20 p.m., the H&P indicated that Patient 2 was admitted due to altered mental status (a condition characterized by changes in awareness, orientation, behavior, or mental function) and seizure. The H&P also stated that Patient 2 had a past medical history (PMH) of seizure disorder, was confused, and unable to provide history. Additionally, the H&P stated: "We will try to locate the family to get further information ..."

During a review of the History and Physical (H&P) dated 7/1/2024, the H&P noted the following: the patient's (Patient 2) alcohol level was negative, indicating no measurable alcohol in the patient's (Patient 2) system at the time of evaluation. The CT scan (computed tomography, an imaging diagnostic test) of the head revealed nonspecific hypoattenuation (refers to an area of lower density [thickness]on the scan that may indicate potential abnormalities such as ischemia (lack of blood supply to a part of the body), edema, or other conditions) in the posterior [refers to the back] left parietal lobe (a region of the brain associated with sensory perception and integration, spatial reasoning [the ability to understand, visualize, and manipulate objects or shapes in a given space], and coordination).

During further review of Patient 2's medical record (MR) titled, "Neurological Consultation (a specialized evaluation conducted by a neurologist (diagnoses, treats, and manages conditions affecting the brain, spinal cord, and nerves) to assess and diagnose conditions related to the nervous system, including the brain, spinal cord, and nerves)," dated 7/3/2024, the MR indicated the following: "The patient (Patient 2) with unclear PMH (past medical history) has not seen a primary physician for years. History obtained with family at the bedside and on the phone. The patient (Patient 2) presented to the ED after a seizure with no prior history of seizures. Patient (Patient 2) was diagnosed with a stroke (a medical emergency that occurs when blood flow to a part of the brain is interrupted or reduced, preventing brain tissue from receiving oxygen and nutrients) and presented on exam aphasic (a condition characterized by an impaired ability to speak, understand, or process language, typically due to brain damage such as from a stroke) and with left-sided hemiparesis (weakness or partial loss of strength on the left side of the body, often caused by a neurological event like a stroke). Patient (Patient 2) was started on stroke protocol (standardized, evidence-based set of procedures designed to ensure the timely identification, evaluation, and treatment of patients presenting with symptoms of a stroke)."

During an interview on 11/13/2024 at 11:44 a.m. with the physician (MD 11), MD 11 stated the following: "I remember the patient somewhat; I just reviewed the chart. I remember the patient (Patient 2) was confused. What I got from the ED, was questionable alcohol use and seizure. I wanted to rule out (r/u) alcohol seizure. Based on the imaging results (diagnostic tests) there was a questionable mass. If it's a mass, I am not going to entertain the idea of a stroke. I carried the diagnosis of alcohol disorder. I did order the MRI, and it happened within 24 hours. If stroke was a strong possibility, we would have done the MRI much faster. The patient was unresponsive, and I had no family available to interview regarding past medical history. If I have a number, I usually call the family."

During a concurrent interview and record review on 11/13/2024 at 1:40 p.m. with the Director of the Emergency Department (DED), the DED stated the following regarding obtaining a patient's relevant medical history: "Nurses get a verbal report from paramedics, and they chart the information in the assessment as much as possible. They assign the interventions based on the presentation of the patient. We rely on the paramedics' description. Nurses should follow up on the assessment, and if the family is present, we try to obtain patient's history and medications, vaccination history, social habits, and primary physician information. Whenever possible, the nurse should obtain accurate information, and if the family arrives, we interview them."

During an interview on 11/13/2024 at 1:57 p.m. with the Director of the Emergency Department (DED), the DED stated: "We expect staff to collect a thorough history, gathering any information that pertains to the patient. Medical history and medication history are especially important because, for example, if the patient stopped taking medications abruptly, that could be critical to understanding their current condition and making an accurate diagnosis. The triage nurse typically gathers the initial information about the patient, and the assigned registered nurse should follow up on the patient's pertinent history and ensure accurate documentation."

During an interview on 11/13/2024 at 2:40 p.m. with the Medical Director of the Emergency Department (MD 9), MD 9 stated: "Obtaining medical history and contacting the family is common practice in the ED. We typically approach the family and ask. Nurses and physicians both do this. I did not see the family [Patient 2's family]; I signed off (the process by which a physician transfers responsibility for the care of a patient to another provider, typically at the end of their shift or upon the patient's admission to another unit) shortly after the patient was admitted."

During a review of the facility's policy and procedure (P&P) titled, "Standards of Care," dated 7/2023, the P&P indicated that the collection of data pertinent to the health status of an individual is to be systematic and continuous. After recording, such data is to be communicated to and retrievable by appropriate persons.

During a review of the facility's policy and procedure (P&P) titled, Patient Rights and Responsibilities," dated 6/2022, the P&P indicated that patients have the right to considerate care.

During a review of the facility document "Medical Staff: General Rules and Regulations (section of the medical staff bylaws that describes more detailed operational policies for a hospital's medical staff)," reviewed/revised 10/2024, the Rules and Regulations indicated the following: "The admitting physician or designee is responsible for completion of the admission history and physical examination. There shall be communication among all practitioners involved in patient care, treatment, and services."

2. During a review of Patient 19's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 10/31/2024, the report indicated Patient 19 was admitted to the facility with a diagnosis of spinal stenosis (a medical condition that occurs when the spinal canal narrows, putting pressure on the spinal cord [a column of nerve tissues that runs from the base of the skull to the lower back] and nerves.) The H&P further indicated Patient 19 had a history of seizures disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), schizophrenia (a mental illness that is characterized by disturbances in thought), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).

During a review of Patient 19's "Letters of Conservatorship (Mentally Disoriented)," with a file date of 11/18/2015, the letter indicated "These letters are in effect for one year and shall expire on 12/13/2016."

During an interview on 11/14/2024 at 11:28 a.m. with Clinical Nursing Supervisor (CNS 6), CNS 6 stated for a patient who was conserved, an official conservatorship (a court-ordered arrangement where a judge appoints a person to manage the affairs of another person who is unable to do so themselves) letter should be filed in the patient's record. CNS 6 stated the nurses should check that the patient's conservatorship letter was filed on the patient's record.

During an interview on 11/14/2024 at 2:30 p.m. with the Manager of Social Services (MSS, plan, direct, or coordinate the activities of a social service program). The MSS stated, "I did not know this conservatorship form for Patient 19 was expired...is important to validate conservatorship because the patient is unable to make his own decision, and the conservator is the decision maker. The main reason they are the decision maker."

During an interview on 11/14/2024 at 12:04 p.m., with the Social Worker (SW, offer counseling services, advocating for patient care, and assist patients in the admission and discharge process during hospitalization). The SW stated, "I am not aware of a policy for the conservatorship ...I was told verbally that this patient (Patient 19) has a conservator. Usually, I will keep the legal documents in the patient's chart." The SW stated, "On my notes entered (11/8/2024) I informed the conservator, the patient (Patient 19) and Regional Director they verbally corroborated that this patient has conservator."

In the same interview on 11/14/2024 at 12:04 p.m., the SW stated she (SW) had never seen a conservatorship legal document. The SW stated when a patient was under conservatorship, she would document it on the patient's record. The SW further stated she was not aware of the facility's procedure for a patient with conservatorship and that she was not aware of the facility's conservatorship policy.

During an interview on 11/14/2024 at 2:19 p.m. with the Manager of Social Services (MSS), the MSS stated she had not seen the facility's conservatorship policy. The MSS stated when a patient was known to be conserved, this should be verified by calling the county and ask if the patient has a conservator. The MSS stated it usually takes 48 hours for the county to call back and verify the patient's conservatorship status.

During a concurrent interview and record review on 11/14/2024 at 2:30 p.m., with the MSS, the Patient 19's "Letters of Conservatorship (Mentally Disordered)," dated November 2015, was reviewed. The MSS verified Patient 19's conservatorship letter was expired. The MSS stated, "I do not know this (Patient 19's) conservator form is expired. I do not know who provided this (Patient 19's) conservatorship. Family members can be a conservator, and we must validate."

In the same interview on 11/14/2024 at 2:30 p.m., the MSS stated the patient's conservatorship status should be validated because the patient was not capable of making his own decision and the patient's conservator would be the decision maker. The MSS stated when a conservatorship letter was expired, the regional center should be involved, and the facility should ask for the updated conservatorship.

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights & Responsibilities," dated 06/2022, the P&P indicated, "You or your representative(s) have the right to: Be informed before care is given or discontinued whenever possible. Receive accurate and current information regarding your health status in terms you can understand, allowing you to make informed decisions. Participate in planning for your treatment care and discharge recommendations. Surrogate who you may select can represent you if you cannot make your own decisions according to state law."

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

1. Ensure safety precautions were in place for two of 34 sampled patients (Patients 4 and 34), when safety straps (immobilizes patients on a table to prevent falls [unplanned descent to the floor with or without injury to the patient]) were not utilized, in accordance with the manufacturer's instructions, for Patients 4 and 34 while on the cardiac catheterization laboratory (cath lab, a hospital room where doctors perform procedures and tests to diagnose and treat heart and blood vessel conditions) table, and Patients 4 and 34 fell off the cath lab table.

This deficient practice had the potential for Patients 4 and 34 to suffer bodily injury, including but not limited to head trauma, broken bones, and skin injuries.

2. Ensure for one of 34 sampled patients (Patient 19), code green (the facility's notification of emergency to the staff indicating a missing/eloping patient who is determined to be a danger to themselves or has been identified as a safety risk) was activated, when Patient 19 eloped (the act of leaving a facility unsupervised and without prior authorization) from the facility on 11/12/2024 at 1:40 p.m., in accordance with the facility's policy and procedure regarding "Emergency Management."

This deficient practice resulted in Patient 19 leaving the facility unsupervised and may have the potential to result in Patient 19 harming self and could cause injury and/or death to the patient.

Findings:

1.a. During a review of Patient 4's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/22/2024 at 9:41 a.m., the H&P indicated that Patient 4 was admitted to the facility on 7/21/2024 at 12:06 p.m. with a diagnosis of hyperglycemia (elevated blood sugar).

During a concurrent observation and interview on 11/12/2024 at 11:40 a.m. with the Registered Nurse 13 (RN 13) in the cardiac catheterization laboratory (cath lab, a hospital room where doctors perform procedures and tests to diagnose and treat heart and blood vessel conditions) room 3, the cath lab table was observed. RN 13 confirmed the cath lab table (in cath lab room 3) did not have safety straps (immobilizes patients on the table to prevent falls) attached to the table. RN 13 verified that all cath lab rooms (1, 2, and 3) have two black safety straps (not attached to the table) used for cath lab tables. RN 13 stated the following: There were two straps used to attach patients to the cath lab tables (1, 2, and 3). Two straps should have been used, whenever a patient was on the cath lab table.

During an interview on 11/12/2024 at 3:00 p.m. with the Radiological Technologist 2 (RAT 2), the RAT 2 stated the following: Patient 4 was on the cath lab table, when Patient 4 fell off the table. Safety straps were not used to strap the patient to the table. There have never been safety straps for the cath lab tables. After Patient 4 fell, two safety straps were ordered and implemented for patient use on the cath lab table.

During an interview on 11/12/2024 at 3:24 p.m. with the Radiological Technologist 1 (RAT 1), the RAT 1 stated the following: Patient 4 was brought to the cath lab (room 3) for a procedure. The Certified Registered Anesthetist 1 (CRNA 1, assigned to Patient 4's procedure) was upset that the room (cath lab room 3) was not prepared prior to CRNA 1's arrival. The CRNA 1 verbally stated that CRNA 1 was unhappy that the room was not ready. The CRNA was very irritated with [facility] staff and made this very clear in front of the patient (Patient 4). This agitated Patient 4, and Patient 4 stated that he (Patient 4) did not feel comfortable with CRNA 1 and wished CRNA 1 would just calm down. Patient 4 was tilting his (Patient 4's) head back in CRNA 1's direction. CRNA 1 kept arguing with Patient 4. Patient 4 fell off the cath lab table in the same direction he (Patient 4) was looking back (towards CRNA 1). Patient 4's fall was prior to the procedure, before Patient 4 was fully sedated (a state of calmness, relaxation, or sleepiness caused by certain drugs).

During the same interview on 11/12/2024 at 3:24 p.m. with the RAT 1, the RAT 1 further stated the following: At the time of Patient 4's procedure (7/26/2024), safety straps were not in use for the cath lab table. Patient 4 fell off the cath lab table (room 3) and Cardiovascular Technician 2 (CVT 2) was able to catch the patient before he (Patient 4) hit the floor, and then assisted Patient 4 to the floor.

During an interview on 11/12/2024 at 3:00 p.m. with the CVT 2, the CVT 2 stated the following: Patient 4 fell off the cath lab table and CVT 2 was able to catch Patient 4's upper body and head. Patient 4 was assisted to the floor by staff. Patient 4 did not have any safety straps applied at the time he (Patient 4) fell from the table.

During a concurrent interview and record review on 11/13/2024 at 1:23 p.m. with the Clinical Nursing Supervisor 3 (CNS 3), the CNS 3 verified the following information in Patient 4's medical record: Patient 4's "Clinical Cardiac Electrophysiology (the study of the heart's electrical activity, including its function, performance, and mechanisms) Progress Note (a document that outlines a patient's condition and the rationale for their treatment)," dated 7/26/2024, indicated " ...[Patient 4] suffered an accidental fall (unplanned descent to the floor with or without injury to the patient) from the cath lab table. Fortunately, his fall was broken by the Cardiovascular Technician [CVT 2] who was standing nearby. She prevented [Patient 4] from striking his head on the x-ray (creates pictures of the inside of your body) equipment on the floor. He did land on his right side and hip ..."

During a concurrent interview and record review on 11/14/2024 at 10:03 a.m. with the Biomed Engineering Manager (BEM) and the Cardiovascular Technician 3 (CVT 3), the document titled "GE HealthCare: Safety and Regulatory," no date, provided by the facility for the cath lab tables (1, 2, and 3), was reviewed. BEM and CVT 3 verified this was the user manual for the Innova Table (cath lab tables 1, 2, and 3). The user manual indicated " ...The Innova Table Top mattress is provided with a set of Velcro strips on the bottom side. While loading or unloading the patient it is recommended to grip the Velcro strips to avoid the mattress shifting. Ensure the Velcro strips are well stuck on the tabletop prior to loading or unloading the patient ..." The BEM acknowledged safety straps should be used as indicated in the user manual.

During the same concurrent interview and record review on 11/14/2024 at 10:03 a.m. with the BEM and the CVT 3, the CVT 3 stated that the cath lab has had the Innova (cath lab) tables for at least 6 years. The CVT 3 further stated that the standard of practice was to strap the patient to the cath lab table when using the table.

During an interview on 11/15/2024 at 2:25 p.m. with the Director of Cardiovascular Services (DCVS), the DVCS stated the following in regard to Patient 4's fall: It was important to use safety straps to immobilize patients on the cath lab table. If straps were not used, this could lead to patient falls and harm. The safety straps should have been used when patients were on the table.

During a record review the document (cath lab table user manual) titled, "GE HealthCare: Safety and Regulatory," no date, provided by the facility indicated " ...Never leave a patient unattended. An unattended patient could fall from the table ..., which could be hazardous. In addition, it is recommended to use restraints (a device to restrict a person's movement or access to their body), such as Velcro straps ..."

1.b. During a review of Patient 34's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/3/2024, the H&P indicated that Patient 34 was admitted to facility on 9/3/2024 with a past medical history of obesity (when there is an excessive amount of fat in the body which can negatively affect health), atrial fibrillation (a heart disorder that causes irregular heart beat) and diastolic heart failure (a part of the heart that stiffens and does not relax to allow the heart to properly pump blood).

During a concurrent observation and interview on 11/12/2024 at 11:40 a.m. with the Registered Nurse 13 (RN 13) in the cardiac catheterization laboratory (cath lab,a hospital room where doctors perform procedures and tests to diagnose and treat heart and blood vessel conditions) room 3, the cath lab table was observed. RN 13 confirmed the cath lab table (in cath lab room 3) did not have safety straps (immobilizes patients on the table to prevent falls [unplanned descent to the floor with or without injury to the patient) attached to the table. RN 13 verified that all cath lab rooms (1, 2, and 3) have two black safety straps (not attached to the table) used for cath lab tables. RN 13 stated the following: There were two straps used to attach patients to the cath lab tables (1, 2, and 3). Two straps should have been used, whenever a patient was on the cath lab table.

During an interview on 11/13/2024 at 10:36 a.m. with the Registered Nurse 14 (RN 14), RN 14 stated the following: Following Patient 34's cath lab procedure (on 9/10/2024 in cath lab room 2), Patient 34 fell off the cath lab table and RN 14 assisted Patient 34 to the floor. RN 14 was attempting to place a hold belt (applies pressure to prevent bleeding after a procedure) on Patient 34 when Patient 34 fell. RN 14 did not recall if safety straps (immobilizes patients on the table to prevent falls) were applied to Patient 34 at the time of the fall. It was important to use the safety straps for patients, so they would not fall.

During a concurrent interview on 11/13/2024 at 11:20 a.m. with the Radiological Technologist 3 (RAT 3), the RAT 3 stated the following: RAT 3 was applying pressure to Patient 34's arterial site (a location in the body where a catheter can be inserted into an artery for medical procedures) following a cath lab procedure. RAT 3 was placing pressure device (hold belt) on Patient 34's arterial site, when Patient 34 fell. Patient 34 was assisted to the floor. Safety straps were not applied to Patient 34 when Patient 34 was on the cath lab table and they (referring to the safety straps) should have been. Straps should have only been removed immediately before transferring a patient from the cath lab table to a gurney (a wheeled stretcher used for transporting hospital patients).

During a concurrent interview and record review on 11/14/2024 at 8:45 a.m. with the Clinical Nursing Supervisor 5 (CNS 5), the CNS 5 verified the following in Patient 34's medical record: Patient 34's medical record titled, "Cardiology (the branch of medicine that deals with diseases and abnormalities of the heart) Progress Note," dated 9/10/2024 at 9:42 a.m., indicated "[Patient 34] unfortunately fell off the cath table during transport ..."

During a concurrent interview and record review on 11/14/2024 at 10:03 a.m. with the Biomed Engineering Manager (BEM) and the Cardiovascular Technician 3 (CVT 3), the document titled "GE HealthCare: Safety and Regulatory," no date, provided by the facility for the cath lab tables (1, 2, and 3), was reviewed. BEM and CVT 3 verified this was the user manual for the Innova Table (cath lab tables 1, 2, and 3). The user manual indicated " ...The Innova Table Top mattress is provided with a set of Velcro strips on the bottom side. While loading or unloading the patient it is recommended to grip the Velcro strips to avoid the mattress shifting. Ensure the Velcro strips are well stuck on the tabletop prior to loading or unloading the patient ..." The BEM acknowledged safety straps should be used as indicated in the user manual.

During the same concurrent interview and record review on 11/14/2024 at 10:03 a.m. with the BEM and the CVT 3, the CVT 3 stated that the cath lab has had the Innova (cath lab) tables for at least 6 years. The CVT 3 further stated that the standard of practice was to strap the patient to the cath lab table when using the table.

During an interview on 11/15/2024 at 2:25 p.m. with the Director of Cardiovascular Services (DCVS), the DVCS stated the following in regard to Patient 34's fall: It was important to use safety straps to immobilize patients on the cath lab table. If straps were not used, this could lead to patient falls and harm. The safety straps should have been used when patients were on the table.

During a review of the document (cath lab table user manual) titled, "GE HealthCare: Safety and Regulatory," no date, provided by the facility indicated " ...Never leave a patient unattended. An unattended patient could fall from the table ..., which could be hazardous. In addition, it is recommended to use restraints (a device to restrict a person's movement or access to their body), such as Velcro straps ..."

2. During a review of Patient 19's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 10/31/2024, the H&P indicated Patient 19 was admitted to the facility with a diagnosis of spinal stenosis (a medical condition that occurs when the spinal canal narrows, putting pressure on the spinal cord and nerves). The H&P further indicated Patient 19 had a history of seizures disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), schizophrenia (a mental illness that is characterized by disturbances in thought), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).

During a review of Patient 19's "Columbia-Suicide Severity Rating Scale (CSSRS, a suicidal ideation and behavior rating scale)," dated 11/5/2024, Patient 19's CSSRS indicated Patient 19 had a high suicidal risk.

