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A. Based on document review and interview, it was determined that for 2 of 3 (Pt. #1 and Pt. #4) sampled patients on the 9 East and 10 East units, the Hospital failed to ensure that patient assessments were conducted, as required.

Findings include:

1. On 6/18/19, the Hospital's policy titled, "Documentation of Patient Care Inpatient Nursing" was reviewed and required "...Full head to toe patient assessments are performed and documented by each RN (Registered Nurse) at the point of entry into the Medical Center, at point of transfer of care..."

2. On 6/18/19 the Hospital's policy titled, "Pain - Assessment, Documentation and Education" (revised 5/19) was reviewed and included, "Pain Reassessment...The patient will be re-assessed for the presence of pain with each set of scheduled vital signs. If pain is identified, a more detailed assessment is completed...The frequency of reassessment should be based on the individual's pain level...more often as warranted by patient condition or acuity...After each pharmacologic...intervention...once sufficient time has lapsed for the treatment to reach peak effect.

3. On 6/18/19, the 9 East Admission/Transfer Log dated 6/16/19 was reviewed. The Log indicated that Pt #1's time of arrival on 9 East was at 2:00 PM.

4. On 6/18/19, Pt #1's clinical record was reviewed. Pt #1 was a 61 year old male admitted to the Hospital's ICU on 6/15/19 with the diagnosis of shortness of breath. Pt #1 was transferred from ICU to a Telemetry Medical Surgical Unit on 6/16/19 at 2:00 PM, according to the 9 East Admission/Transfer Log dated 6/16/19. However, Pt #1's flowsheets dated 6/16/19 indicated that the nursing assessment documentation was not initiated until the next shift at 8:00 PM (6 hours delay in assessment).

5. On 6/18/19 at approximately 11:27 AM, the clinical record of Pt #4 was reviewed. Pt #4 was a 57 year-old male, admitted to the Hospital's Hematology/Oncology Unit (10 E) on 6/7/19 with a diagnosis of acute leukemia (a form of cancer affecting the blood). A physician's order dated 6/14/19, included, "Tramadol (pain medication used to treat severe pain-Peak time 1.6 to 1.9 hours after an oral dose) 50 mg (milligram) every 6 hours as needed for pain by mouth. Acetaminophen (pain medication used to treat minor to moderate pain-Peak time approximately 15 minutes after administration) 650 mg every 6 hours as needed for pain by mouth.

-The Medication Administration Record for 6/18/19 at 9:14 AM, indicated that Tramadol 50mg and Acetaminophen 650 mg were administered.

-On 6/18/19 at 9:14 AM, Pt # 4 reported pain at 7, rated on a pain scale of 1-10 (0 indicated no pain and 10 the most severe pain). Pt #4 received oral analgesic for pain at 9:15 AM. The clinical record indicated that Pt #4 was not reassessed for effectiveness of pain medication until 3:38 PM (approximately 5 hours delayed after medication administration).

6. On 6/18/19 at 10:35 AM, an interview was conducted with the Registered Nurse (E #2). E #2 stated that there is a concern regarding being short staffed when patients are admitted to the unit because there is not enough time to spend time in assessing the patient. E #2 stated that she worked on 6/16/19 and there was only 7 nurses working 7:00 AM to 7:00 PM. E #2 stated that her assignment included a patient (Pt. #1).

7. On 6/18/19 at approximately 11:35 AM, an interview was conducted with the Nurse Manager (E #10). E #10 stated that, pain assessments are done upon admission and then when vital signs are checked at least every four hours. On 6/18/19, E #10 stated if a patient reports pain and is given pain medication, the RN should reassess and document at least thirty (30) minutes later to assess effectiveness of the medication.



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B. Based on document review, observation, and interview, it was determined that for 4 of 4 Emergency Crash Carts (medical equipment used for medical emergencies) on the Hematology/Oncology Unit (10 East), the Hospital failed to ensure that the Registered Nurse fully evaluated the crash carts for readiness, in patient care use. This potentially affected approximately 39 patients, on census as of 6/18/19.

Findings include:

1. On 6/18/19 at approximately 10:40 AM, an observational tour of the 10 E unit was conducted. The unit had a total of four (4) adult Crash Carts. The Emergency Equipment Checklist for all 4 carts for the month of June 2019 was reviewed. For all four carts, from 6/1/19 through 6/17/19, the checklist lacked documentation of printed records, to evidence that the defibrillator (equipment used for heart resuscitation) had been checked and was ready for use.