During a concurrent interview and record review on 11/14/2024 at 10:40 a.m., with Clinical Nursing Supervisor 6 (CNS 6), CNS 6 verified Patient 19's "Progress Notes," dated 11/12/2024 at 2:29 p.m. (after Patient 19's elopement [the act of leaving a facility unsupervised and without prior authorization] incident on 11/12/2024 at 1:40 p.m.), authored by the psychiatrist (a medical doctor that specialist in mental health), indicated "denies suicidal (thoughts of self-harm with the intent to die) or homicidal ideation (thoughts about killing another person), able to contract safety." CNS 6 verified Patient 19 had no other psychiatric note prior to the 11/12/2024.

During a review of Patient's 19 "ARU (Acute Rehabilitation Unit, provides intensive, specialized therapy for patients who need to regain abilities or adapt to new limitations after an injury, surgery, or medical event) OT (Occupational Therapist, helps patient live more independently by developing, recovering, or maintaining skills for daily living and working) Treatment Note," dated 11/12/2024, the note indicated, "Pt. (Patient 19) cleared for OT treatment session by (RN 15). Pt. Received sitting at edge of bed eating lunch... Pt. was very agitated (a feeling of severe restlessness or uneasiness) beginning of session...Therapist (OT 1) attempted to calm pt. down...Pt. suddenly got up and got his FWW (Front wheel walker - a mobility aid with two wheels on the front legs and two straight legs on the back) and started walking out. Therapist attempted to request for help from nursing staff. Therapist also notified Rehab Tech (RT 1) for assistance. RT 1 went to notify nursing staff. Pt. went down elevator. Therapist notified security for assistance, security guards attempted to stop the pt. and talk with the pt. Pt. continued to ambulate outside of the hospital and non-compliant towards security guards. Security reported that they are unable to physically stop the pt. And pt. Has right to leave AMA (Against Medical Advice -when a patient leaves a hospital without the physician's recommendation). Pt. does not need to sign anything and is able to leave AMA. Therapist notified Director of Medical Surgical (DMS), Director of Acute Rehabilitation (DAR), and Director of Physical Therapy (DPT) regarding the situation. DPT notified therapist that they will look for pt. (Patient 19)."

During an interview on 11/13/2024 at 11:43 a.m., with OT 1, OT 1 stated she (OT 1) went to see Patient 19 at around 1:40 p.m., to do therapy. OT 1 stated Patient 19 became agitated and was resistant, Patient 19 got the walker and walked outside his room. OT 1 stated she asked for help and told her coworker "I need help, nobody will help me."

In the same interview on 11/13/2024 at 11:43 a.m., OT 1 stated she (OT 1) followed Patient 19 to the elevator down to the entrance lobby of the facility. OT 1 stated she told the security guard that Patient 1 was trying to leave, and the security guard told her, "We can't avoid patient from AMA.". OT 1 stated she last saw Patient 19, after exiting the facility, turned left, and kept walking out towards the street and the security told her (OT 1), "patients have the right to leave." OT 1 stated Patient 19 was alone for about 10-20 minutes on the street at the corner of the facility.

During an interview on 11/13/2024 at 11:57 a.m., with the Director of Physical Therapy (DPT), the DPT stated when OT reported to her that Patient 19 left the facility, she went to look for the patient (Patient 19). The DPT stated, "I found (Patient 19) on Flower Street sitting alone by the sidewalk. The DPT stated Patient 19's nurse came down and the other staff to help bring Patient 19 back to the unit. The DPT stated, "I did not hear anyone call a Code Green (when Patient 19 eloped)."

During an interview on 11/13/2024 at 10:23 a.m., with Clinical Nursing Supervisor of Medical Surgical Unit (CNS 2), CNS 2 stated when a patient elopes, she first calls the physician, the family and/or the conservator (a legally responsible person who has the power to make healthcare decisions for another person). CNS 2 stated, "we call rapid response (Rapid Response Team [RRT] - a group of trained medical professionals who are called to a patient's bedside to assess and treat a medical emergency), the security, and document the circumstances to make sure the patient understands the situation and the danger to discharge themselves."

In a follow-up interview on 11/13/2024 at 10:42 a.m., CNS 2 stated, "I always call Rapid Response Team for any issue," "to be honest I do not know the codes." CNS 2 stated she (CNS 2) knew Patient 19 was a high-risk patient and she should have called the code for elopement, "but I am not familiar." CNS 2 stated she was notified about Patient 19 elopement on 11/12/2024 before 6:00 p.m.

During an interview on 11/13/2024 at 11:43 a.m., with OT 1, OT 1 stated, "I never got training to call for Code Green (a missing /eloping patient who is determined to be a danger to themselves or has been identified as a safety risk)." OT 1 stated she (OT 1) only informed her Director (DPT) when Patient 19 eloped.

During an interview on 11/13/2024 at 11:57 a.m., with the Director of Physical Therapy (DPT), DPT stated Code green is called by the nurse or whoever identified that the patient was missing or eloped. The DPT stated, "I did not hear anyone call Code Green. The security did not get involved."

During an interview on 11/14/2024 at 11:56 a.m., with the Clinical Nursing Supervisor (CNS 6), CNS 6 stated when a patient eloped, it was important to call a Code Green to alert everyone to look for the patient. CNS 6 stated anybody can call a Code Green.

During a review of the facility's policy and procedure (P&P) titled, "Emergency Management," dated 10/2024, the P&P indicated the following:

- "To provide appropriate staff notification of emergency situations utilizing the overhead paging system."

- (Section II, Definitions) "Code Green- a missing /eloping patient who is determined to be a danger to themselves or has been identified as a safety risk."

- "When an emergency occurs, call the emergency page operator at ext. 5555 and provide the nature of the emergency and the location of the incident."

- "The emergency page operator will immediately notify the appropriate management authority and response personnel in accordance with the corresponding policy is listed in "Section II, Definitions."

- "If an overhead page is required, the emergency page operator will use the appropriate emergency code and repeat it three times via the overhead paging system."

- "Terminating an emergency code a. when the incident response is complete, the appropriate
authority (e.g., Incident Commander, Team Leader, House Supervisor, etc ...) will call the emergency page operator and request that they announce an "All Clear." b. When instructed by the appropriate authority, the emergency page operator will announce "the [Code Name] is All Clear" three times via the overhead paging system."

- "All employees must be familiar with the following:
a. Code Names

Based on observation, interview, and record review, the facility failed to ensure one of 34 sampled patients (Patient 22), was free from restraint (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) when, Patients 22's four siderails of the bed were observed raised without a physician's order and in accordance with the facility's policy and procedure regarding use of restraints.

This deficient practice resulted in inappropriate, unnecessary use of restraints, and had violated Patient 22 rights regarding being free from inappropriate restraints use. In addition, this deficient practice had the potential for Patient 22 to suffer from physical harm such as strangulation (obstruction of blood vessels and/or airflow in the neck resulting in asphyxia [lack of oxygen]), skin tear, loss of consciousness, broken skull, bleeding in the brain, etc.

Findings:

During a concurrent observation and interview on 11/12/2024 at 3:15 p.m. with Registered Nurse (RN) 16, Patient 22 was observed in bed, awake and oriented to person. Patient 22's four side rails of the bed were raised. RN 16 stated she (RN 16) was the RN assigned to Patient 22. RN 16 stated Patient 22's four side rails should not be raised as it is considered a restraint (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely). RN 16 stated having all four side rails up could cause a risk for the patient (Patient 22) to fall (unplanned descent to the floor with or without injury to the patient).

During a review of Patient 22's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 11/3/2024, the H&P indicated Patient 22 was admitted to the facility for cerebrovascular accident (CVA, referred to as stroke which is the loss of blood flow to a part of the brain).

During a review of Patient 22's "Critical Care/Step Down Shift" physical assessment, dated 11/12/2024, the assessment indicated Patient 22 had right side mild weakness and left side severe weakness. Patient 22's mobility was "very limited," with a fall risk score of 50 (using the Morse fall scale [a tool used to assess a patient's risk of falling], score of 45 and above is a high risk for fall]).

During a concurrent interview and record review on 11/15/24 at 10:30 a.m. with the Clinical Nursing Supervisor (CNS) 3, CNS 3 stated Patient 22's record did not indicate an order for restraints including having 4 siderails up. CNS 3 stated "the patient (Patient 22) do not need 4 side rails up, if they have 4 side rails up the patient can fall, he can hang, is considered restriction."

During a review of the facility's policy and procedure (P&P) titled, "Restraints," reviewed on 4/2024, the P&P indicated, "Patient's Rights Related to Restraint/Restraint Alternatives: All patients have the right to be free from restraint of any form as means of coercion, discipline, convenience or retaliation by staff ...The use of side rails to assist a patient with safety, unless the use is such that the side rails prevent patient's mobility (e.g. all four side rails up). Such usage is intended to achieve a proper body position, balance, alignment, or to allow greater mobility."

Based on interview and record review, the Quality Assurance Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all the services provided by the hospital) Committee failed to develop and implement a corrective action plan (a detailed plan outlining the specific actions that will be taken to address the root causes of a problem to prevent the issues from occurring again) following a root cause analysis (RCA, a structured process for identifying the underlying causes of a problem or adverse event and developing corrective actions) to ensure that safety straps are used when patients are placed on the cardiac catheterization laboratory (cath lab, a hospital room where doctors perform procedures and tests to diagnose and treat heart and blood vessel conditions) table for procedures, in accordance with the facility's policy and procedure (P&P) titled, "Root Cause Analysis," after one of 34 sampled patients (Patient 4) fell off the cardiac catheterization laboratory table on 7/26/2024.

This deficient practice led to a second patient's (Patient 34's) fall from the cath lab table, when safety straps (immobilizes patients on a table to prevent falls) were not applied on Patient 34 who was undergoing a cath lab procedure on 9/10/2024. This deficient practice also had the potential for increased risk of similar incidents occurring in the future, which has a negative impact on patient safety (Example: fractures [broken bones], etc.).

Findings:

During a review of Patient 4's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/22/2024 at 9:41 a.m., the H&P indicated that Patient 4 was admitted to the facility on 7/21/2024 at 12:06 p.m. with a diagnosis of hyperglycemia (elevated blood sugar).

During an interview on 11/12/2024 at 3:00 p.m. with the Radiological Technologist 2 (RAT 2), the RAT 2 stated the following: Patient 4 was on the cardiac catheterization laboratory (cath lab, a hospital room where doctors perform procedures and tests to diagnose and treat heart and blood vessel conditions) table, when Patient 4 fell off the table. Safety straps (immobilizes patients on a table to prevent falls [unplanned descent to the floor with or without injury to the patient]) were not used to strap the patient to the table. After Patient 4 fell, two safety straps were ordered and implemented for patient use on the cath lab table. There was no manufacturer's instructions or information for the use of the safety straps. The facility did not provide an in-service or education on the use of the safety straps.

During the same interview on 11/12/2024 at 3:24 p.m. with the Radiological Technologist 1 (RAT 1), the RAT 1 stated the following: At the time of Patient 4's procedure {on 7/26/2024}, safety straps were not in use for the cath lab tables. Patient 4 fell off the cath lab table (room 3) and the Cardiovascular Technician 2 (CVT 2) was able to catch the patient before he (Patient 4) hit the floor, and then assisted Patient 4 to the floor. There was another patient fall (happened on 9/10/2024) after Patient 4's fall, where the other patient (Patient 34) fell off the cath lab table. There was no in-service or education provided by the facility for staff once the new safety straps were ordered and implemented after patient 4's fall (fall happened on 7/26/2024).

During a concurrent interview and record review on 11/13/2024 at 1:23 p.m. with the Clinical Nursing Supervisor 3 (CNS 3), the CNS 3 verified the following information in Patient 4's medical record: Patient 4's "Clinical Cardiac Electrophysiology (the study of the heart's electrical activity, including its function, performance, and mechanisms) Progress Note (a document that outlines a patient's condition and the rationale for their treatment)," dated 7/26/2024, indicated " ...[Patient 4] suffered an accidental fall from the cath lab table. Fortunately, his fall was broken by the Cardiovascular Technician (CVT 2) who was standing nearby. She (CVT 2) prevented [Patient 4] from striking his (Patient 4) head on the x-ray (creates pictures of the inside of your body) equipment on the floor. He (Patient 4) did land on his right side and hip ..."

During a concurrent interview and record review on 11/15/2024 at 9:44 a.m. with the Director of Quality and Performance Improvement (DQPI), the DQPI verified there was no corrective action plan (a detailed plan outlining the specific actions that will be taken to address the root causes of a problem to prevent the issues from occurring again) submitted following the root cause analysis (RCA, a structured process for identifying the underlying causes of a problem or adverse event and developing corrective actions) [completed 11/15/2024], after Patient 4's fall. The DQPI stated the following: The RCA identified there was no safety straps being used on the cath lab beds, and new safety straps were subsequently ordered. It was the responsibility of the cath lab Director to create and implement the corrective action plan (to address the use of safety straps on patients who are placed on the cath lab tables for a procedure) and send this (referring to the corrective action plan) to the Quality Assurance Performance Improvement (QAPI, a process by which a hospital can fully examine the quality of care it delivers and then implement specific improvement activities and projects on an ongoing basis for all the services provided by the hospital) Committee, for review. The QAPI committee did not receive an action plan following Patient 4's fall. There should have been a corrective action plan completed within 30 days of the identified adverse event (an undesirable outcome that results from a medical treatment or procedure).

During the same interview on 11/15/2024 at 9:44 a.m. with the DQPI, the DQPI said the Chief Nursing Officer (CNO) was responsible to ensure that any education provided to staff was completed. It was the responsibility of the QAPI Committee to follow up and ensure the corrective action plan was completed to determine the appropriateness of the corrective action plan. Since the action plan was not completed, this could not be communicated to the Medical Executive Committee (MEC, a governing body in a hospital or healthcare organization that represents the medical staff and makes decisions about patient care, medical staff, and clinical services) and the Governing Board (GB, a group of people who are legally responsible for the management and direction of an organization) to ensure oversight [for the prevention of future adverse events].

During the same interview and record review on 11/15/2024 at 9:44 a.m. with the DQPI, the DQPI verified that there was a second fall in the cath lab on 9/10/2024, when Patient 34 fell off the cath lab table (Patient 34 also did not have safety straps on). The DQPI further verified the facility in-service document provided, titled, "Increased awareness of fall prevention measures," dated September 2024, did not include education of cath lab staff for use of safety straps (on patients being placed on the cath lab tables for procedures). The DPQI also stated the following: Following Patient 4's fall (7/26/2024), there was an in-service (a type of education that is provided to the employees to improve their working capacity and efficiency) completed for fall prevention. The DPQI said an in-service was completed for the use of the new safety straps, but the DQPI did not have documentation to support when this occurred, what was educated, and who attended. The DQPI also verified that the fall prevention in-service was not completed by all cath lab staff listed on the in-service document. The DQPI acknowledged that the fall reduction in-services should have been completed by all cath lab staff.

During an interview on 11/15/2024 at 12:13 p.m. with the CNO, the CNO stated that when the new safety straps were brought into the facility, cath lab staff should have been in-serviced to understand how to use the safety straps in a safe way, so there was no patient harm.

During a review of the facility's policy and procedure (P&P) titled, "Root Cause Analysis," dated 6/2023, the P&P indicated, " ...Policy Statement: When an unexpected occurrence takes place and is determined to meet the definition of "Sentinel Event," [the facility] will act immediately to protect the patient(s), family member(s), visitors, volunteers, employees or physicians, from further injury. [The facility] will provide a formal process for thorough and credible root cause analysis of the event; implement improvements to reduce the probability of similar occurrences; and evaluate the effectiveness of these improvements ... These events will be addressed promptly by a multidisciplinary team (a diverse group of professionals who work collaboratively to provide coordinated, patient-centered care) comprised of medical staff and employees in order to: 1. Protect all parties from further injury 2. Gather facts surrounding the event 3. Identify the root cause of the event within 30 days 4. Recommend system or process changes to reduce the probability of a similar occurrence in the future ... Procedure: ...4.2 Follow-up actions: ...4.2.1.6 Perform root cause analysis (RCA) ... 4.2.1.12 Develop an action plan to eliminate or reduce risks; 4.2.1.13 Determine improvement strategies for casual processes or systems identified by the root cause analysis, which could reduce the probability of a similar occurrence in the future, by redesign of existing processes or development of a new system of process; 4.2.1.14 determine tasks necessary to complete above strategies; 4.2.1.15 Develop timeline for completion of these tasks; 4.2.1.16 Identify who is responsible for all tasks; 4.2.1.17 Determine how the effectiveness of the strategies will be measured; 4.2.1.18 Present findings and action plan to the Quality Council (a group of people within an organization that is responsible for driving quality improvement) and Medical Executive Committee ..."

Based on interview and record review, the facility failed to ensure Medical Staff (an organized body of licensed physicians) adhered to facility Medical Staff Bylaws (a document that provides the framework for the organization, responsibilities and self-governance of the medical staff) for one of 34 sampled patients (Patient 4), when Patient 4, who had been assessed by cardiology (the branch of medicine concerned with the diagnosis and treatment of heart-related diseases and disorders) consultant as clinically unstable for discharge from the facility, was transferred to a Skilled Nursing Facility (SNF, an inpatient treatment and rehabilitation center where patients receive care after a hospital stay) without the primary medical team obtaining medical clearance (a physician, or another health care provider has determined that a person is medically stable) from cardiology or conferring with cardiology prior to hospital discharge.

This deficient practice had the potential for Patient 4's pacemaker device's (a small, battery-powered device that prevents the heart from beating too slowly) failure (Patient 4's pacemaker remained in end of battery life since 2/8/2024 and needed battery replacement), which may result in cardiac (heart) complications including death.

Findings:

During a review of Patient 4's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/22/2024 at 9:41 a.m., the H&P indicated that Patient 4 was admitted to the facility on 7/21/2024 at 12:06 p.m. with a diagnosis of hyperglycemia (elevated blood sugar). The H&P further indicated that Patient 4 required a consultation with a Cardiologist (a physician who is an expert in the care of the heart).

During a review of Patient 4's "Cardiology Progress Notes," dated 7/22/2024 through 7/30/2024, the progress notes indicated Patient 4 was not stable for discharge and required telemetry monitoring (the process of automatically measuring and transmitting cardiac [heart] data from the patient to a central location for analysis and monitoring).

During a review of Patient 4's Physician "Progress Notes," dated 7/25/2024 at 2:25 p.m., the progress notes indicated the following: " ...Plan for discharge once cleared by Cardiology to SNF versus home with home health with Physical Therapy (PT, treatment that helps improve how the body performs physical movements) and visiting nurse ..."

During a review of Patient 4's "(Clinical Cardiac Electrophysiology, a medical specialty that focuses on diagnosing and treating heart rhythm disorders) Consultation Report," dated 7/25/2024 at 7:53 p.m., the progress note indicated the following: "Reason for visit: Evaluation of pacemaker (a small, battery-powered device that prevents the heart from beating too slowly) end of battery life ... Pacemaker analysis shows (Patient 4) remains in Elective Replacement Indicator (ERI, a status that indicates a pacemaker is nearing the end of its life and needs to be replaced) status which [Patient 4] reached on February 8 of this year (2024)."

During a concurrent interview and record review on 11/13/2024 at 1:23 p.m. with the Clinical Nursing Supervisor 3 (CNS 3), Patient 4's medical record (MR) titled, "Cardiac Electrophysiology Consultation Report (a document that outlines a patient's condition and the rationale for their treatment)," dated 7/25/2024, was reviewed. The MR indicated Patient 4's pacemaker (a small, battery-powered device that prevents the heart from beating too slowly) remained in end of battery life since 2/8/2024 and needed battery replacement at [name of the facility].

During a review of Patient 4's medical record (MR) titled, "Clinical Cardiac Electrophysiology Progress Note," dated 7/26/2024, the progress note indicated the following: "Assessment: Pacemaker generator replacement (a surgical procedure that replaces the battery and electrical circuitry in a pacemaker) an upgrade to cardiac resynchronization therapy pacemaker (CRT-P, a device that helps treat heart failure) was canceled today (7/26/2024) due to an accidental fall (unplanned descent to the floor with or without injury to the patient) from the cardiac catheterization laboratory (Cath Lab, a hospital room where doctors perform procedures and tests to diagnose and treat heart and blood vessel conditions) table.

During further record review of Patient 4's MR titled, "Clinical Cardiac Electrophysiology Progress Note," dated 7/26/2024, the MR indicated that Patient 4 and the physician (MD 2) discussed two treatment options for Patient 4's pacemaker:
"Option 1: The patient's pacemaker device would be checked the following day (7/27/2024) to obtain an accurate assessment of the remaining battery longevity. If adequate battery longevity was confirmed, the patient could choose to go to another facility for treatment."
"Option 2: Proceed with the generator replacement and insertion of a new left bundle branch pacing lead to upgrade to a CRT-P as previously planned on Tuesday [7/30/2024]."
The MR also indicated that Patient 4 elected to remain hospitalized and undergo the pacemaker battery replacement and CRT pacemaker upgrade with left bundle branch area pacing on Tuesday morning [7/30/2024] and expressed a desire to remain at the current facility, stating, "My healthcare team and doctors are here, so I want to stay here, and have it done before I go home."

During a review of Patient 4's "Internal Medicine (a medical specialty that focuses on the diagnosis, prevention, and treatment of adult diseases without surgery) Progress Notes," dated 7/29/2024 at 11:32 a.m., the progress notes indicated the following: " ...await pacer generator exchange ..."

During a review of Patient 4's "Nursing Discharge Note," dated 7/30/2024 at 11:41 p.m., the discharge note indicated the following: Patient 4 was discharged from the facility on 7/30/2024 at 11:20 p.m.

During the same concurrent interview and record review on 11/13/2024 at 1:23 p.m. with the CNS 3, Patient 4's MR titled, "Patient Orders (communicates the medical care that the patient is to receive) Detail," dated 7/30/2024, was reviewed. The MR indicated MD 3's physician's order to discharge (the formal process of a patient leaving a hospital after receiving treatment or care) Patient 4 to a Skilled Nursing Facility (SNF, an inpatient treatment and rehabilitation center where patients receive care after a hospital stay) was placed on 7/30/2024.

During an interview on 11/13/2024 at 1:23 p.m. with the CNS 3, Patient 4's MR titled, "Internal Medicine Progress Notes," dated 7/30/2024 and "Discharge Summary (a clinical document that summarizes a patient's hospital stay and care plan so that the patient's primary care provider can continue their care)," dated 7/30/2024, were reviewed. The CNS 3 stated that Patient 4's medical records contained no documentation indicating that Patient 4 was medically cleared (a physician, or another health care provider has determined that a person is medically stable) by Cardiology prior to discharge. The CNS 3 also stated that there was no documentation that Patient 4 had a pacemaker interrogation (a procedure that allows a cardiologist to check the function of a pacemaker) prior to discharge.

During an interview on 11/14/2024 at 2:15 p.m. with Medical Doctor 2 (MD 2) regarding Patient 4's pacemaker replacement procedure, MD 2 stated that Patient 4 was referred to MD 2 several times over 6-8-month period but was non-compliant with following-up to have the pacemaker replacement done. The MD 2 stated that on 7/26/2024 (on the day of procedure) Patient 4 fell off the Cath Lab table and the procedure got postponed and got rescheduled for 7/30/2024. The MD 2 then stated, on 7/30/2024, Patient 4 had a fever, and MD 2 postponed the procedure again, and made the hospitalist aware about the need to reschedule the procedure.

During the same interview on 11/14/2024 at 2:15 p.m. with MD 2 regarding Patient 4's discharge, the MD 2 stated that on 7/30/2024, MD 2 was not involved with Patient 4's discharge. MD 2 also stated they (MD 2's team) believed the patient (Patient 4) left against medical advice (AMA, when a patient leaves before their doctor recommends discharge) and stated, "I would not have recommended to discharge the patient (Patient 4)."

During an interview on 11/14/2024 at 2:32 p.m. with Medical Doctor 3 (MD 3), MD 3 stated the following: (MD 3) was the Internal Medicine Doctor for Patient 4 during their [July 2024] admission at the facility. If there was an active cardiac issue, there should have been a Cardiology clearance. If the [Cardiology] Consultant was called for clearance, this would have been documented in the discharge summary. If Cardiology follow-up was needed, there should have been documentation that the patient needed follow-up at discharge.

During an interview on 11/14/2024 at 2:41 p.m. with Medical Doctor 4 (MD 4), MD 4 stated the following: [MD 4] was a Cardiology Consultant for Patient 4. Patient 4's pacemaker was at the end of life when seen in the office, prior to admission. Patient 4 had been completely non-compliant with dates for follow-up for pacemaker replacement. Patient 4 was supposed to see [MD 2] and it never happened. If a patient was in the hospital and was unable to have the pacemaker replacement, there should have been documentation within the cardiology notes that the patient could be discharged, although the procedure was not completed. There should have been a clearance by Cardiology prior to Patient 4's discharge. There was a potential cardiac risk when Patient 4 was discharged without being cleared by Cardiology.

During a review of the facility document "Medical Staff: General Rules and Regulations (section of the medical staff bylaws that describes more detailed operational policies for a hospital's medical staff)," reviewed/revised 10/2024, the Rules and Regulations indicated the following: " ...1.8 Duties of Attending Physician: ...1.8-3 Coordinating the selection of consultants, including personally contacting them except in case of emergency in which attending is physically occupied with a patient requiring immediate attention. 1.8-4 Communicating with consultants regarding the findings of their examination and recommendations ..."

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibilities," dated 6/2022, the P&P indicated that "Patients have the right to be informed by the physician, or a delegate of the physician, about continuing healthcare requirements and options following discharge and/or transfer within or outside the hospital."

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

1. The facility failed to ensure one of 34 sampled patients (Patient 3), who was identified as cognitively impaired (having limitations in mental functions that affect their ability to process or communicate information) and nonverbal (unable to use spoken words to communicate), was properly assessed using a pain scale specifically designed for non-verbal patients, in accordance with the facility's policy regarding pain assessment and management of patients who are unable to speak or express pain verbally and/or have mental impairment.

This deficient practice had the potential to result in Patient 3 not receiving accurate pain assessment and management and potentially placing Patient 3 at risk for uncontrolled pain, worsening pain level, psychological distress such as anxiety (feeling of uneasiness), etc. (Refer to A-0395)

2. The facility failed to ensure one of 34 sampled patient's (Patient 3), pain re-assessment (the process of re-evaluating a patient's pain level after an intervention, such as medication, to determine its effectiveness and ensure proper pain management) was conducted, following the administration of Toradol (a nonsteroidal anti-inflammatory drug [NSAID] used for short-term management of moderate to severe pain), in accordance with the facility's policy regarding pain management and re-assessment.

This deficient practice had the potential to result in Patient 3's pain not being sufficiently managed/addressed, leading to discomfort or progression to uncontrolled pain or psychological distress such as anxiety (feeling of uneasiness), etc. (Refer to A-0395)

3. The facility failed to ensure that nursing staff activated the stroke protocol (a set of standardized procedures designed to rapidly assess, diagnose, and treat patients presenting with stroke [interruption of blood flow to the brain leading to potential brain damage] symptoms to minimize brain damage and improve outcomes) for one of 34 sampled patients (Patient 2), when on 7/2/2024 at 8:01 a.m., Patient 2 started showing signs and symptoms of stroke (observable indicators of a stroke, such as sudden paralysis [the loss of muscle function or control, on one side of the body]; aphasia [a language disorder caused by brain damage, affecting the ability to speak, understand, read, or write]; and facial droop [weakness or paralysis of the facial muscles, often causing one side of the face to sag or appear asymmetrical]).

The deficient practice had the potential to result in delayed diagnosis and treatment for Patient 2 and increase the risk of permanent neurological damage or other complications associated with untreated stroke symptoms. (Refer to A-0395)

4. The facility failed to ensure one of 34 sampled patient's (Patient 3) nutritional status (the condition of a patient's health as influenced by the intake and utilization of nutrients necessary for maintaining bodily functions, growth, and repair) and hydration status (the balance of fluids in the body required to support normal physiological processes, such as circulation, temperature regulation, and organ function) were monitored, assessed, and documented in accordance with the facility's policy regarding "Standard of Care" and "Nursing Documentation."

This deficient practice had the potential to result in complications such as dehydration, unexpected weight loss, etc., when the patient's (Patient 3) nutritional and hydration status are not properly assessed and monitored leading to a delay in making informed decisions to meet Patient 3's individual nutritional and hydration needs. (Refer to A-0395)

5. The facility failed to ensure one of 34 sampled patient's (Patient 24) pain was reassessed (reevaluation), in accordance with the facility's policy and procedure regarding pain management, after Patient 24 received pain medication of Ibuprofen (Motrin, pain medication) 600 milligram (mg, metric unit of measurement, used for medication dosage and/or amount), which was administered by mouth.

This deficient practice had the potential to result in Patient 24's pain to not be appropriately managed in which Patient 24's pain remains unresolved, leading to worsening of pain, psychological distress due to pain, and a prolonged hospitalization. (Refer to A-0395)

6. The facility failed to ensure for two of 34 sampled patients (Patient 11 and Patient 12), the following:

6.a. For Patient 11, an individualized nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for fall (unplanned descent to the floor with or without injury to the patient) precaution (proactive steps to prevent someone from falling by addressing potential hazards in their environment and promoting behaviors that minimize the risk of a fall), was developed upon admission, in accordance with the facility's policy and procedure regarding care planning..

This deficient practice had the potential for Patient 11's needs and risks not to be identified and addressed, which may result in a fall with complications such as fracture (break in the bones), etc. (Refer to A-0396)

6.b. For Patient 12, an individualized nursing care plan for management of Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) was developed upon admission, in accordance with the facility's policy and procedure regarding care planning.

This deficient practice had the potential to result in the delayed provision of care to Patient 12 by not identifying Patient 12's need and risks, which may result in complications such as hypoglycemia (low blood sugar), diabetic coma (a life-threatening complication when a patient's blood sugar levels are dangerously high or low, causing them to become unconscious), and/or death. (Refer to A-0396)

7. The facility failed to ensure that for one of 34 sampled patients (Patient 3), nursing staff documented intake and output (the measurement and recording of all fluids a patient takes in, such as through drinking or IV fluids [intravenous fluids, which are liquids administered directly into a vein to provide hydration, medications, or nutrients], and fluids they lose, such as through urination or vomiting) throughout Patient 3's admission stay at the facility, in accordance with the facility's policy regarding "Standard of Care" and "Nursing Documentation."

This deficient practice potentially placed Patient 3 at risk for missed opportunities to detect and address changes in the patient's fluid status (the balance of fluids in the body, which is essential for maintaining normal bodily functions), which may result in complications such as dehydration (excessive loss of fluid), low blood pressure, etc. (Refer to A-0398)

8. The facility failed to ensure that, for one patient out of 34 sampled patients (Patient 3), nursing staff obtained a urine sample (a collection of urine used for diagnostic purposes, such as detecting infections, assessing kidney function) as indicated by the physician's order and in accordance with the facility's policy regarding carrying-out all physician's orders.

This deficient practice had the potential to result in Patient 3's delayed diagnosis and treatment of underlying medical conditions such as urinary tract infections (UTIs, infections occurring in any part of the urinary system, including the bladder, urethra [the tube that carries urine out of the body], or kidneys, which can cause symptoms such as pain, burning during urination, and fever, and if untreated, may lead to serious kidney complications) leading to worsening of symptoms and compromising patient's (Patient 3) health and recovery. (Refer to A-0398)

9. The facility failed to ensure that, for one of 34 sampled patients (Patient 2), the mental status (assessed to identify abnormalities such as confusion, disorientation, or unresponsiveness) during the triage assessment (the initial evaluation of a patient upon arrival to the emergency department), was accurately documented based on Patient 2's presenting condition, in accordance with the facility's policy regarding documentation in the ED patient care record (a comprehensive record of care provided in the emergency department).

This deficient practice resulted in Patient 2 not being assigned a correct ESI level (Emergency Severity Index, a triage tool used to categorize patients based on acuity-the severity of a patient's condition and the urgency of medical intervention required-and resource needs, such as diagnostic tests or treatments), which could potentially lead to delayed prioritization of care (failure to provide timely or suitable medical attention based on the patient's actual condition and needs, potentially compromising outcomes). (Refer to A-0398)

10. The facility failed to ensure one of 34 sampled patient's (Patient 6's) pain was assessed and addressed after sustaining an unwitnessed fall (an unplanned descent to the floor with or without injury to the patient) and on two other occasions when Patient 6's family reported that Patient 6 had pain, in accordance with the facility policy and procedure regarding assessment, reassessment, and pain management.

This deficient practice likely resulted in Patient 6 experiencing unrelieved pain and had the potential for delay in needed treatment, which can result in complications such as worsening pain level, psychological distress due to uncontrolled pain, etc. (Refer to A-0398)

11. The facility failed to ensure one of 34 sampled patient's (Patient 6's) fall risk was reassessed using the Morse Fall Scale (MFS, a tool to identify patients at risk for falling that includes history of falling, secondary diagnosis, ambulatory [related to walking] aids [example: cane], intravenous [medication administered into the vein] therapy, gait abnormalities [the pattern of how a person walks], and mental status, with the summed range from 0 to 125, higher scores indicating a higher risk for falling) after sustaining a fall (unplanned descent to the floor with or without injury to the patient) on 10/4/2024 and for the MFS score to reflect Patient 6's post-fall status.

This deficient practice may lead to the wrong fall preventative measures used and compromise Patient 6's safety, which may result in another fall with complications such as fracture (broken bones). (Refer to A-0398)

12. The facility failed to ensure, the facility staff followed the chain of command (crucial for ensuring patient safety by providing a structured process for staff to escalate concerns about patient care, report issues, and seek necessary interventions through a clear hierarchy of authority, ultimately leading to better decision-making and addressing problems promptly when they arise) when unable to immediately contact and notify the physician regarding one of 34 sampled patient's (Patient 6's) critical laboratory values (potentially life-threatening laboratory results that must be conveyed immediately to the physician so that therapeutic measures can be instituted rapidly) such as elevated Troponin (is a protein that's found in the cells of the heart muscle) level of 80.0 ng (nanograms, a unit of measurement) per milliliter (mL, a unit of measurement, a normal troponin levels range is from 0-0.04 ng/ml) and a Hemoglobin level of 6.2 (normal range of hemoglobin for adult men is 13.5 to 17.5 g/dL ) , in accordance with the facility's policy and procedure regarding utilization of chain of command.

This deficient practice may lead to a delay in necessary interventions and jeopardize Patient 6's safety, resulting in complications such as cardiac arrest [when the heart stops beating], dizziness, fatigue, shortness of breath [difficulty breathing], etc. (Refer to A-0398)

13. The facility failed to ensure one of 34 sampled patients (Patient 5) was turned and repositioned (to change someone's body position by physically turning them over to a different orientation, shifting body weight distribution to relieve pressure on a particular area of the body) every 2 hours, in accordance with facility policy and procedure regarding skin integrity (refers to the health and unbroken state of the skin).

This deficient practice had the potential for patient 34's existing sacrogluteal (buttock [butt] area) pressure injuries (localized damage to the skin or soft tissue caused by prolonged or severe pressure, often over a bony part of the body) to worsen, resulting in complications such as infection, the need for surgery to debride (remove) dead tissue, etc. (Refer to A-0398)

14. The facility failed to ensure for one of 34 sampled patients (Patient 9), Patient 9's seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) precautions (refers to safety measures taken before a patient experiences a seizure) was implemented, in accordance with the facility's policy and procedure regarding seizure management when, Patient 9 was observed to not have all the four side rails padded.

This deficient practice had the potential for Patient 9 to suffer from pain and injury (such as fracture [broken bones]) during a seizure activity. (Refer to A-0398)

15. The facility failed to ensure for one of 30 sampled patients (Patient 20), the facility's policies and procedures (P&P) for fall (an unplanned descent to the floor with or without injury to the patient) reduction was implemented when, Patient 20, who was a high risk for fall, was not wearing yellow socks (yellow socks indicate the patient was at risk for fall) and the patient's (Patient 20) bed alarm was not turned on/activated (a bed alarm will go off to alert staff when a patient gets out of bed).

This deficient practice had the potential to result in an unsafe care that may lead to Patient 20 suffering from a fall injury with possible complications such as fracture (broken bones), the need for surgery (in case of severe injury requiring surgery), brain bleed (if the patient hits the head on the floor), etc. (Refer to A-0398)

16. The facility failed to ensure one of seven sampled emergency crash carts (Crash Cart 2, a wheeled container carrying medicine and equipment for use in emergency resuscitations [procedure used to restart a patient's breathing and heartbeat when they have stopped]), had complete and readily available equipment for use when, Crash Cart 2 was missing a cardiac backboard (rigid surface used to support a patient during a cardiopulmonary resuscitation [CPR, a life-saving emergency procedure that combines chest compressions and rescue breathing to help someone who is not breathing or heartbeat has stopped]).

This deficient practice had the potential to delay critical emergency care if the crash cart equipment was not inspected for completeness and verified for availability potentially leading to worsened patient outcomes and/or patient death. (Refer to A-0398)

17. The facility failed to ensure that for one patient out of 34 sampled patients (Patient 3), the ordered medications- Colace (a stool softener taken orally), Mag-Al Plus (a magnesium-aluminum-based oral laxative (a medication that makes it easier to pass stool) used to relieve constipation and reduce stomach acid), and Dulcolax suppository (a rectal medication that stimulates bowel movements to alleviate constipation)- were administered on an as-needed basis (PRN; a medical directive to provide medication only when symptoms or conditions, such as constipation, are present and require intervention), in accordance with the physician's order, when indicated, and in alignment with the facility's nursing standard of care.

This deficient practice had the potential to compromise Patient 3's overall health and well-being, leading to worsened constipation, increased discomfort or pain, and progression to more severe complications such as bowel obstruction (a serious condition where the intestine is partially or completely blocked, preventing the normal passage of stool, gas, or fluids, which can cause severe pain, nausea, and vomiting) or impaction (a condition where hardened stool becomes lodged in the rectum, making it extremely difficult or impossible to pass without medical intervention). (Refer to A-0406)

18. The facility failed to ensure one of 34 sampled patients (Patient 6's), was administered a PRN (as needed) Levophed (norepinephrine bitartrate, a prescribed medication used to treat life-threatening low blood pressure) when Patient 6's mean arterial pressure (MAP, the average blood pressure during a single cardiac [heart] cycle) was at 53 (on 10/7/2024 at 9:00 a.m.), below 65 mmHg (millimeters of mercury, unit of measurement), as ordered by the physician.

This deficient practice resulted in a delay in the intervention that was prescribed to prevent low blood pressure for Patient 6 and likely contributed to a code blue (an overhead page to summon trained staff to a patient having a medical emergency, usually cardiac [heart] or respiratory [breathing] arrest [when breathing stops or when the heart stops beating]) being called. (Refer to A-0406)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments.

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

1.a. Ensure one of 34 sampled patients (Patient 3), who was identified as cognitively impaired (having limitations in mental functions that affect their ability to process or communicate information) and nonverbal (unable to use spoken words to communicate), was properly assessed using a pain scale specifically designed for non-verbal patients, in accordance with the facility's policy regarding pain assessment and management of patients who are unable to speak or express pain verbally and/or have mental impairment.

This deficient practice had the potential to result in Patient 3 not receiving accurate pain assessment and management and potentially placing Patient 3 at risk for uncontrolled pain, worsening pain level, psychological distress such as anxiety (feeling of uneasiness), etc.

1.b. Ensure one of 34 sampled patient's (Patient 3), pain re-assessment (the process of re-evaluating a patient's pain level after an intervention, such as medication, to determine its effectiveness and ensure proper pain management) was conducted, following the administration of Toradol (a nonsteroidal anti-inflammatory drug [NSAID] used for short-term management of moderate to severe pain), in accordance with the facility's policy regarding pain management and re-assessment.

This deficient practice had the potential to result in Patient 3's pain not being sufficiently managed/addressed, leading to discomfort or progression to uncontrolled pain or psychological distress such as anxiety (feeling of uneasiness), etc.

2. Ensure that nursing staff activated the stroke protocol (a set of standardized procedures designed to rapidly assess, diagnose, and treat patients presenting with stroke [interruption of blood flow to the brain leading to potential brain damage] symptoms to minimize brain damage and improve outcomes) for one of 34 sampled patients (Patient 2), when on 7/2/2024 at 8:01 a.m., Patient 2 started showing signs and symptoms of stroke (observable indicators of a stroke, such as sudden paralysis [the loss of muscle function or control, on one side of the body]; aphasia [a language disorder caused by brain damage, affecting the ability to speak, understand, read, or write]; and facial droop [weakness or paralysis of the facial muscles, often causing one side of the face to sag or appear asymmetrical]).