2. The Hospital's policy titled, "Emergency Equipment Readiness" (11/18) was reviewed and included, "Registered Nurses or assigned individuals...are responsible for checking the Adult...Crash Cart, defibrillator, and portable suction in their work area. a. once a shift...verified and documented on the Emergency Equipment Checklist...2. Registered Nurses...are responsible for...Confirm defibrillator is plugged into red emergency wall outlet, 1. Power On...3. Push Charge button... Unit will discharge energy into Test load and print record on paper...5. turn off..."

3. On 6/18/19 at approximately 10:50 AM, an interview was conducted with the Nurse Manager of 10 E (E #10). When E #10 was asked for the defibrillator strips for all four carts for June 2019, E #10 stated that, staff does not check the defibrillator because it is the responsibility of the Engineering department, and therefore E #10 was not able to show any strips. E #10 stated that the assigned RN will check all other areas of the Crash Cart, including the portable suction machine by plugging it into an outlet and turning it on.

A. Based on document review and interview, it was determined that for 1 of 2 (Pt. #4) clinical records reviewed for patients who received blood transfusions, the Hospital failed to ensure vital signs were checked in accordance with the blood administration policy.

Findings include:

1. On 6/18/19 the Hospital's policy titled, "Blood Products, Procurement and Administration" (revised 5/19) was reviewed and included, "Preparation to Administer Product to the Patient...c. Vital signs (temperature, pulse, respirations, and blood pressure) must be taken and record in EPIC (Hospital's computer documentation system) minimally just before initiating blood product, within fifteen (15) minutes after initiating...and after the transfusion is completed."

2. On 6/18/19 at approximately 11:27 AM, the clinical record of Pt #4 was reviewed. Pt #4 was a 57 year-old male, admitted to the Hospital's Hematology/Oncology Unit (10 E) on 6/7/19 with a diagnosis of acute leukemia (a form of cancer affecting the blood). A physician's order dated 6/18/19, included "Transfuse Packed RBC (Red Blood Cells-PRBC) 2 Units..."

-The blood transfusion record for the first unit of PRBC for Pt #4 indicated that the transfusion was started on 6/18/19 at 11:00 AM. Pt #4's vital signs were recorded at 11:00:19 AM (19 seconds after start of transfusion), the next set of vital signs were recorded at 11:37 AM, thirty-seven (37) minutes after start. The clinical record lacked documentation of vital signs every fifteen (15) minutes after the start of transfusion.

3. On 6/18/19 at approximately 11:35 AM, an interview was conducted with the Nurse Manager (E #10). E #10 stated that, vital signs should be monitored prior to starting the blood transfusion, and again at fifteen (15) minutes. E #10 stated vital signs are to be recorded in the EPIC (electronic medical record) system immediately and that there is no other area where the staff can document this information. E #10 stated that, the vital signs were not documented in the Epic system, therefore E #10 cannot say that the vital signs were done.

B. Based on observation, document review and interview, it was determined that for 3 of 4 patients (Pt #4, Pt #11, and Pt #12) receiving intravenous medications (IV - medication given into a blood vessel) on the 10 East Unit, the Hospital failed to ensure that the IV tubing was labeled and dated properly.

Findings include:

1. During an observational tour of the 10 East Unit on 6/18/19, at approximately 10:40 AM the following was observed:

Pt #4 was receiving Mycamine (medication used to treat fungal infections) 50 mg (milligrams) in 0.9 Sodium Chloride 100 ml (milliliters) via intravenous route. The IV tubing was labeled with only a date of 6/16/19 and lacked the RN's initials and date of tubing expiration.

Pt #11 was receiving Rocephin (medication used to treat infections) 2gm (grams) in 50 ml 0.9 Sodium Chloride via intravenous route. The IV tubing was labeled with the date 6/17/19 and lacked the RN's initials and date of tubing expiration.

Pt #12 was receiving Azatcam (medication used to treat bacterial infections) 2gm in 50 ml of 0.9 Sodium Chloride via intravenous route. The IV tubing was labeled with the date 6/16/19 and lacked the RN's initials and date of tubing expiration.

2. The Hospital's policy titled, "Peripheral Vascular Access Devices" (revised 9/18) was reviewed and included, "Tubing care and Maintenance...3. Tubing should be labeled with the date of expiration and clinician's initials..."

3. On 6/18/19 at approximately 11:00 AM, an interview with the Nurse Manager (E #10) was conducted. E #10 stated that IV tubing should be labeled with the date initiated, date tubing needs to be changed and the nurse's initials.