The deficient practice had the potential to result in delayed diagnosis and treatment for Patient 2 and increase the risk of permanent neurological damage or other complications associated with untreated stroke symptoms.

3. Ensure one of 34 sampled patient's (Patient 3) nutritional status (the condition of a patient's health as influenced by the intake and utilization of nutrients necessary for maintaining bodily functions, growth, and repair) and hydration status (the balance of fluids in the body required to support normal physiological processes, such as circulation, temperature regulation, and organ function) were monitored, assessed, and documented in accordance with the facility's policy regarding "Standard of Care" and "Nursing Documentation."

This deficient practice had the potential to result in complications such as dehydration, unexpected weight loss, etc., when the patient's (Patient 3) nutritional and hydration status are not properly assessed and monitored leading to a delay in making informed decisions to meet Patient 3's individual nutritional and hydration needs.

4. Ensure one of 34 sampled patient's (Patient 24) pain was reassessed (reevaluation), in accordance with the facility's policy and procedure regarding pain management, after Patient 24 received pain medication of Ibuprofen (Motrin, pain medication) 600 milligram (mg, metric unit of measurement, used for medication dosage and/or amount), which was administered by mouth.

This deficient practice had the potential to result in Patient 24's pain to not be appropriately managed in which Patient 24's pain remains unresolved, leading to worsening of pain, psychological distress due to pain, and a prolonged hospitalization.

Findings:

1.a. During a review of Patient 3's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/9/2024, the H&P indicated that Patient 3 had past medical history (PMH, a record of all previously diagnosed medical conditions, treatments, and surgeries that could impact the patient's current health or care plan) of dementia (progressive decline in mental functions) and hypertension (high blood pressure). The H&P also indicated that Patient 3 was admitted due to constipation (a condition marked by infrequent or difficult bowel movements), failure to thrive (FTT, a state of poor nutrition or significant weight loss), refusing to eat (a medical or behavioral issue where the patient declines food intake), and acute (sudden) on chronic (long-duration) encephalopathy (worsening of brain function).

During a review of Patient 3's medical record (MR) titled, "Urology Consultation (a formal assessment by a specialist in urology to evaluate and manage conditions affecting the urinary tract [the system responsible for removing waste and excess fluids from the body, including the kidneys, ureters, bladder, and urethra] or the male reproductive system)," dated 9/10/2024, the MR indicated that a urologist (a physician specializing in the diagnosis and treatment of disorders related to the urinary system, including the kidneys, ureters, bladder, and urethra [the tube that carries urine from the bladder out of the body], as well as the male reproductive organs) was consulted to evaluate Patient 3's medical condition related to a left mid urethral stone (a hard, solid mass that forms in the ureter, the tube connecting the kidneys to the bladder, potentially causing pain and urinary obstruction [blockage]), with hydronephrosis (swelling of a kidney due to a buildup of urine caused by an obstruction or blockage in the urinary tract), and possible colic (severe, intermittent pain caused by spasms or contractions in the urinary tract, often associated with kidney stones or other obstructions).

During a review of Patient 3's medical record (MR) titled, "Pain Assessment," dated 9/13/2024 at 4:00 a.m., the MR indicated that Patient 3's pain level was documented using a numerical pain scale (a tool where patients rate their pain intensity on a scale from 0 to 10, with 0 meaning no pain and 10 representing the worst pain imaginable) as 7 out of 10 (7 out of 10 typically indicates severe pain).

During a record review on 11/14/2024 at 3:50 p.m. with the Quality Assurance Nurse (QAN), Patient 3's "Pain Assessment" medical record, dated 9/13/2024, was reviewed. The QAN verified that Patient 3's MR indicated that Patient 3's pain intensity level was assessed using a numerical pain scale.

During a concurrent interview and record review on 11/14/2024 at 3:50 p.m. with the Quality Assurance Nurse (QAN), Patient 3's medical record (MR) titled, "Nursing Shift Assessment (an evaluation completed by nurses to document a patient's physical, emotional, and mental status during each shift)," dated 9/13/2024, was reviewed. The QAN stated that the MR documentation indicated that Patient 3's mental status was recorded as confused and non-verbal on 9/13/2024. The QAN said that nurses were expected to use a pain scale tailored to the patient's ability to communicate pain. Since Patient 3 was unable to communicate verbally, the QAN stated that the nurses should have used a pain scale specifically designed for non-verbal patients to accurately assess the patient's pain intensity level. Instead, the nurses used a numerical rating pain scale, which implies that the patient verbalized their pain level, despite the patient (Patient 3) being identified as confused and non-verbal.

During a review of the facility's policy and procedure (P&P) titled, "Pain Management," dated July 2023, the P&P stated that pain intensity should be assessed using one of the following pain scales consistently, based on the patient's age and developmental level. For non-verbal patients, the FLACC Behavioral Scale (a tool used to evaluate pain based on five behavioral criteria: Face, Legs, Activity, Cry, and Consolability) or the Checklist of Nonverbal Pain Indicators (CNPI, a tool used for adults who are nonverbal to measure pain behaviors, particularly in cognitively impaired older adults, where "cognitively impaired" refers to limitations in memory, attention, reasoning, or other mental functions) may be used to assess pain intensity. The P&P also indicated that other measures may be used to detect pain and evaluate interventions, particularly when self-reporting is not possible. In such cases, staff should document that self-reporting cannot be used. Additional considerations for pain management outlined in the P&P included:
Identifying pathological conditions or procedures that may cause pain.
Listing behaviors observed by caregivers or others familiar with the patient that may indicate pain.
Documenting "Assume Pain Present" (APP) in cases where pain is suspected but cannot be directly reported by the patient.

1.b. During a review of Patient 3's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/9/2024, the H&P indicated that Patient 3 had past medical history (PMH, a record of all previously diagnosed medical conditions, treatments, and surgeries that could impact the patient's current health or care plan) of dementia (progressive decline in mental functions) and hypertension (high blood pressure). The H&P also indicated that Patient 3 was admitted due to constipation (a condition marked by infrequent or difficult bowel movements), failure to thrive (FTT, a state of poor nutrition or significant weight loss), refusing to eat (a medical or behavioral issue where the patient declines food intake), and acute (sudden) on chronic (long-duration) encephalopathy (worsening of brain function).

During a review of Patient 3's "Medication Administration Record (MAR)," dated 9/11/2024, the MAR indicated that on 9/11/2024 at 6:36 p.m., Patient 3 received 15 milligrams (mg, a unit of measurement) of Toradol (a nonsteroidal anti-inflammatory drug [NSAID] used for short-term management of moderate to severe pain) for a reported pain level of 6 out of 10 (a pain numeric scale is a tool used to rate pain intensity on a scale from 0 to 10, where 0 indicates no pain, 1-3 indicates mild pain, 4-6 indicates moderate pain, and 7-10 indicates severe pain).

During a review of Patient 3's medical record (MR) titled, "Pain Assessment," dated 9/11/2024 through 9/12/2024, the MR indicated that Patient 3's pain intensity level was not re-assessed after the administration of Toradol on 9/11/2024 at 6:36 p.m. The MR further indicated that the next pain assessment for Patient 3 was not documented until 3:36 a.m. on 9/12/2024 (9 hours from the time the Toradol was administered).

During an interview on 11/14/2024 at 3:50 p.m. with the Quality Assurance Nurse (QAN), the QAN stated that nurses were expected to reassess a patient's pain intensity level after administering pain medication. The QAN further stated that, according to the facility's policy, the reassessment of pain should be performed within 30 minutes of administering pain medication to ensure the intervention was effective.

During a review of the facility's policy and procedure (P&P) titled, "Pain Management," dated 7/2023, the P&P stated: "After each pain management intervention, once sufficient time has elapsed for the treatment to reach peak effect (the time when a medication achieves its maximum therapeutic impact), the goal is reassessment and documentation within one hour of the intervention. Documentation should include the patient's response to the intervention and any side effects or adverse responses."

2. During a review of Patient 2's EMS (Emergency Medical Services, prehospital care provided by paramedics or emergency responders) Patient Care Report (PCR), dated 7/1/2024 at 10:47 a.m., the PCR indicated that paramedics (healthcare professionals trained to provide emergency medical care and transport patients to medical facilities) brought Patient 2 to the facility's Emergency Department (ED, a specialized hospital unit providing acute care for patients with severe or urgent medical conditions) on 7/1/2024 at 11:29 a.m. The PCR also indicated that Patient 2 was alert and oriented to none (meaning the patient was not oriented to person, place, time, or situation, typically indicating a state of confusion or altered mental status). The PCR also indicated that bystanders on scene witnessed the patient (Patient 2) come out of the bathroom, fall down, and start having full body shakes. The PCR also indicated that patient (Patient 2) had a history of seizures (a sudden, uncontrolled electrical disturbance in the brain that can cause changes in behavior, movements, feelings, or consciousness), unknown if compliant with medications and that the patient (Patient 2 was possibly postictal [a state following a seizure characterized by confusion, drowsiness, or disorientation as the brain recovers]).

During a review of Patient 2's HPI (History of Present Illness, a detailed narrative of the patient's current health complaint, including onset, progression, and associated symptoms), dated 7/1/2024, the HPI indicated that Patient 2 presented to the Emergency Department (ED, a specialized unit in a hospital equipped to provide immediate care for urgent and life-threatening medical conditions) on 7/1/2024 at 11:29 a.m. after experiencing a seizure (a sudden, uncontrolled electrical disturbance in the brain that can cause changes in behavior, movements, feelings, or level of consciousness).
The HPI also noted that Patient 2 had no prior visits to the facility's ED. Additionally, the HPI stated that Patient 2 had a past medical history (PMH, a record of previously diagnosed medical conditions, treatments, and surgeries) of seizures and alcoholism (a chronic disease characterized by an inability to control or stop alcohol use despite negative social, occupational, or health consequences).

During a review of Patient 2's HPI, dated 7/1/2024, the HPI indicated that Patient 2 was treated with Versed (medication used to control seizures and provide sedation) upon arrival to the ED and Intravenous (IV, administered through a vein) Keppra (levetiracetam, medication used to prevent and treat seizures). The workup (a series of diagnostic tests and evaluations performed to identify the cause of a patient's symptoms) was done with head CT (computed tomography, an imaging study to produce detailed pictures of the brain and skull to detect conditions like strokes, tumors, or trauma), CBC (complete blood count, a blood test to identify infection, anemia [when the body does not have enough red blood cells that carries oxygen to other parts of the body], or other abnormalities), BMP (basic metabolic panel, a blood test to identify metabolic [related to the body's metabolism- the conversion of food into energy] or organ dysfunction), and toxicology screen (a test to detect drugs, toxins, or alcohol in the body). The HPI indicated that Patient 2 continued to remain postictal (a state of altered consciousness or confusion following a seizure) and required to be admitted (the process of formally entering a patient into a hospital for inpatient care and monitoring) to the facility.

During a review of Patient 2's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 7/1/2024, at 5:20 p.m., the H&P indicated that Patient 2 was admitted due to altered mental status (a condition characterized by changes in awareness, orientation, behavior, or mental function) and seizure. The H&P also indicated that Patient 2 had a past medical history (PMH, a record of previously diagnosed medical conditions, treatments, and surgeries) of seizure disorder, was confused, and unable to provide history. Most of the history was taken from the chart and EMR (Electronic Medical Record, a digital version of a patient's medical chart that contains their medical history, treatment plans, lab results, and other health information). Additionally, the H&P stated: "We will try to locate the family to get further information ..."

During a review of Patient 2's History & Physical (H&P) dated 7/1/2024, the H&P indicated that Patient 2 was alert, awake, oriented to none (not oriented to person, place, or time, indicating severe confusion or altered mental status); opened eyes with painful stimuli (a response to a physical stimulus, such as a pinch, used to assess consciousness level); followed commands, but was falling back to sleep; moved all extremities spontaneously (able to move arms and legs without assistance, indicating intact motor function and absence of significant paralysis).

During further review of the History and Physical (H&P) dated 7/1/2024, the H&P noted the following: the patient's (Patient 2) alcohol level was negative, indicating no measurable alcohol in the patient's (Patient 2) system at the time of evaluation. The CT scan of the head revealed nonspecific hypoattenuation [refers to an area of lower density [thickness]on the scan that may indicate potential abnormalities such as ischemia, edema, or other conditions] in the posterior [refers to the back] left parietal lobe [a region of the brain associated with sensory perception and integration, spatial reasoning [the ability to understand, visualize, and manipulate objects or shapes in a given space], and coordination]).

During a review of Patient 2's medical record (MR) titled, "Patient Order Details," dated 7/1/2024, the MR indicated that on 7/1/2024 at 2:38 p.m., the physician ordered an MRI (magnetic resonance imaging, a diagnostic test that creates detailed images of the brain and other structures) brain with and without contrast (contrast refers to a special dye injected into the body to enhance the clarity of the images and help detect abnormalities) as a routine order (a routine MRI is typically scheduled for the next available slot, which could be later the same day or within a few days, depending on the facility's workflow and patient volume. Routine orders are not prioritized over urgent or emergent cases).

During a review of Patient 2's medical record (MR) titled, "Shift Assessment (a routine evaluation conducted by nursing staff during a shift to monitor a patient's condition and document any changes)," dated 7/2/2024 at 8:00 a.m., the MR indicated that Patient 2's speech was garbled (unclear or slurred speech that is difficult to understand, often indicative of neurological impairment). Strength assessment (an evaluation of a patient's muscle strength, typically graded on a scale from normal to severe weakness) was documented as mild weakness (reduced muscle strength that limits function but does not significantly impair movement). The focus of care (the primary concern or objective of medical or nursing care during a given time, often guided by the patient's current condition or complaints) was recorded to be "pain."

During a review of Patient 2's MR (Medical Record) titled, "Shift Assessment," dated 7/2/2024 at 8:01 a.m., the MR indicated that Patient 2's speech was aphasic (a condition characterized by the inability to produce or understand speech, often resulting from brain damage such as a stroke). Strength assessment of the left leg and left arm was recorded as flaccid (a state of complete loss of muscle tone, resulting in limp and unresponsive muscles, often indicative of significant neurological damage). The focus of care was recorded to be "neurological" (relating to the diagnosis, treatment, or monitoring of disorders affecting the nervous system, including the brain, spinal cord, and nerves).

During further review of Patient 2's medical record (MR) titled, "NIH Stroke Scale(National Institutes of Health Stroke Scale, a standardized scoring system used to evaluate the severity of stroke-related neurological deficits, based on assessments of various functions such as consciousness, vision, motor ability (movement), sensation, and language), dated 7/2/2024, at 8:01 a.m., the MR indicated that the NIH score was 21 (a score on the NIH Stroke Scale ranging from 0 to 42; a score of 21 indicates a severe stroke with significant neurological impairment, such as loss of motor function, speech difficulties, or cognitive deficits). The MR also indicated that that the onset (the time when symptoms of the stroke first began or were last known to occur) was more than 24 hours. The MR also stated that MD was not notified on 7/2/2024 at 8:01 a.m.

During a review of Patient 2's Medical Record (MR) titled, "NIH Stroke Scale," dated 7/2/2024 at 10:00 a.m., the MR indicated the NIH score was 21 (a severe stroke, indicating significant neurological impairment), and the attending physician (a medical doctor responsible for overseeing a patient's care, coordinating the treatment plan, and guiding other healthcare team members) (MD 11) was notified at 10:00 a.m. on 7/2/2024.

During further review of Patient 2's medical record (MR) titled, "Progress Note (a section of the medical record where physicians document updates on a patient's condition, treatment, and response over time)," dated 7/2/2024 at 3:41 a.m., the MR indicated that patient (Patient 2) was not moving the left side. The note stated, "Probable stroke, await neurology consult (a formal request for evaluation and recommendations from a neurologist, a specialist in diagnosing and treating disorders of the nervous system, including strokes)."

During further review of Patient 2's medical record (MR) titled, "Neurological Consultation (a specialized evaluation conducted by a neurologist to assess and diagnose conditions related to the nervous system, including the brain, spinal cord, and nerves)," dated 7/3/2024, the MR indicated the following: "The patient (Patient 2) with unclear PMH (past medical history) has not seen a primary physician for years. History obtained with family at the bedside and on the phone. The patient (Patient 2) presented to the ED status after a seizure with no prior history of seizures. Patient (Patient 2) was diagnosed with a stroke (a medical emergency that occurs when blood flow to a part of the brain is interrupted or reduced, preventing brain tissue from receiving oxygen and nutrients) and presented on exam aphasic (a condition characterized by an impaired ability to speak, understand, or process language, typically due to brain damage such as from a stroke) and with left-sided hemiparesis (weakness or partial loss of strength on the left side of the body, often caused by a neurological event like a stroke). Patient (Patient 2) was started on stroke protocol (standardized, evidence-based set of procedures designed to ensure the timely identification, evaluation, and treatment of patients presenting with symptoms of a stroke)."

During an interview on 11/13/2024 at 11:44 a.m. with the physician (MD 11), MD 11 stated the following: "I remember the patient somewhat; I just reviewed the chart. I remember the patient (Patient 2) was confused. The CT (computed tomography (CT), an imaging technique used to create detailed internal images of the body) results were abnormal, showing a questionable mass. I did an MRI (magnetic resonance imaging, a detailed imaging method used to diagnose conditions such as strokes or masses), and it showed multiple infarcts (areas of dead tissue caused by a lack of blood supply). The patient (Patient 2) ended up with a PEG (percutaneous endoscopic gastrostomy, a feeding tube placed directly into the stomach), and might have aspirated, leading to intubation (the insertion of a breathing tube to maintain an airway). The patient (Patient 2) was later extubated (removal of the breathing tube) and ultimately discharged to a SNF (skilled nursing facility, a healthcare facility providing medical and rehabilitative care)."

In the same interview on 11/13/2024 at 11:46 a.m. with the physician (MD 11), MD 11 stated the following: I received the patient [Patient 2] from the ED with questionable alcohol use and seizure, so I initially wanted to rule out an alcohol-related seizure. Based on the CT scan, there was a questionable mass, and the findings were abnormal. If it's a mass, I am not going to entertain the idea of a stroke. Unfortunately, we did not give the appropriate treatment at the beginning. I did not start any treatment because I had to consider the possibility that the patient might need surgery. The time frame was within 24 hours, and I ordered the MRI as soon as I saw the patient. However, I carried the diagnosis of alcohol use disorder, which influenced my initial assessment. The MRI happened within 24 hours, but I acknowledge that MRI should have been done faster, especially since this is a stroke center. If stroke had been a possibility from the start, we would have expedited the MRI process much faster. The patient was unresponsive, and I had no family available to provide further history or clarification through an interview.

During an interview on 11/13/2024 at 12:00 p.m. with the Chief of Staff (MD 10), MD 10 stated the following regarding Patient 2's head CT images (a computed tomography [CT] scan of the head that produces detailed images of the brain and skull, commonly used to identify bleeding, trauma, or other abnormalities) obtained on 7/1/2024 at 12:36 p.m.: "Initial CT [on 7/1/2024 at 12:36 p.m.] - typically, I don't comment on the cerebellum (the part of the brain located at the back of the skull, responsible for balance, coordination, and fine motor skills, and affected by Patient 2's stroke) if the findings are unremarkable. If there's nothing notable, it's not something we (radiologists, medical doctors specializing in interpreting imaging studies like CTs) would specifically mention in a non-contrast (a type of imaging study performed without contrast dye, primarily used to detect large abnormalities such as bleeding or mass effect) head CT. The follow-up MRI (magnetic resonance imaging, a detailed imaging technique that produces high-resolution images of the brain and other structures) was done on 7/2/2024 at 12:02 p.m. and demonstrated a large area of acute ischemia (restricted blood flow to brain tissue leading to oxygen deprivation and potential brain cell death), which was already subacute (occurring 24 hours to 7 days after the initial ischemic event). It was unusual to find these results after an unremarkable head CT was done the day before."

In the same interview on 11/13/2024 at 12:00 p.m. with the Chief of Staff (MD 10), MD 10 stated the following: The initial CT scan (for Patient 2) was not performed under a Code Stroke protocol but was ordered due to (Patient 2's) altered mental status. If it had been a stroke order, the radiologist would have followed a different protocol. The MRI would show the stroke immediately. We would need to know the last known well time (the last time the patient was observed to be neurologically normal), and a CT angiography (a specialized CT imaging technique using contrast dye to visualize blood vessels and identify blockages or abnormalities) might have warranted a different intervention (for Patient 2). A negative head CT is only sufficient to rule out a hemorrhagic stroke (a type of stroke caused by bleeding in or around the brain, rather than a blockage).

During an interview on 11/13/2024 at 2:40 p.m. with the Medical Director of the Emergency Department (MD 9), MD 9 stated the following: Patient (Patient 2) presented altered to the ED. I would assume the patient was post-ictal. I ordered a head CT, which is common for altered patients. The patient was found altered and down and was outside the window for stroke intervention because we did not know the patient's (Patient 2) last known well time. I would not call a code stroke for such a patient. Altered mental status is not an indicator to call a Code Stroke. If an MRI was ordered, it would be more sensitive than a CT, but there was no indication to call a Code Stroke (for Patient 2). The patient was admitted first, and only then started showing symptoms of stroke.

During an interview on 11/14/2024 at 10:45 a.m. with the Quality Assurance Nurse/Stroke Coordinator (QAN), the QAN stated the following: "In our policy, the Code Stroke (a hospital protocol activated to expedite the assessment, diagnosis, and treatment of patients presenting with acute (sudden) stroke symptoms) is activated for someone who has stroke (a medical condition where blood flow to the brain is interrupted, leading to potential brain damage and neurological deficits) symptoms within 24 hours of onset. Once the nurse identifies a change in condition [stroke], and the symptoms are within 24 hours, she [the nurse] can activate the Code Stroke. If it is more than 24 hours, she [the nurse] should call the physician regarding signs and symptoms of a stroke."

During a review of Patient 2's medical record (MR), dated 7/2/2024, the MR indicated that Code Stroke [for Patient 2] was never activated on 7/2/2024. Additionally, the MR indicated that there were no previously documented neurological changes in Patient 2's condition (from 7/1/2024 at 11:46 a.m. to 7/2/2024 at 8:01 a.m.) to suggest that the onset of stroke symptoms occurred more than 24 hours prior to the time Patient 2's NIH Stroke Scale was documented as 21 (severe stroke) on 7/2/2024 at 8:01 a.m. The QAN (Quality Assurance Nurse) reviewed the record and verified that the first recorded Patient 2's neurological changes were documented only on 7/2/2024 at 8:01 a.m.

During a review of the facility's policy and procedure (P&P) titled, "Acute Stroke," dated 10/2023, the P&P indicated that the purpose of the policy is to outline the standard of care provided to all patients arriving or admitted with a working diagnosis of ischemic stroke ...and to outline the role of the Code Stroke Team responding to any acute stroke patients or inpatient with suspected stroke. Consistent care will be delivered to all patients with a working diagnosis of ischemic stroke ...throughout the continuum of care ...The Code Stroke Team will respond to all acute onset stroke patients 24 hours a day, year-round. Acute onset is defined as any patients identified within 6 hours of the onset of stroke symptoms. Acute phase: Patients presenting acute symptoms of stroke: 3.1.1 when an inpatient is suspected of sustaining an acute stroke, the RN calls the Code Stroke. 3.1.2. The primary care nurse or RRT (Rapid Response Team, a group of healthcare professionals trained to respond quickly to acute changes in a patient's condition to prevent further deterioration) will contact the primary care physician. 3.1.3. The Code Stroke Team arrive within 10 minutes. 3.1.4. Code Stroke Orders are initiated. 3.1.8. All Code Stroke Patients will be evaluated via Tele-Neurology (a remote consultation service where neurologists evaluate and provide recommendations for patients using telecommunication technologies, such as video conferencing or electronic data exchange), and it is available 24/7 ...

3. During a review of Patient 3's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/9/2024, the H&P indicated that Patient 3 had past medical history (PMH, a record of all previously diagnosed medical conditions, treatments, and surgeries that could impact the patient's current health or care plan) of dementia (progressive decline in mental functions) and hypertension (high blood pressure). The H&P also indicated that Patient 3 was admitted due to constipation (a condition marked by infrequent or difficult bowel movements), failure to thrive (FTT, a state of poor nutrition or significant weight loss), refusing to eat (a medical or behavioral issue where the patient declines food intake), and acute (sudden) on chronic encephalopathy (a sudden worsening of brain function).

During a review of Patient 3's medical record (MR) titled, "Nutritional Intake (a section of the medical record used to document the amount and type of food and beverages consumed by the patient to monitor their nutritional status)," dated 9/9/2024 through 9/13/2024, the MR indicated that during Patient 3's stay at the facility (9/9/2024 through 9/13/2024), Patient 3 had only one meal intake documented on 9/13/2024 at 8:00 a.m. indicating that Patient 3 ate 75% (seventy-five percent, meaning

Based on interview and records review, the facility failed to ensure for two of 34 sampled patients (Patient 11 and Patient 12), the following:

1. For Patient 11, an individualized nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for fall (unplanned descent to the floor with or without injury to the patient) precaution (proactive steps to prevent someone from falling by addressing potential hazards in their environment and promoting behaviors that minimize the risk of a fall), was developed upon admission, in accordance with the facility's policy and procedure regarding care planning..

This deficient practice had the potential for Patient 11's needs and risks not to be identified and addressed, which may result in a fall with complications such as fracture (break in the bones), etc.

2. For Patient 12, an individualized nursing care plan for management of Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) was developed upon admission, in accordance with the facility's policy and procedure regarding care planning.

This deficient practice had the potential to result in the delayed provision of care to Patient 12 by not identifying Patient 12's need and risks, which may result in complications such as hypoglycemia (low blood sugar), diabetic coma (a life-threatening complication when a patient's blood sugar levels are dangerously high or low, causing them to become unconscious), and/or death.

Findings:

1. During a review of Patient 11's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 11/05/24, the H&P indicated Patient 11 was admitted to the facility with chief complaints of being unable to walk and poor oral (by mouth) intake.

During an interview and record review on 11/14/2024 at 10:43 a.m., with Clinical Nurse Supervisor 1 (CNS 1), CNS 1 verified Patient 11's Morse Fall Scale (a tool used for patient to identify risk factors for falls [unplanned descent to the floor with or without injury to the patient]) score upon admission on 11/06/2024 was 35 (Moderate risk score is between 25-44). CNS 1 stated Patient 11 was a moderate risk for fall and a care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for fall precaution should have had been initiated upon admission.

In the same interview on 11/14/2024 at 10:43 a.m., CNS 1 stated care plans were initiated at the time of patient admission to know how patient care would be communicated among the nurses.

During a review on 11/15/2024 at 10:49 a.m. with CNS 1, Patient 11's care plan was reviewed. CNS 1 verified Patient 11's care plan for fall precaution was initiated on 11/08/2024 (three days after Patient 11 was admitted to the facility).

During a review of the facility's policy and procedure (P&P) titled, "Plan of Care: Patient, Interdisciplinary," last reviewed in 4/2023 , the P&P indicated, " ...ensure that a Plan of Care is developed for each patient that is individualized to meet the patients' unique needs ...Age and other relevant factors will be taken into consideration when developing the plan, which will be initiated by a Registered Nurse within 24 hours of admission ..."

2. During a review of Patient 12's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 11/06/2024, the H&P indicated, Patient 12 was admitted to the facility with a chief complaint of weakness. The H&P also indicated Patient 12 had a past medical history of Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing).

During an interview and record review on 11/14/2024 at 11:11 a.m., with Clinical Nurse Supervisor 1 (CNS 1) and Registered Nurse 10 (RN 10), CNS 1 stated Patient 12's care plan for DM was not initiated at the time patient was admitted to the facility. RN 10 stated a care plan helps nurses focus on care and monitor the progress of the patients.

During a review on 11/15/24 at 10:33 a.m. with CNS 1, Patient 12's care plan regarding Diabetes Mellitus management, was reviewed. CNS 1 verified Patient 12's care plan for management of DM was initiated on 11/08/2024 (two days after Patient 12's admission to the facility).

During a review of the facility's policy and procedure (P&P) titled, "Plan of Care: Patient, Interdisciplinary," last reviewed in 4/2023, the P&P indicated, " ...ensure that a Plan of Care is developed for each patient that is individualized to meet the patients' unique needs ...Age and other relevant factors will be taken into consideration when developing the plan, which will be initiated by a Registered Nurse within 24 hours of admission ..."

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

1. Ensure that for one of 34 sampled patients (Patient 3), nursing staff documented intake and output (the measurement and recording of all fluids a patient takes in, such as through drinking or IV fluids [intravenous fluids, which are liquids administered directly into a vein to provide hydration, medications, or nutrients], and fluids they lose, such as through urination or vomiting) throughout Patient 3's admission stay at the facility, in accordance with the facility's policy regarding "Standard of Care" and "Nursing Documentation."

This deficient practice potentially placed Patient 3 at risk for missed opportunities to detect and address changes in the patient's fluid status (the balance of fluids in the body, which is essential for maintaining normal bodily functions), which may result in complications such as dehydration (excessive loss of fluid), low blood pressure, etc.

2. Ensure that, for one patient out of 34 sampled patients (Patient 3), nursing staff obtained a urine sample (a collection of urine used for diagnostic purposes, such as detecting infections, assessing kidney function) as indicated by the physician's order and in accordance with the facility's policy regarding carrying-out all physician's orders.

This deficient practice had the potential to result in Patient 3's delayed diagnosis and treatment of underlying medical conditions such as urinary tract infections (UTIs, infections occurring in any part of the urinary system, including the bladder, urethra [the tube that carries urine out of the body], or kidneys, which can cause symptoms such as pain, burning during urination, and fever, and if untreated, may lead to serious kidney complications) leading to worsening of symptoms and compromising patient's (Patient 3) health and recovery.

3. Ensure that, for one of 34 sampled patients (Patient 2), the mental status (assessed to identify abnormalities such as confusion, disorientation, or unresponsiveness) during the triage assessment (the initial evaluation of a patient upon arrival to the emergency department), was accurately documented based on Patient 2's presenting condition, in accordance with the facility's policy regarding documentation in the ED patient care record (a comprehensive record of care provided in the emergency department).

This deficient practice resulted in Patient 2 not being assigned a correct ESI level (Emergency Severity Index, a triage tool used to categorize patients based on acuity-the severity of a patient's condition and the urgency of medical intervention required-and resource needs, such as diagnostic tests or treatments), which could potentially lead to delayed prioritization of care (failure to provide timely or suitable medical attention based on the patient's actual condition and needs, potentially compromising outcomes).

4. Ensure one of 34 sampled patient's (Patient 6's) pain was assessed and addressed after sustaining an unwitnessed fall (an unplanned descent to the floor with or without injury to the patient) and on two other occasions when Patient 6's family reported that Patient 6 had pain, in accordance with the facility policy and procedure regarding assessment, reassessment, and pain management.

This deficient practice likely resulted in Patient 6 experiencing unrelieved pain and had the potential for delay in needed treatment, which can result in complications such as worsening pain level, psychological distress due to uncontrolled pain, etc.

5. Ensure one of 34 sampled patient's (Patient 6's) fall risk was reassessed using the Morse Fall Scale (MFS, a tool to identify patients at risk for falling that includes history of falling, secondary diagnosis, ambulatory [related to walking] aids [example: cane], intravenous [medication administered into the vein] therapy, gait abnormalities [the pattern of how a person walks], and mental status, with the summed range from 0 to 125, higher scores indicating a higher risk for falling) after sustaining a fall (unplanned descent to the floor with or without injury to the patient) on 10/4/2024 and for the MFS score to reflect Patient 6's post-fall status.

This deficient practice may lead to the wrong fall preventative measures used and compromise Patient 6's safety, which may result in another fall with complications such as fracture (broken bones).

6. Ensure, the facility staff followed the chain of command (crucial for ensuring patient safety by providing a structured process for staff to escalate concerns about patient care, report issues, and seek necessary interventions through a clear hierarchy of authority, ultimately leading to better decision-making and addressing problems promptly when they arise) when unable to immediately contact and notify the physician regarding one of 34 sampled patient's (Patient 6's) critical laboratory values (potentially life-threatening laboratory results that must be conveyed immediately to the physician so that therapeutic measures can be instituted rapidly) such as elevated Troponin (is a protein that's found in the cells of the heart muscle) level of 80.0 ng (nanograms, a unit of measurement) per milliliter (mL, a unit of measurement, a normal troponin levels range is from 0-0.04 ng/ml) and a Hemoglobin level of 6.2 (normal range of hemoglobin for adult men is 13.5 to 17.5 g/dL) , in accordance with the facility's policy and procedure regarding utilization of chain of command.

This deficient practice may lead to a delay in necessary interventions and jeopardize Patient 6's safety, resulting in complications such as cardiac arrest [when the heart stops beating], dizziness, fatigue, shortness of breath [difficulty breathing], etc.

7. Ensure one of 34 sampled patients (Patient 5) was turned and repositioned (to change someone's body position by physically turning them over to a different orientation, shifting body weight distribution to relieve pressure on a particular area of the body) every 2 hours, in accordance with facility policy and procedure regarding skin integrity (refers to the health and unbroken state of the skin).

This deficient practice had the potential for patient 34's existing sacrogluteal (buttock [butt] area) pressure injuries (localized damage to the skin or soft tissue caused by prolonged or severe pressure, often over a bony part of the body) to worsen, resulting in complications such as infection, the need for surgery to debride (remove) dead tissue, etc.

8. Ensure for one of 34 sampled patients (Patient 9), Patient 9's seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) precautions (refers to safety measures taken before a patient experiences a seizure) was implemented, in accordance with the facility's policy and procedure regarding seizure management when, Patient 9 was observed to not have all the four side rails padded.

This deficient practice had the potential for Patient 9 to suffer from pain and injury (such as fracture [broken bones]) during a seizure activity.

9. Ensure for one of 30 sampled patients (Patient 20), the facility's policies and procedures (P&P) for fall (an unplanned descent to the floor with or without injury to the patient) reduction was implemented when, Patient 20, who was a high risk for fall, was not wearing yellow socks (yellow socks indicate the patient was at risk for fall) and the patient's (Patient 20) bed alarm was not turned on/activated (a bed alarm will go off to alert staff when a patient gets out of bed).

This deficient practice had the potential to result in an unsafe care that may lead to Patient 20 suffering from a fall injury with possible complications such as fracture (broken bones), the need for surgery (in case of severe injury requiring surgery), brain bleed (if the patient hits the head on the floor), etc.

10. Ensure one of seven sampled emergency crash carts (Crash Cart 2, a wheeled container carrying medicine and equipment for use in emergency resuscitations [procedure used to restart a patient's breathing and heartbeat when they have stopped]), had complete and readily available equipment for use when, Crash Cart 2 was missing a cardiac backboard (rigid surface used to support a patient during a cardiopulmonary resuscitation [CPR, a life-saving emergency procedure that combines chest compressions and rescue breathing to help someone who is not breathing or heartbeat has stopped]).

This deficient practice had the potential to delay critical emergency care if the crash cart equipment was not inspected for completeness and verified for availability potentially leading to worsened patient outcomes and/or patient death.


Findings:

1. During a review of Patient 3's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/9/2024, the H&P indicated that Patient 3 had past medical history (PMH, a record of all previously diagnosed medical conditions, treatments, and surgeries that could impact the patient's current health or care plan) of dementia (progressive decline in mental functions) and hypertension (high blood pressure). The H&P also indicated that Patient 3 was admitted due to constipation (a condition marked by infrequent or difficult bowel movements), failure to thrive (FTT, a state of poor nutrition or significant weight loss), refusing to eat (a medical or behavioral issue where the patient declines food intake), and acute (sudden) on chronic (long-duration) encephalopathy (worsening of brain function).

During a review of Patient 3's medical record (MR) titled, "Urology Consultation (a formal assessment by a specialist in urology to evaluate and manage conditions affecting the urinary tract [the system responsible for removing waste and excess fluids from the body, including the kidneys, ureters, bladder, and urethra] or the male reproductive system)," dated 9/10/2024, the MR indicated that a urologist (a physician specializing in the diagnosis and treatment of disorders related to the urinary system, including the kidneys, ureters, bladder, and urethra [the tube that carries urine from the bladder out of the body], as well as the male reproductive organs) was consulted to evaluate Patient 3's medical condition related to a left mid urethral stone (a hard, solid mass that forms in the ureter, the tube connecting the kidneys to the bladder, potentially causing pain and urinary obstruction [blockage]), with hydronephrosis (swelling of a kidney due to a buildup of urine caused by an obstruction or blockage in the urinary tract), and possible colic (severe, intermittent pain caused by spasms or contractions in the urinary tract, often associated with kidney stones or other obstructions).

During a review of Patient 3's medical record (MR), specifically the "Post-Operative Note (a note documenting the patient's condition and care following a surgical procedure)," dated 9/11/2024, the record indicated that on 9/11/2024, Patient 3 underwent left ureteroscopy (a procedure involving the insertion of a thin scope [tube] into the ureter (the duct through which urine passes from the kidney to the bladder), laser lithotripsy (a procedure using laser energy to break kidney stones into smaller pieces for easier removal), and double-J stent placement (a medical device placed in the ureter to ensure proper drainage of urine from the kidney to the bladder).

During a review of Patient 3's MR titled, "Intake and Output, (I&O, is a medical term referring to the monitoring and recording of all fluids a patient consumes [intake] and eliminates [output] over a specified period, typically 24 hours)," the MR indicated the following:
On 9/9/2024 Total Oral Intake: 0 milliliters (ml, measuring unit); Total Output: not recorded.
On 9/10/2024 Total Oral Intake: 0 ml Total Output:1 ml.
On 9/11/2024 Total Oral Intake: 0 ml; Total Output for 9/11/2024: 4 ml + 1 void (act of urination)
On 9/12/2024 Total Oral Intake: 0 ml; Total Output for 9/12/2024: 3 voids
On 9/13/2024 Total Oral Intake: 0 ml; Total Output for 9/13/2024: 3 voids

During a concurrent interview and record review on 11/15/2024 at 10:10 a.m. with the Quality Assurance Nurse (QAN), Patient 3's "IV Spreadsheet (a document used to record the amount and type of intravenous (IV) fluids administered to a patient over a specified period)," was reviewed. The QAN reviewed the IV Spreadsheet and verified that Patient 3's IV Spreadsheet contained no documentation of the amount of IV fluids administered during the patient's stay at the facility from 9/9/2024 through 9/13/2024. The QAN stated that nurses were required to document the 24-hour cumulative (total) intake of intravenous fluids for each patient daily in accordance with the facility's practice.

During an interview on 11/15/2024 at 11:35 a.m. with the Director of the Medical-Surgical Unit (Med-Surg, a hospital unit specializing in the care of patients requiring medical treatment or surgical intervention) (DMS), the DMS stated the following: "Documenting intake and output (I&Os) is a requirement. Nurses are expected to document I&Os at least by the end of each shift. Intake means recording everything the patient receives orally or intravenously, while output measures fluids such as urine and emesis (vomited stomach contents). It's important to document I&Os because they allow nurses and physicians to track the patient's fluid balance and determine if the patient is dehydrated (a condition in which the body loses more fluid than it takes in, leading to insufficient fluids for normal functioning) or fluid overloaded (a condition where there is too much fluid in the body, often causing swelling and strain on the heart and lungs). Proper documentation is essential to maintain body fluid balance, and effectively manage the patient's hydration status. The DMS also stated that for a patient with identified kidney stones and urinary tract problems, it is especially important to ensure there is no retention (inability to fully empty the bladder during urination) of urine and that the intake and output remain balanced."

During a review of the facility's policy and procedure (P&P) titled, "Standard of Care," dated July 2024, the P&P stated that the collection of data pertinent to an individual's health status must be conducted systematically and continuously. The policy further indicated that, once recorded, such data should be communicated to appropriate personnel and remain retrievable for use as needed.

During a review of the facility's policy and procedure (P&P) titled, "Documentation in the ED Patient Care Record," dated October 2023, the P&P indicated that Intake and Output (I&Os) must be documented and tallied for all patients receiving IV fluids, diuretics (medications that promote urine production to help remove excess fluid from the body), and for patients being admitted.

During a review of the facility's policy and procedure (P&P) titled, "Assessment and Re-assessment of the Patient," dated 7/2023, the P&P indicated that to effectively monitor a patient's status and to evaluate the patient's response to the treatment or care, reassessment of the patient will occur, at a minimum, at the time of change in shift or at any time there is a change in the condition of the patient.

During a review of the facility's policy and procedure (P&P) titled, "Nursing documentation," dated 10/2023, the P&P indicated that Intake and Output will be charted within the appropriate assessments within patient's electronic care system. Documentation will include implementation of physician orders and nursing actions, clinical observations and outcomes.

2. During a review of Patient 3's "HPI (History of Present Illness, a detailed account of the patient's current medical issues)," dated 9/9/2024, the HPI indicated that Patient 3 was admitted due to decreased appetite and constipation for one week. The HPI also stated that Patient 3 had significant renal insufficiency (impaired kidney function affecting waste filtration and fluid balance), a left mid ureteral stone (a stone located in the ureter, the tube that carries urine from the kidney to the bladder, causing pain or obstruction), and hydronephrosis (swelling of the kidney due to a buildup of urine from obstruction).

During a review of Patient 3's medical record (MR) titled, "Patient Orders Detail (a section of the medical record that documents physician orders for tests, treatments, or interventions)," the MR indicated that on 9/9/2024 at 3:09 p.m., the physician ordered a urine sample to be obtained STAT (immediately, as a matter of urgent priority). The order specified that the sample was to be collected from Patient 3 by performing a straight catheterization (a medical procedure in which a thin, flexible tube is inserted into the bladder to obtain a sterile [free of bacteria] urine sample).

During further review of Patient 3's medical record (MR) titled, "Patient Orders Detail," the MR indicated that on 9/9/2024 at 7:15 p.m., the physician placed an order for a urinalysis (a diagnostic test used to examine the content and characteristics of urine to detect abnormalities, such as infections, kidney disease, or other medical conditions).

During further review of Patient 3's medical record (MR) titled, "Lab Reports (a section of the medical record documenting laboratory test results ordered to diagnose, monitor, or treat medical conditions)," dated 9/9/2024 through 9/11/2024, the MR indicated that Patient 3's Lab Report contained no urinalysis results.

During an interview on 11/15/2024 at 9:56 a.m. with the Quality Assurance Nurse (QAN), the QAN reviewed Patient 3's laboratory results and stated that Patient 3's medical record contained no documentation of urinalysis results. The QAN further stated that Patient 3's urine sample was not obtained at any time during Patient 3's stay at the facility, from 9/9/2024 through 9/13/2024, despite a physician order for urinalysis on 9/9/2024.

During an interview on 11/15/2024 at 11:35 a.m. with the Director of the Medical-Surgical Unit (Med-Surg, a hospital unit providing care for patients recovering from surgery or being treated for various medical conditions) (DMS), the DMS stated that if there was an order for a urinalysis, it should be carried out. The DMS further stated that the nurse on each shift was responsible for reviewing orders that have not been completed and following up. The DMS said, "Nurses document the 24-hour chart check (a process in which nurses review the patient's medical record to ensure all physician's orders are acknowledged and carried out within a 24-hour period). Nurses are expected to review physician orders each shift to ensure they are completed, as the goal is to always ensure that all physician orders are followed through."

During a review of the facility's policy and procedure (P&P) titled, "Chart Checks - 24 Hour," dated 10/2023, the P&P indicated the following: To ensure that all physician orders from the previous 12/24 hours have been correctly noted and/or completed by the Registered Nurse (RN). Written orders within the patient's medical record must be reviewed every 12 hours. If a specific order has not been noted or completed by the primary RN, it becomes the responsibility of the oncoming primary RN to note or complete the order. This process is repeated every 12 hours.

3. During a review of Patient 2's EMS (Emergency Medical Services, prehospital care provided by paramedics or emergency responders) Patient Care Report (PCR), dated 7/1/2024 at 10:47 a.m., the PCR indicated that paramedics (healthcare professionals trained to provide emergency medical care and transport patients to medical facilities) brought Patient 2 to the facility's Emergency Department (ED, a specialized hospital unit providing acute care for patients with severe or urgent medical conditions) on 7/1/2024 at 11:29 a.m. The PCR also indicated that Patient 2 was alert and oriented to none (meaning the patient was not oriented to person, place, time, or situation, typically indicating a state of confusion or altered mental status).

During a review of Patient 2's HPI (History of Present Illness, a detailed narrative of the patient's current health complaint, including onset, progression, and associated symptoms), dated 7/1/2024, the HPI indicated that Patient 2 presented to the emergency department (ED, a specialized hospital unit providing acute care for patients with severe or urgent medical conditions) on 7/1/2024 after experiencing a seizure (a sudden, uncontrolled electrical disturbance in the brain that can cause changes in behavior, movements, feelings, or consciousness). The HPI also indicated that Patient 2 was post-ictal (a state following a seizure characterized by confusion, drowsiness, or disorientation as the brain recovers).

During a review of Patient 2's "Triage Assessment (the initial evaluation performed upon a patient's arrival to the emergency department to prioritize care based on the severity of their condition)," dated 7/1/2024, at 11:46 a.m., the record indicated that Patient 2 arrived altered (exhibiting changes in awareness, orientation, or behavior that differ from their baseline mental state). The record also indicated that the triage nurse documented that Patient 2 did not have an acute change in mental status (a sudden or rapid alteration in cognition, behavior, or consciousness compared to the patient's normal baseline) and assigned an ESI level 3 to Patient 2 (The Emergency Severity Index [ESI] is a five-level triage tool used in emergency departments to categorize patients based on the severity of their condition and the resources they are likely to require. ESI Level 3 indicated a patient required urgent attention but remained stable [the patient's condition is not rapidly changing or life-threatening]).

During an interview on 11/13/2024 at 10:43 a.m. with the Emergency Department Supervisor (EDS), the EDS reviewed Patient 2's "Triage Assessment" record, dated 7/1/2024, and stated that the triage nurse, in the section where it was asked, "Does the patient have an acute change in mental status?" marked the answer as "no." The EDS stated, that if a patient arrives with altered mental status (a significant deviation from the patient's baseline mental state), the triage nurse should have marked the box as "yes," and assign Patient 2 an ESI level 2 (indicating a high-risk, more critical condition requiring immediate care). The EDS further stated that the ESI level was crucial because it determines the urgency of the patient's care, and the priority of resources needed. An incorrect ESI level can delay timely evaluation and treatment, potentially worsening the patient's condition.

During a review of the facility's policy and procedure (P&P) titled, "Standard of Nursing Care," dated 7/2023, the P&P stated that the Registered Nurse (RN) will carry out the nursing process by following the Standards of Nursing Practice. These include:

1.A.1. Assessment: The process of identifying and collecting information concerning the health status of assigned patients.
1.A.3. Organization of Information: The organization of information should be conducted in a manner that promotes accuracy.

During a review of the facility's policy and procedure (P&P) titled, "Documentation in the ED Patient Care Record," dated 10/2023, the P&P indicated that triage classification should utilize the Emergency Severity Index (ESI) algorithm to ensure quality and accurate documentation.

4. During a review of Patient 6's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/28/2024, the "H&P" indicated that Patient 6's past medical history included diabetes (a disease that occurs when the body is unable to regulate the amount of sugar in the blood) and hypertension (high blood pressure). Patient 6 was admitted to the facility on 9/28/2024 for generalized weakness and decreased oral (by mouth) intake for a few days. The H&P further indicated, "Patient (Patient 6) recently discharged from (name of another facility) after testing positive for COVID (Coronavirus disease [COVID-19] is an infectious disease caused by a virus, causing respiratory illness). Patient (Patient 6) reports congestion (when mucus builds up in the lungs making it difficult to breathe) and says he has been eating less ..."

During a concurrent interview and record review on 11/12/2024 at 2:30 p.m. with the Clinical Nursing Supervisor Telemetry (CNS) 3, Patient 6's electronic medical record (EMR, digitizes a patient's paper chart. It collects the patient's history of conditions, tests and treatments) titled, "Nursing Notes," dated 10/4/2024 at 5:15 a.m., was reviewed. The nursing notes indicated Patient 6 sustained an "unwitnessed fall [unplanned descent to the floor with or without injury to the patient)" Observed on the floor, right side of the bed, sitting on buttocks during rounds ..."

During a concurrent interview and record review on 11/13/2024 at 9:35 a.m. with the Quality Assurance Nurse (QAN), Patient 6's EMR titled, "Pain Assessment," dated 10/4/2024, was reviewed. QAN verified that there was no pain assessment completed after Patient 6 fell on 10/4/2024 at 5:15 a.m. until 8:00 a.m. when a routine every 4 hours assessment was done indicating Patient 6 had no pain.

During a concurrent interview and record review on 11/13/2024 at 11:00 a.m. with the Clinical Nursing Supervisor Telemetry (CNS) 3, Patient 6's EMR titled, "Nursing Notes," documented by RN 17, dated 10/5/2024 at 6:45 p.m., was reviewed. The nursing notes indicated, "PT (Patient 6) reports right sided hip pain. Unable to assess further details due to mentation change. New order received for hip x-ray (a type of medical imaging that uses radiation to take pictures of the inside of the body). Will enter and carry out order." CNS 3 verified there was no assessment for pain using a nonverbal pain tool which will not require Patient 6 to verbalize the pain.

During a concurrent interview and record review on 11/13/2024 at 11:05 a.m. with the Clinical Nursing Supervisor Telemetry (CNS) 3, Patient 6's EMR titled, "Nursing Notes," documented by RN 6, dated 10/7/2024 at 7:59 p.m., was reviewed. The nursing note indicated, "PT's (Patient 6's) daughter asked about pain medication because patient complained whole body ache during night." CNS 3 confirmed there was no documentation of intervention implemented to address Patient 6' pain.

During a concurrent interview and record review on 11/13/2024 at 11:10 a.m. with the Clinical Nursing Supervisor Telemetry (CNS) 3, Patient 6's EMR titled, "Medication Administration Record (MAR, a report detailing the drugs administered to a patient) dated from 10/4/2024 through 10/7/2024, was reviewed. There was no pain medication order for Patient 6. CNS 3 stated it was important that patient's pain be addressed. CNS 3 stated the RN should assess for pain intensity, location of the pain, if there are relieving factor, and use a scale that is appropriate for the patient to document the level of pain, call the physician for pain medication, and reassess after administration of pain medication to see if this is working. CNS 3 stated, "the RN failed to do these."

During a review of the facility's policy and procedure (P&P) titled, "Pain Management," dated April 2023, the P&P indicated, "(Name of the facility) respects and supports the rights of patients to safe, timely, and effective pain management. We place emphasis on improving the outcomes of pain management including comfort, managing side effects and complications, and patient satisfaction. Patient age, developmental status, physical, emotional, cultural, spiritual, and cognitive condition and preferences shall be considered. Patient participation in the pain management process is imperative and expected. The single most reliable indicator of the existence and intensity of pain is the patient's self-report. A comprehensive pain assessment is conducted as appropriate to the patient's condition and the scope of care, treatment, and services. Patients will define their goals for pain relief and participate in a plan of care to achieve these goals. Behavioral and physiological indicators are important indices for assessment of pain in patients unable to self-report. Assess for pain using a pain scale (numeric, visual analog, or text based) consistently as follows: With each new report of pain ... Pain intensity will be assessed using one of the following pain scales consistently according to age and developmental level as appropriate: Neonatal Infant Pain Scale, FLACC Behavioral Scale, Pain Faces Scale, Numeric Pain Intensity Scale, CPOT tool can be used to assess intubated or sedated patient pain based on facial expressions, muscle tension and movement as well as compliance with ventilated breaths for intubated patient or vocalized pain for non-intubated patients."

During a review of the facility's policy and procedure (P&P) titled, "Assessment and Reassessment of the Patient," dated July 2023, the P&P indicated, "Each patient will have an initial assessment completed upon admission based on unit-specific parameters and interdisciplinary variables. The initial assessment is documented on the Admission Assessment form. Assessment and reassessment information includes the patient's perception of the effectiveness of, and any side effects related to medications. e.g., relief of symptoms of nausea or pain. Reassessment occurs at regular intervals and will be defined by each discipline, based on the patient's diagnosis, care setting, significant changes in condition, and response to any previous care in order to determine the patient's response to intervention..."

During a review of the facility's policy and procedure (P&P) titled, "Standard of Nursing Practice," dated July 2023, the P&P indicated, "to provide all patients with ongoing assessment of their physical and emotional needs during the nursing process. which is defined as the ongoing assessment planning and implementation and evaluation of a patient's care. Based on these processes, the practice of nursing shall be in compliance with hospital policies, protocols, and procedures. Quality, productivity, and responsiveness, to the needs of patients, physicians, and employees are foundational to such care. The RN will carry out the nursing process by following the Standards of Nursing Practice: Assessment: This is the process of identifying and collecting Information concerning the health status of assigned patients on the unit. assessment is to be complete, continuous, and systematic... Information obtained from the patient family and other caregivers on the unit, from other departments and from the community... Assuming responsibility and accountability for ensuring that a stated 1eve of quality is maintained as it relates to individual patents."

5. During a review of Patient 6's electronic medical record (EMR, digitizes a patient's paper chart. It collects the patient's history of conditions, tests and treatments) titled, "Emergency Department Report," dated 9/28/2024, the report indicated, "Presenting with generalized weakness and decreased oral intake for a few days. Per family, the patient was discharged from (name of another facility) two weeks ago for a fall (an unplanned descent to the floor with or without injury to the patient) ..."

During a concurrent interview and record review on 11/12/2024 at 2:30 p.m. with the Clinical Nursing Supervisor Telemetry (CNS) 3, Patient 6's EMR titled, "Nursing Notes," dated 10/4/2024 at 5:15 a.m. was reviewed. The nursing notes indicated Patient 6 sustained an "unwitnessed fall." Observed on the floor, right side of the bed, sitting on buttocks during rounds ..."

During a concurrent interview and record review on 11/12/2024 at 2:49 p.m. with the Clinical Nursing Supervisor Telemetry (CNS) 3, Patient 6's EMR titled, "Morse Fall Scale (MFS), a quick tool to identify patients at risk for falling, including history of falling, secondary diagnosis, ambulatory (related to walking) aids (example: cane), intravenous therapy, gait abnormalities (the pattern of how a person walks), and mental status, with the scores summed from 0 to 125, with higher scores indicating a higher risk for falling. A low fall risk score is 0-24, a moderate fall risk score is 25-44, and a high fall risk score is 45 and above (or falls during hospitalization), dated from 10/2/2024 through 10/5/2024, was reviewed. The flowsheet indicated the

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

1. Ensure that for one patient out of 34 sampled patients (Patient 3), the ordered medications-Colace (a stool softener taken orally), Mag-Al Plus (a magnesium-aluminum-based oral laxative used to relieve constipation and reduce stomach acid), and Dulcolax suppository (a rectal medication that stimulates bowel movements to alleviate constipation)-were administered on an as-needed basis (PRN; a medical directive to provide medication only when symptoms or conditions, such as constipation, are present and require intervention), in accordance with the physician's order, when indicated, and in alignment with the facility's nursing standard of care.

This deficient practice had the potential to compromise Patient 3's overall health and well-being, leading to worsened constipation, increased discomfort or pain, and progression to more severe complications such as bowel obstruction (a serious condition where the intestine is partially or completely blocked, preventing the normal passage of stool, gas, or fluids, which can cause severe pain, nausea, and vomiting) or impaction (a condition where hardened stool becomes lodged in the rectum, making it extremely difficult or impossible to pass without medical intervention).

2. Ensure one of 34 sampled patients (Patient 6's), was administered a PRN (as needed) Levophed (norepinephrine bitartrate, a prescribed medication used to treat life-threatening low blood pressure) when Patient 6's mean arterial pressure (MAP, the average blood pressure during a single cardiac [heart] cycle) was at 53 (on 10/7/2024 at 9:00 a.m.), below 65 mmHg (millimeters of mercury, unit of measurement), as ordered by the physician.

This deficient practice resulted in a delay in the intervention that was prescribed to prevent low blood pressure for Patient 6 and likely contributed to a code blue (an overhead page to summon trained staff to a patient having a medical emergency, usually cardiac [heart] or respiratory [breathing] arrest [when breathing stops or when the heart stops beating]) being called.

Findings:

1. During a review of Patient 3's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/9/2024, the H&P indicated that Patient 3 had past medical history (PMH, a record of all previously diagnosed medical conditions, treatments, and surgeries that could impact the patient's current health or care plan) of dementia (progressive decline in mental functions) and hypertension (high blood pressure). The H&P also indicated that Patient 3 was admitted due to constipation (a condition marked by infrequent or difficult bowel movements), failure to thrive (FTT, a state of poor nutrition or significant weight loss), refusing to eat (a medical or behavioral issue where the patient declines food intake), and acute (sudden) on chronic encephalopathy (a sudden worsening of brain function).

During further review of Patient 3's H&P, dated 9/9/2024, the H&P indicated that Patient 3 was non-verbal (unable to communicate using spoken words) and that Patient 3's dementia had been progressively worsening, leading to significant weight loss. The H&P also noted that Patient 3's past medical history (PMH) was obtained from Patient 3's caregiver, who reported that Patient 3 had been chewing on and swallowing parts of blankets. The caregiver expressed concern that this behavior might be causing a blockage in Patient 3's intestines and noted that Patient 3 had been experiencing constipation for the past four days (prior to admission on 9/9/2024).

During a concurrent interview and record review on 11/15/2024 at 9:56 a.m. with the Quality Assurance Nurse (QAN), Patient 3's medical record (MR) titled, "Bowel Movements (a section of the medical record used to document the frequency, consistency, and characteristics of a patient's bowel movements to monitor digestive health and identify potential issues such as constipation or diarrhea [loose stool])." was reviewed. The record, dated 9/10/2024 through 9/13/2024, indicated that Patient 3 had no recorded bowel movements during that time period (9/10/2024 to 9/13/2024). The QAN stated that nursing documentation indicated that Patient 3 was constipated.

During a concurrent interview and record review on 11/15/2024 at 10:43 a.m. with the Quality Assurance Nurse (QAN), Patient 3's medical record (MR) titled, "Medication Administration Record (MAR)," dated 9/10/2024, was reviewed. The QAN stated that Patient 3 had three standing orders (pre-approved medical directives that allow medications or treatments to be administered under specific conditions without requiring additional physician authorization) for the following medications: 100 milligrams (mg, measuring unit) Colace (a stool softener to be administered orally twice a day, as needed [order date 9/9/2024]), 30 milliliters (ml, measuring unit) Mag-Al Plus (a magnesium-aluminum-based oral laxative used to relieve constipation and reduce stomach acid, to be given orally as needed, daily [order date 9/9/2024]), and 10 mg Dulcolax suppository, a rectal (anal route) medication that stimulates bowel movements to alleviate constipation) to be given as needed, daily [order date 9/10/2024]) to be administered for constipation as needed (PRN, a medical abbreviation for "pro re nata," meaning the medication should be administered only when the patient's condition or symptoms indicates a need).

During the same interview on 11/15/2024 at 10:43 a.m. with the Quality Assurance Nurse (QAN), the QAN further stated that the MAR contained no record indicating that the medications were administered to Patient 3 at any time from 9/10/2024 through 9/13/2024. The QAN then stated, "Assessing patient needs, such as constipation, falls under the standards of nursing care (the level of professional nursing practice expected in providing safe, effective, and ethical care based on developed recommendations for patient care that are based on the best available research, clinical expertise, and patient values, facility policies, and the needs of the patient). It is expected of nursing staff to assess patient needs and address them by administering medications to relieve constipation, especially when there are PRN standing orders in place."

During an interview on 11/15/2024 at 11:51 a.m. with the Director of Medical-Surgical Unit (DMS) [a hospital department that provides care for a wide variety of patients recovering from surgery or managing other illnesses], the DMS stated the following: "When nurses complete their head-to-toe assessments (a systematic and comprehensive physical evaluation of a patient from head to toe, assessing all major body systems to identify any issues, monitor changes, and prioritize care needs), if they determine that the patient was constipated, they should review the physician's orders to see if any medication can be administered and educate the patient about the condition.
This is part of their assessment and intervention, especially if there was a standing PRN order. Nurses should ask the patient about their bowel movements and assess the patient every shift. For confused patients, nurses should monitor their bowel movements as part of their care. If a patient has not had a bowel movement for an extended time during their stay, the nurse should determine whether a laxative (medication used to relieve constipation by stimulating bowel movements or softening the stool to make it easier to pass) or other intervention was required. This is part of the nursing standard of care."

During a review of the facility's policy and procedure (P&P) titled, "Standard of Nursing Practice," dated September 2023, the P&P indicated that the base standards for nursing practice (the foundational principles and guidelines that ensure consistent, safe, and effective patient care across all nursing activities) govern the provision of patient care throughout the facility's Nursing Services Department (the organizational unit responsible for delivering nursing care to patients, including the coordination and management of nursing staff and services). The P&P indicated that all patients should receive ongoing assessment of their physical and emotional needs during the nursing process, defined as the ongoing assessment, planning, implementation, and evaluation of a patient's care. Based on these processes, nursing practice must comply with hospital policies, protocols, and procedures, ensuring responsiveness to the needs of patients, physicians, and employees as foundational to quality care.

During a review of the facility's policy and procedure (P&P) titled, "Standard of Nursing Practice," dated September 2023, the P&P indicated that the Registered Nurse (RN) was responsible for carrying out the nursing process by identifying and collecting information concerning the health status of assigned patients on the unit. Assessment must be complete, continuous, and systematic, involving a comprehensive psychosocial and physical evaluation of the patient through interview, observation, inspection, palpation, and reports. Additionally, the RN must implement the plan of care necessary to achieve planned, desired outcomes, as evidenced by the delivery of quality nursing care.

2. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/28/2024, the "H&P" indicated that Patient 6's past medical history included diabetes (a disease that occurs when the body is unable to regulate the amount of sugar in the blood) and hypertension (high blood pressure). Patient 6 was admitted to the facility on 9/28/2024 for generalized weakness and decreased oral intake for a few days. The H&P further indicated, "Patient (Patient 6) recently discharged from (name of another facility) after testing positive for COVID (Coronavirus disease [COVID-19] is an infectious disease caused by a virus, causing respiratory illness). Patient (Patient 6) reports congestion (when mucus builds up in the lungs making it difficult to breathe) and says he has been eating less ..."

During a concurrent interview and record review on 11/12/2024 at 2:49 p.m. with the Clinical Nursing Supervisor Telemetry (CNS) 3, Patient 6's electronic medical record (EMR, digitizes a patient's paper chart. It collects the patient's history of conditions, tests and treatments) titled, "Nurses Notes," documented by Registered Nurse (RN) 2 in the telemetry (continuous heart monitor) unit, dated 10/5/2024 at 1:30 p.m., indicated, "Provider notified of change of mental status (a disruption in how the brain works that causes a change in behavior) and decreased blood pressure." CNS 3 verified that Patient 6 was transferred to ICU (a unit in a hospital providing intensive care for critically ill or injured patients that is staffed by specially trained medical personnel) on 10/5/2024 due to a drop in blood pressure and decline in mentation (the process of using the mind to consider something carefully).

During an interview on 11/13/2024 at 3:34 p.m. by phone with Registered Nurse (RN) 7, RN 7 stated that on 10/7/2024, while assigned as the charge nurse in the ICU, RN 6 approached her in the hallway requesting assistance. RN 7 stated when she got to Patient 6's bedside, the respiratory therapist (RT, a healthcare provider who helps diagnose, treat and manage conditions that affect your lungs) was placing a non-rebreather mask (a mask that delivers high level of oxygen) on Patient 6. RN 7 confirmed that Patient 6's mean arterial pressure (MAP, the average blood pressure during a single cardiac [heart] cycle) dropped below 65, but Levophed was not at the bedside and was not administered. RN 7 stated, "Since the patient was transferred from the telemetry (continuous heart monitor) unit to ICU due to low blood pressure, the patient (Patient 6) has a PRN order for Levophed and should be started." RN 7 further stated the primary physician was paged but had not returned the call, thus the resident (a medical school graduate and doctor in training) was called, and while on the phone with the resident, Patient 6' lost pulse (rhythm made by the heartbeat), and a code blue was called.

During a concurrent interview and record review on 11/14/2024 at 9:06 a.m. with the Clinical Nursing Supervisor Telemetry (CNS) 3, Patient 6's "Vitals flowsheet," dated 10/7/2024, was reviewed. The flowsheet indicated the following:

On 10/7/2024 at 7:30 a.m., the blood pressure was 154/116 and a MAP of 129.
On 10/7/2024 at 7:45 a.m., the blood pressure was 129/60 and a MAP of 83.
On 10/7/2024 at 8:00 a.m., the blood pressure was 110/65 and a MAP of 80.
On 10/7/2024 at 8:30 a.m., the blood pressure was 102/56 and a MAP of 71.
On 10/7/2024 at 8:45 a.m., the blood pressure was 117/61 and a MAP of 79.
On 10/7/2024 at 9:00 a.m., the blood pressure was 64/46 and a MAP of 53.
CNS 3 stated when the MAP dropped below 65, the Levophed should be administered to maintain the MAP above 65. CNS 3 verified that at 9:23 a.m., Patient 6's MAP dropped to 40 mmHg, and at 9:31 a.m., Patient 6 lost pulse, and a code blue was called. CNS stated when Patient 6 MAP dropped to 53 at 9:00 a.m., "If the patient was on telemetry unit, a rapid response (RRT; when a patient demonstrates signs of imminent clinical deterioration [examples: changes in respiration, blood pressure, heart rate, difficulty breathing, etc.], a team of providers is summoned to treat the patient with the goal of preventing cardiac arrest [heart stop] or death), would be called but in the ICU we don't call RRT because the team is here in the unit. The ICU nurse may start protocol during RRT in the ICU.

During a concurrent interview and record review on 11/14/2024 at 10:10 a.m. with the Clinical Nursing Supervisor Telemetry (CNS) 3, Patient 6's "Medication Administration Record (MAR, a report detailing the drugs administered to a patient), dated from 10/5/2024 at 7:00 p.m. through 10/7/24 at 9:41 a.m., was reviewed. The MAR indicated Levophed at 8 mg (milligrams, a unit of measurement) per 250 mL (milliliters, a unit of measurement) to keep MAP (mean arterial pressure, the average pressure in an artery during one cardiac [heart] cycle) greater than 65. The CNS 3 verified that the MAR indicated Levophed was not scanned and administered. CNS stated, "When the patient (Patient 6's) MAP dropped to 53 (on 10/7/2024 at 9:00 a.m.), the nurse should start the Levophed to maintain the MAP above 65."

During an interview on 11/14/2024 at 11:34 a.m. with Registered Nurse (RN) 6, RN 6 stated that when Patient 6's daughter reported to RN 6 that Patient 6 looked anxious, RN 6 stated she (RN 6) checked on Patient 6, he (Patient 6) was "desatting (desaturating, saturation of oxygen levels dropping)," so she (RN 6) applied oxygen. RN 6 stated, Patient 6 looked agitated (appearing troubled or nervous), and the blood pressure was dropping. RN 6 further stated she (RN 6) had difficulty getting a reading for the blood pressure, so she (RN 6) asked another nurse (RN 7) to help. RN 6 stated she (RN 6) recalled pulling the Levophed medication and handing the Levophed to another nurse, but she (RN 6) did not recall if the medication was scanned or administered.

During a review of the facility's policy and procedure (P&P) titled, "Standard of Nursing Practice," dated September 2023, the P&P indicated, "To describe the base standards for nursing practice that govern the provision of patient care throughout the Nursing Services Department at (name of the facility). It 1s the policy of (name of the facility) to provide all patients with ongoing assessment of their physical and emotional needs during the nursing process. which is defined as the ongoing assessment planning and implementation and evaluation of a patient's care. Based on these processes, the practice of nursing shall be in compliance with hospital policies, protocols, and procedures. Quality, productivity, and responsiveness, to the needs of patients, physicians, and employees are foundational to such care ... The RN will carry out the nursing process by following the Standards of Nursing Practice: Assessment: This is the process of identifying and collecting Information concerning the health status of assigned patients on the unit. assessment is to be complete, continuous, and systematic as evidenced by: The complete psychosocial and physical assessment of the patent through interview. observation inspection, palpation, and reports. Implementation of the plan of care which is necessary to achieve the planned desired outcomes. This is evidenced by delivery quality nursing."

During a review of the facility's policy and procedure (P&P) titled, "administration of Medications," dated September 2023, the P&P indicated, "Medications shall be administered according to procedures and guidelines established by the Pharmacy and Therapeutics Committee, as approved, for the limitations on the intravenous administration of medications and the timing of administration of doses."

Based on observation, interview, and record review, the facility failed to meet the Condition of Participation (CoP) for Discharge Planning as evidenced by:

1.The facility failed to ensure that, for one of 34 sampled patients (Patient 1), the discharge planning evaluation (a process conducted by healthcare providers to identify a patient's post-hospital care needs, including medical equipment, support services, and living arrangements, to ensure a safe and effective transition from the facility) was completed upon admission, in accordance with the facility's policy regarding Discharge Planning. In addition, the facility failed to ensure that the discharge planning assessment included a functional assessment (an evaluation conducted to determine a person's ability to perform activities necessary for daily living and maintain independence) of the patient (Patient 1) and an evaluation of whether the patient (Patient 1) required any specialized durable medical equipment (DME, medical equipment prescribed by a doctor for use at home, designed to help patients manage their health conditions and perform daily activities after leaving the hospital. Example: walker or cane) prior to discharge to a recuperative care facility (a type of transitional housing or facility that provides short-term medical care and supportive services for individuals who are homeless or lack stable housing).

This deficient practice resulted in Patient 1 falling shortly and sustaining a fracture (break in the bone) of the left humerus (the long bone that connects the shoulder to the elbow) while Patient 1 was walking to the recuperative care facility after being dropped off by arranged transportation at the discharge destination point. This deficient practice also led to Patient 1 being readmitted to the facility only a few hours after discharge. (Refer to A-0807)

2. The facility failed to include a discharge planning evaluation (an assessment required to identify a patient's post-hospital needs, including the likelihood of requiring services such as rehabilitation, home care, or follow-up treatment, and the capacity for self-care or support in their living environment, as part of ensuring a safe and effective transition from the hospital) in the medical record for two of 34 sampled patients (Patient 1 and Patient 3), in accordance with the facility's policy regarding discharge planning when:

2.a. Patient 1's discharge planning evaluation was not documented during Patient 1's admission stay at the facility. Additionally, Patient 1 was not actively engaged in the development of their (Patient 1's) discharge plan (a detailed plan developed by healthcare providers to ensure a patient transitions safely and effectively from a healthcare facility to their next care setting).

This deficient practice resulted in unsafe transition with no continuity of care and unmet post-discharge needs for Patient 1, leading to Patient 1's re-admission to the facility the same day Patient 1 was discharged (7/5/2024). In addition, this deficient practice violated Patient 1's right (the right of a patient to participate in decisions about their care, including being informed, consulted, and involved in the planning and implementation of patient's treatment and discharge plans) to be involved in the development and implementation of their (Patient 1') discharge plan. (Refer to A-0808)

2.b. Patient 3's discharge planning evaluation was not conducted or documented in Patient 3's medical record during Patient 3's admission at the facility.

This deficient practice violated Patient 3's right to be involved in the development and implementation of their (Patient 3's) discharge plan. In addition, this deficient practice resulted in Patient 3 being placed at risk for an unsafe transition and unmet post-discharge needs, potentially leading to complications such as readmission, or a decline in health. (Refer to A-0808)

3. The facility failed to ensure one of 34 sampled patients (Patient 4) received care coordination for cardiac follow-up care prior to discharge (the formal release of a hospitalized individual due to conclusion of the hospitalization stay, either by death, return home, or transfer to another institution), in accordance with the facility's policy regarding Discharge Planning, when Patient 4 was discharged to a Skilled Nursing Facility (SNF, an inpatient treatment and rehabilitation center where patients receive care after a hospital stay). Patient 4's pacemaker (a small, battery-powered device that prevents the heart from beating too slowly) remained in end of battery life since 2/8/2024 and needed battery replacement.

This deficient practice had the potential for Patient 4's pacemaker device failure, resulting in cardiac (heart) complications including death. (Refer to A-0813)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments.

Based on interview and record review, the facility failed to ensure that, for one of 34 sampled patients (Patient 1), the discharge planning evaluation (a process conducted by healthcare providers to identify a patient's post-hospital care needs, including medical equipment, support services, and living arrangements, to ensure a safe and effective transition from the facility) was completed upon admission, in accordance with the facility's policy regarding Discharge Planning. In addition, the facility failed to ensure that the discharge planning assessment included a functional assessment (an evaluation conducted to determine a person's ability to perform activities necessary for daily living and maintain independence) of the patient (Patient 1) and an evaluation of whether the patient (Patient 1) required any specialized durable medical equipment (DME, medical equipment prescribed by a doctor for use at home, designed to help patients manage their health conditions and perform daily activities after leaving the hospital. Example: walker or cane) prior to discharge to a recuperative care facility (a type of transitional housing or facility that provides short-term medical care and supportive services for individuals who are homeless or lack stable housing).

This deficient practice resulted in Patient 1 falling shortly and sustaining a fracture (break in the bone) of the left humerus (the long bone that connects the shoulder to the elbow) while Patient 1 was walking to the recuperative care facility after being dropped off by arranged transportation at the discharge destination point. This deficient practice also led to Patient 1 being readmitted to the facility only a few hours after discharge.

Findings:

During a review of Patient 1's history and physical (H&P, a formal and complete assessment of the patient and the problem), dated 7/3/2024, the H&P indicated that Patient 1 was admitted to the facility on 7/3/2024 due to an episode of hypoglycemia (low blood sugar). The H&P also indicated that Patient 1 had a past medical history (a record of previous illnesses, conditions, and treatments) of diabetes (high blood sugar levels), but Patient 1 was unable to recall or name the medications Patient 1 was currently taking.

During a review of Patient 1's medical record (MR) titled, Discharge Planning Assessment (an evaluation conducted to identify a patient's needs for post-hospital care, including living arrangements, medical equipment, follow-up services, and other resources to ensure a safe and effective discharge), the record indicated that there was no documented discharge planning assessment for Patient 1 within the first 24-48 hours after admission (7/3/2024 through 7/5/2024).

During an interview on 11/12/2024 at 2:04 p.m. with the Director of Case Management and Social Services (DCM), the DCM stated the following: "Discharge planning starts on admission or within 24-48 hours upon admission to the inpatient. The Case Managers (CM) should do their discharge planning assessment where they assess prior living situation, interview the patient, and assess the need for outpatient services such as home health services, SNF (Skilled Nursing Facility, a healthcare facility providing medical and rehabilitative care), DMEs (Durable Medical Equipment, medical equipment prescribed by a doctor for use at home, designed to help patients manage their health conditions and perform daily activities after leaving the hospital. Example: walker or cane), etc. The CM should round (in-person visit) on patients every day. If there are any changes to the assessment, documentation must be done in the patient's medical record. The DCM also stated that discharge planning was a collaborative process of a doctor, nurse, and a CM to determine what is the safest disposition (the process of arranging for the patient's placement or care after discharge) plan, so "we (the multidisciplinary team) start with physical evaluation and can make necessary recommendations."

During a review of Patient 1's medical record (MR) titled, "Nursing Notes," dated 7/4/2024, the MR indicated that Patient 1 was identified as homeless on 7/4/2024, and an order for a Social Services Consultation was placed.

During a review of Patient 1's medical record (MR) titled, "Social Services," dated 7/5/2024 at 12:01 p.m., the MR indicated that a social worker (SW) received a consultation order for "homeless." The SW met with Patient 1 at the bedside, where Patient 1 confirmed being homeless, stated Patient 1 could walk with assistance from a walker or cane, and expressed agreement to be discharged to recuperative care (a short-term care program designed to provide medical oversight and support for individuals who are homeless or lack stable housing, allowing them to recover from an illness, injury, or surgery in a safe and structured environment).

During an interview on 11/14/2024 at 11:17 a.m. with the Manager of Social Services (MSS) regarding the homeless needs assessment, the MSS stated that two very important components of the assessment were the functional mobility, which was the assessment of the patient's mobility status, and the mental status, which was done to evaluate the patient's reality orientation to ensure a safe discharge for homeless patients. The MSS then stated that typically, the functional assessment included reviewing the recommendations by physical therapy (PT, therapy focused on improving mobility, strength, and physical function) and occupational therapy (OT, therapy focused on enhancing the patient's ability to perform daily activities), as well as input from the nurse, to determine the patient's physical abilities and whether the patient can walk.

During a concurrent interview and record review on 11/14/2024 at 11:21 a.m. with the Quality Assurance Nurse (QAN), Patient 1's medical record (MR), was reviewed. The MR indicated that physical therapy (PT) and occupational therapy (OT) evaluations were not ordered and not conducted for Patient 1 during Patient 1's stay at the facility from 7/2/2024 through 7/5/2024. The QAN stated that the MR also contained no documentation indicating whether Patient 1 was ambulated (related to walking) during Patient 1's admission at the facility or whether Patient 1 required a walker or a cane for ambulation. The QAN further stated that on 7/5/2024, at 8 a.m., nursing assessment documentation indicated that Patient 1 had an unsteady gait (a condition characterized by difficulty walking or maintaining balance, often associated with a risk of falls [unplanned descent to the floor with or without injury to the patient]).

During a concurrent interview and record review on 11/14/2024 at 11:27 a.m. with the Quality Assurance Nurse (QAN), Patient 1's medical record (MR), was reviewed. The QAN stated that Patient 1's medical record contained no documentation indicating that Patient 1 was discharged with a walker or a cane, nor whether a walker or a cane was provided to Patient 1 prior to discharge to the recuperative care facility on 7/5/2024.

During an interview on 11/14/2024 at 11:30 a.m. with the Manager of Social Services (MSS) regarding durable medical equipment (DME), the MSS stated that nursing should be responsible for ensuring the patient had the necessary DMEs prior to discharge.

During a review of Patient 1's discharge instructions (DI, written guidelines provided to a patient at the time of discharge outlining care plans, medications, follow-up appointments, and any necessary equipment or resources), dated 7/5/2024, the DI indicated that Patient 1 was discharged on 7/5/2024 and picked up by arranged transportation at 2:23 p.m. The DI contained no record indicating that Patient 1 had a cane, or a walker provided prior to discharge.

During a review of Patient 1's HPI (History of Present Illness, a detailed account of the patient's current medical issue and symptoms), dated 7/5/2024, at 6:05 p.m., the HPI indicated that Patient 1 was re-admitted to the facility's emergency department (ED, a hospital unit specializing in the treatment of urgent and acute medical conditions) after being dropped off at a clinic a few hours earlier on the same day (7/5/2024). While walking to the clinic, Patient 1 tripped and fell onto their left side. The HPI further indicated that Patient 1 had fractured their left humerus (the long bone in the upper arm) with evidence of axillary nerve injury (damage to the nerve that runs through the armpit area, controlling the deltoid muscle and providing sensation to part of the shoulder) and had to be re-admitted to the facility on the same day (7/5/2024) for an Open Reduction and Internal Fixation (ORIF, is a surgical procedure used to repair and stabilize a broken bone) of the left humerus (the upper arm bone).

During a review of the facility's policy and procedure (P&P) titled "Discharge Planning," dated 7/2023, the P&P indicated that discharge planning provides patients with a realistic, coordinated plan for hospital discharge. This plan ensures a smooth and timely transition from one level of care to another while addressing the patient's overall healthcare needs. The process begins at the time of admission and is a multidisciplinary effort through which all members of the healthcare team ensure that appropriate and timely plans are made for post-hospital care.

During a review of the facility's policy and procedure (P&P) titled, "Discharge Planning," dated 7/2023, the P&P indicated that the hospital must identify, at an early stage of hospitalization, all patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning. The hospital must complete this evaluation on a timely basis to ensure that appropriate arrangements for post-hospital care are made before discharge.

During a review of the facility's policy and procedure (P&P) titled, "Homeless Patient Discharge, Management of," dated 7/2023, the P&P indicated that to ensure compliance with local ordinances governing homeless patient discharge, the facility must initiate discharge planning upon admission to the hospital or emergency department, recognizing that homelessness is a complex issue requiring early planning. In collaboration with the staff nurse, the social worker shall prepare the patient for discharge and ensure that all necessary steps regarding follow-up clinical care, placement, transportation needs, available local resources, and medication dispensations are addressed.

Based on interview and record review, the facility failed to include a discharge planning evaluation (an assessment required to identify a patient's post-hospital needs, including the likelihood of requiring services such as rehabilitation, home care, or follow-up treatment, and the capacity for self-care or support in their living environment, as part of ensuring a safe and effective transition from the hospital) in the medical record for two of 34 sampled patients (Patient 1 and Patient 3), in accordance with the facility's policy regarding discharge planning when:

1. Patient 1's discharge planning evaluation was not documented during Patient 1's admission stay at the facility. Additionally, Patient 1 was not actively engaged in the development of their (Patient 1's) discharge plan (a detailed plan developed by healthcare providers to ensure a patient transitions safely and effectively from a healthcare facility to their next care setting).

This deficient practice resulted in unsafe transition with no continuity of care and unmet post-discharge needs for Patient 1, leading to Patient 1's re-admission to the facility the same day Patient 1 was discharged (7/5/2024). In addition, this deficient practice violated Patient 1's right (the right of a patient to participate in decisions about their care, including being informed, consulted, and involved in the planning and implementation of patient's treatment and discharge plans) to be involved in the development and implementation of their (Patient 1') discharge plan.

2. Patient 3's discharge planning evaluation was not conducted or documented in Patient 3's medical record during Patient 3's admission at the facility.

This deficient practice violated Patient 3's right to be involved in the development and implementation of their (Patient 3's) discharge plan. In addition, this deficient practice resulted in Patient 3 being placed at risk for an unsafe transition and unmet post-discharge needs, potentially leading to complications such as readmission, or a decline in health.

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 7/3/2024, the H&P indicated that Patient 1 was admitted to the facility on 7/3/2024 due to an episode of hypoglycemia (low blood sugar). The H&P also indicated that Patient 1 had a past medical history (a record of previous illnesses, conditions, and treatments) of diabetes (high blood sugar levels), but Patient 1 was unable to recall or name the medications Patient 1 was currently taking.

During a review of Patient 1's medical record (MR) titled, "Discharge Planning Assessment (an evaluation or assessment conducted to identify a patient's needs for post-hospital care, including living arrangements, medical equipment, follow-up services, and other resources to ensure a safe and effective discharge)," the MR indicated that there was no documented discharge planning assessment for Patient 1 within the first 24-48 hours after admission (7/3/2024 through 7/5/2024).

During an interview on 11/12/2024 at 2:04 p.m. with the Director of Case Management and Social Services (DCM), the DCM stated the following: "Discharge planning starts on admission or within 24-48 hours upon admission to the inpatient area. The Case Managers (CM) should do their discharge planning assessment where they assess prior living situation, interview the patient, and assess the need for outpatient services such as home health services, SNF (Skilled Nursing Facility, a healthcare facility providing medical and rehabilitative care), DMEs (Durable Medical Equipment, medical equipment prescribed by a doctor for use at home, designed to help patients manage their health conditions and perform daily activities after leaving the hospital. Example: walker or cane), etc. The CM should round (in-person patient visits) on patients every day. If there are any changes to the assessment, documentation must be done in the patient's medical record. The DCM also stated that discharge planning was a collaborative process of a doctor, nurse, and a CM to determine what is the safest disposition (the process of arranging for the patient's placement or care after discharge) plan, so "we (the multidisciplinary team) start with physical evaluation and can make necessary recommendations." The CM also stated that the patient or their family should be involved in their discharge planning process.

During a review of Patient 1's medical record (MR) titled, "Social Services," dated 7/5/2024, at 12:01 p.m., the MR indicated that on 7/5/2024, a social worker (SW) documented to receive a consultation order for "homeless" (a designation used when a patient is identified as lacking stable, permanent housing, which prompts an evaluation to address their unique needs for post-discharge care, including housing, resources, and medical support). The MR also indicated, the SW met with Patient 1 at the bedside and educated Patient 1 of the importance of recuperative care (programs provide room, board, and medical care coordination in a post acute care setting for people experiencing homelessness who are too ill or frail to recover from a physical illness or injury on the streets or in shelter, but who are not ill enough to be in a hospital). The SW then documented that Patient 1 was agreeable to recuperative care.

During a review of the medical record (MR) titled, "Social Services," dated 7/5/2024, at 12:24 p.m., the MR indicated that the social worker (SW) obtained confirmation of Patient 1 being accepted to [Organization] recuperative care and documented the address where Patient 1 would be going after discharge. However, the SW did not document a discussion with Patient 1 regarding the recuperative care facility, nor did the record indicate that Patient 1 had agreed to go to the particular receiving facility.

During a review of Patient 1's medical record (MR) titled, "Discharge Note-Nurses Note," dated 7/5/2024, at 2:40 p.m., the MR indicated the following: "Is the patient identified as homeless? If yes, be certain that the Homeless Waiver Form (a document confirming that the patient has been informed of their discharge plan and resources available to them) is signed and witnessed."

During a concurrent interview and record review on 11/14/2024 at 11:35 a.m. with the Quality Assurance Nurse (QAN), Patient 1's medical chart was reviewed to locate the uploaded Homeless Waiver Form. The QAN stated that Patient 1's medical chart contained no record of the Homeless Waiver Form completed and signed by Patient 1.

During an interview on 11/14/2024 at 11:30 a.m. with the Director of Case Management (DCM) and Manager of Social Services (MSS) regarding the Homeless Waiver Form, both stated that the Homeless Waiver Form was only required when a homeless patient refuses the hospital's proposed discharge plan. If the discharge plan was accepted, completion of the form was unnecessary.

During a review of Patient 1's HPI (History of Present Illness, a detailed account of the patient's current medical issue and symptoms), dated 7/5/2024, at 6:05 p.m., the HPI indicated that Patient 1 was re-admitted to the facility's emergency department (ED, a hospital unit specializing in the treatment of urgent and acute medical conditions) after being dropped off at a clinic (recuperative care facility). While walking to the "clinic?" [clinic was documented with a question mark, indicating uncertainty about the exact location], Patient 1 tripped and fell onto their left side. The HPI further indicated that Patient 1 had fractured (break in the bones) their left humerus (the long bone in the upper arm) with evidence of axillary nerve injury (damage to the nerve that runs through the armpit area, controlling the deltoid muscle and providing sensation to part of the shoulder) and had to be re-admitted to the facility on the same day (7/5/2024) for an Open Reduction and Internal Fixation (ORIF, is a surgical procedure used to repair and stabilize a broken bone) of the left humerus (the upper arm bone).

During a review of the facility's policy and procedure (P&P) titled, "Homeless Patient Discharge, Management of," dated 7/2023, the P&P indicated the following requirements for treat-and-release homeless patients:

1. An identified discharge plan must be established to ensure that all necessary steps regarding follow-up clinical care, placement, transportation needs, available local resources, and medication dispensations (where appropriate and initiated by the physician) are addressed.

2. The patient must sign a completed Homeless Patient Waiver Form, and this endorsement must be witnessed by two staff members.

The P&P also indicated that the facility's discharge procedure for facilitating homeless patient discharge to any type of facility also requires the following information to be documented in the patient's medical chart:
a. The name of the receiving facility.
b. The name of the intake staff at the receiving facility who accepted the homeless patient.
c. Confirmation that the patient has agreed to go to the particular receiving facility.
d. Documentation indicating that the patient completed and signed the Homeless Patient Waiver form or declined to do so.

During a review of the facility's policy and procedures (P&P) titled, "Discharge Planning," dated 4/2023, the P&P indicated the following: " ...Discharge planning begins at the time of admission. It is an interdisciplinary process through which all members of the healthcare team ensure that appropriate and timely plans are made for post-hospital care. Discharge planning provides patients with a realistic, coordinated plan for hospital discharge that will ensure a smooth and timely transition from one level of care to another and meet the patient's overall healthcare needs ... Objectives: ...2. Coordinate all patient care and support services consonant with the attending physician's plan of care ... 7. Ensure compliance with discharge planning standards as defined by regulatory and accrediting bodies ..."

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibilities," dated 6/2022, the P&P indicated that patients have the right to be involved in the development and implementation of their discharge plan.

2. During a review of Patient 3's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/9/2024, the H&P indicated that Patient 3 had past medical history (PMH, a record of all previously diagnosed medical conditions, treatments, and surgeries that could impact the patient's current health or care plan) of dementia (progressive decline in mental functions) and hypertension (high blood pressure). The H&P also indicated that Patient 3 was admitted due to constipation (a condition marked by infrequent or difficult bowel movements), failure to thrive (FTT, a state of poor nutrition or significant weight loss), refusing to eat (a medical or behavioral issue where the patient declines food intake), and acute (sudden) on chronic encephalopathy (a sudden worsening of brain function).

During further review of Patient 3's H&P, dated 9/9/2024, the H&P indicated that Patient 3 was non-verbal (unable to communicate using spoken words) and that Patient 3's dementia had been progressively worsening, causing significant weight loss. The H&P also indicated that Patient 3's past medical history (PMH) was obtained from Patient 3's caregiver, who stated that Patient 3 had been chewing on and swallowing parts of blankets.

During a review of Patient 3's medical record (MR) titled, "Patient Orders Detail (a section of the medical record that documents physician orders for tests, treatments, or interventions)," dated 9/9/2024, the MR indicated that on 9/9/2024 at 7:15 p.m., the physician placed an order for a Social Service consultation (a service provided to assess and address a patient's social, emotional, and practical needs related to their medical condition and care). The consultation order included an evaluation and assessment for home safety (ensuring the patient's living environment is free from hazards and supports their health and mobility) and home health services (medical and non-medical support provided at home, such as nursing care, therapy, or assistance with daily activities).

During a review of Patient 3's medical chart, no record of Social Services consultation was found in Patient 3's chart.

During a concurrent interview and record review on 11/14/2024 at 3:50 p.m. with the Quality Assurance Nurse (QAN), Patient 3's medical record (MR) titled, "Admission Assessment (an initial evaluation conducted upon a patient's admission to gather detailed information about their medical history, current condition, and immediate needs)," dated 9/10/2024, was reviewed. The MR indicated that Patient 3's "Discharge Case Manager" score was 4 (a scoring system used to assess the complexity of a patient's case and their need for case management services, with a score of 4 typically indicating a high level of need for support in planning post-discharge care). The QAN stated that when the discharge assessment score was assessed to be 4, a referral for case management (CM, a collaborative process in healthcare where a professional, typically a case manager, coordinates and oversees a patient's care to ensure they receive the appropriate services and resources) and discharge planning evaluation (an assessment performed by healthcare professionals to determine a patient's needs for a safe and effective transition from a hospital or healthcare facility to their next care setting or home) was automatically populated for case management to follow up and conduct the evaluation of the patient's post-discharge needs.

During a concurrent interview and record review on 11/15/2024 at 11:27 a.m. with the Quality Assurance Nurse (QAN), Patient 3's discharge planning record (DPR, a section of the medical record that documents the assessment, planning, and coordination of services needed to ensure a safe and effective transition from the facility to the next care setting), dated 9/9/2024 through 9/13/2024, was reviewed. The QAN stated that Patient 3's medical chart contained no documentation indicating that discharge planning had been conducted for Patient 3.

During further review of Patient 3's MR titled, "Case Manager Note," dated 9/11/2024, the MR indicated that on 9/11/2024 at 4:27 p.m., a case manager (CM) documented in Patient 3's chart that discharge planning was discussed with the attending physician (the primary doctor responsible for overseeing the patient's care during their hospital stay and making key decisions about treatment and discharge).

During further review of Patient 3's MR titled, "Discharge Planner (DP)" Note, dated 9/13/2024, the MR indicated that the Discharge Planner (DP) (a healthcare professional responsible for coordinating the discharge process, including arranging post-hospital care, transportation, and necessary follow-up services to ensure a safe transition for the patient) documented that Patient 3 was to be discharged via ambulance (a medical transport vehicle equipped to provide emergency care or non-emergency transportation for patients who are unable to travel independently due to medical conditions). The MR further indicated that the DP found Patient 3's caregiver at bedside and documented that Patient 3's caregiver refused to allow Patient 3 to be discharged. However, the MR contained no record explaining why Patient 3's caregiver refused to allow the discharge.

During an interview on 11/15/2024 at 11:51 a.m. with the Director of Medical-Surgical Unit [a hospital department that provides care for a wide variety of patients recovering from surgery or managing other illnesses] (DMS), the DMS stated the following: "Discharge planning is a collaborative effort. We work alongside discharge planners and case managers. It starts at admission, where we determine the best plan for the patient. We have a team huddle every day to discuss the discharge plan for the patient. Case managers (CMs) are typically on the floors to assist with this process. The CM is responsible, along with their team and nursing staff, to ensure that, as a collaborative group, all of us are involved."

During an interview on 11/15/2024 at 1:39 p.m. regarding the lack of discharge planning documentation for Patient 3 during their admission at the facility [9/9/2024 through 9/13/2024], the Director of Case Management (DCM) stated the following: Discharge planning assessments must be completed as required (in accordance with the facility's policies and federal regulation) and should include a comprehensive evaluation of the patient's emotional status, living arrangements, prior level of functioning, social support, family involvement, and available resources to identify potential post-discharge needs. The DCM further stated that discharge planning was a collaborative process involving multiple healthcare team members, including the physician (MD) and, most importantly, the patient and/or the patient's caregiver. The DCM stated that active patient participation in discharge planning was critical, and it should be clearly documented in the medical record that the discharge plan was discussed with the patient and that the agreement was obtained.

During the same interview on 11/15/2024 at 1:39 p.m. with the Director of Case Management (DCM), the DCM stated, "I have identified many issues with discharge planning since I started working here about 7 months ago. Challenges I have identified include initial assessments not being completed, the patient's involvement in discharge planning is lacking, and a lack of communication with the patient and the patient's family." The DCM further stated, "It took some time; I had to start by providing a lot of education and resources, as well as sharing contacts. I would bring staff into my office to offer counseling and guidance. I hired a new team of case managers and social workers, ensuring they were equipped with the necessary tools and resources to succeed. My plan is to continue focusing on education to strengthen the team. They had been without a director for a long time, which contributed to the challenges we're now addressing."

During a review of the facility's policy and procedures (P&P) titled, "Discharge Planning," dated 4/2023, the P&P indicated the following: " ...Discharge planning begins at the time of admission. It is an interdisciplinary process through which all members of the healthcare team ensure that appropriate and timely plans are made for post-hospital care. Discharge planning provides patients with a realistic, coordinated plan for hospital discharge that will ensure a smooth and timely transition from one level of care to another and meet the patient's overall healthcare needs ... Objectives: ...2. Coordinate all patient care and support services consonant with the attending physician's plan of care ... 7. Ensure compliance with discharge planning standards as defined by regulatory and accrediting bodies ..."

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibilities," dated 6/2022, the P&P indicated that patients have the right to be involved in the development and implementation of their discharge plan.

Based on interview and record review, the facility failed to ensure one of 34 sampled patients (Patient 4) received care coordination for cardiac follow-up care prior to discharge (the formal release of a hospitalized individual due to conclusion of the hospitalization stay, either by death, return home, or transfer to another institution), in accordance with the facility's policy regarding Discharge Planning, when Patient 4 was discharged to a Skilled Nursing Facility (SNF, an inpatient treatment and rehabilitation center where patients receive care after a hospital stay).

This deficient practice had the potential for Patient 4's pacemaker device (a small, battery-powered device that prevents the heart from beating too slowly) failure, resulting in cardiac (heart) complications including death.

Findings:

During a concurrent record review on 11/13/2024 at 1:23 p.m. with the Clinical Nursing Supervisor 3 (CNS 3), the CNS 3 verified the following in Patient 4's medical record: Patient 4's History and Physical (H&P, a physicians formal assessment of a patient's medical history and current condition), dated 7/22/2024, indicated Cardiology (the branch of medicine concerned with the diagnosis and treatment of heart-related diseases and disorders) was consulted by Medical Doctor 3 (MD 3). Patient 4's "(Cardiac Electrophysiology [the study of the heart's electrical activity, including its function, performance, and mechanisms]) Consultation Report (a document that outlines a patient's condition and the rationale for their treatment)," dated 7/25/2024, indicated Patient 4's pacemaker (a small, battery-powered device that prevents the heart from beating too slowly) remained in end of battery life since 2/8/2024 and needed battery replacement at [name of the facility]. Patient 4's "Patient Orders (communicates the medical care that the patient is to receive) Detail," dated 7/30/2024, indicated an order to discharge (the formal process of a patient leaving a hospital after receiving treatment or care) to a Skilled Nursing Facility (SNF, an inpatient treatment and rehabilitation center where patients receive care after a hospital stay) and did not indicate any follow-up care.

Patient 4's "Internal Progress Notes," dated 7/30/2024, did not indicate Patient 4 was medically cleared (a physician, or another health care provider has determined that a person is medically stable) by Cardiology prior to discharge. Patient 4's "Discharge Summary (a clinical document that summarizes a patient's hospital stay and care plan so that the patient's primary care provider can continue their care)," dated 7/30/2024, did not indicate Patient 4 was given follow-up care (the care a patient receives after finishing treatment for a disease or condition) for Cardiology at discharge. There was no documentation Patient 4 had a pacemaker interrogation (a procedure that allows a cardiologist to check the function of a pacemaker) prior to discharge.

During a concurrent interview and record review on 11/14/2024 at 3:21 p.m. with the Director of Case Management (DCM) and the Quality Assurance Nurse (QAN), the DCM verified the following in Patient 4's medical record: The discharge order, dated 7/30/2024 at 9:59 p.m., did not have written follow-up instructions (information relevant to a patient's medical condition or behavioral health issue that is provided to the patient, the patient's representative, or a health care institution). The QAN verified there was no follow-up instructions in the discharge summary, dated 7/30/2024, provided by nursing. The DCM stated the following: The case manager coordinated follow-up care for the patient. If a patient needed follow-up care, this would have been in the Physician's discharge order and incorporated into the discharge instructions for the patient. It is the physician's responsibility to coordinate the follow-up care and discuss this with the interdisciplinary team. The QAN stated it was important to include follow-up care in the discharge summary so the patient would know where to follow-up and how to manage their care after leaving the hospital.

During an interview on 11/15/2024 2:41 p.m. with Medical Doctor 3 (MD 3), MD 3 stated the following: There should have been follow-up information given to Patient 4 at discharge because Patient 4's safety and health was important. Any conversations with [MD 2] about Patient 4's medical care should have been documented in the medical record. Follow-up information should have been documented in Patient 4's discharge summary.

During a review of Patient 4's Face Sheet (gives information at a glance), the Face Sheet indicated Patient 4 was admitted to the facility on 7/21/2024 at 12:06 p.m. with a diagnosis of hyperglycemia (elevated blood sugar). The Face Sheet further indicated Patient 4 was discharged from the facility on 7/30/2024 at 11:30 p.m.

During a review of Patient 4's "History and Physical (H&P)," dated 7/22/2024 at 9:41 a.m., the H&P indicated the following: "Assessment and Plan Notes: ...Cardiology Consulted ..."

During a review of Patient 4's "Cardiology Progress Notes", dated 7/22/2024; 7/23/2024; 7/24/2024; 7/25/2024; 7/26/2024/; 7/27/2024; 7/28/2024; 7/29/2024; and 7/30/2024, the progress note indicated Patient 4 was not stable for discharge.

During a review of Patient 4's "Internal Medicine Progress Notes," dated 7/30/2024 at 4:33 p.m., the progress notes indicated the following: " ...discharge planning to SNF ..."

During a review of Patient 4's "Patient Orders Detail," dated 7/30/2024 at 9:59 p.m., the orders indicated the following: "Discharge patient to SNF ..."

During a review of Patient 4's "Nursing Discharge Note," dated 7/30/2024 at 11:41 p.m., the discharge note indicated the following: Patient 4 was discharged from the facility on 7/30/2024 at 11:20 p.m.

During a review of the facility's policy and procedures (P&P) titled, "Discharge Planning," dated 4/2023, the P&P indicated the following: " ...Discharge planning begins at the time of admission. It is an interdisciplinary process through which all members of the healthcare team ensure that appropriate and timely plans are made for post-hospital care. Discharge planning provides patients with a realistic, coordinated plan for hospital discharge that will ensure a smooth and timely transition from one level of care to another and meet the patient's overall healthcare needs ... Objectives: ...2. Coordinate all patient care and support services consonant with the attending physician's plan of care ... 7. Ensure compliance with discharge planning standards as defined by regulatory and accrediting bodies ..."

During a review of the facility document "Medical Staff: General Rules and Regulations (section of the medical staff bylaws that describes more detailed operational policies for a hospital's medical staff)," reviewed/revised 10/2024, the Rules and Regulations indicated the following: " ... 1.8-10. Medical staff are responsible for collaborating with discharge planning personnel to ensure a smooth and effective transition of the patient to an appropriate post-hospital care setting."

During a review of the facility's policy and procedure (P&P) titled "Patient Rights and Responsibilities," dated 6/2022, the P&P indicated that "Patients have the right to be informed by the physician, or a delegate of the physician, about continuing healthcare requirements and options following discharge and/or transfer within or outside the hospital."