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Based on observation, interview, and record review, the hospital failed to ensure one of 32 sampled patients (Patient 27) was provided pain medication for a pain level of 8 out of 10 on the pain scale (pain assessment tool to measure pain level from 1-10, with 8-10 indicating severe pain). This failure resulted in Patient 27's right to have pain managed to not be upheld.

Findings:

During a review of Patient 27's "Emergency Documentation (EDT)" dated 8/19/24 at 7:01 p.m. the EDT indicated, "This patient is a 16 Years Old Male, with no reported past medical history, who is brought in by mother to the [ED] complaining of infection of left knee and antibiotic reaction. Patient reports that last week on 8/11/24 a car hit the front of his left quad. [quadriceps-leg muscle] He noticed on 8/15/24 an infection started and he had a fever, episode of emesis [vomiting], and no appetite."

During a review of Patient 27's "ED (Emergency Department ) Triage Part 1 (EDT)" dated 8/19/24 at 4:37 p.m. the EDT indicated, "Numeric Pain Score (0-10): 8."

During a review of Patient 27's "Orders (O)," dated 8/19/24, the "O" indicated, "ibuprofen )Motrin-pain medication) 400 mg [milligram - unit of measure] + 20 ml [milliliter-unit of measure], Oral [by mouth], Susp (suspension), every 6 hours, for 45 days, PRN [as needed], First Dose: 08/19/24 10:52 p.m."

During a review of Patient 27's "Pain (P)" dated 8/19/24 at 11:45 p.m. the "P" indicated oral analgesic (pain relief) was given (over 7 hours after pain level assessment of 8).

During a concurrent observation and interview on 8/28/24 at 10:50 a.m. with Patient 27 and Family Member (FM) 1, in Patient 27's room, Patient 27 was lying in his bed with a large wound noted on left upper leg. Patient 27 stated he had been in a lot of pain. FM 1 stated the hospital could improve on providing pain medication and [Patient 27] was not provided pain medication until he was in his hospital room.

During an interview on 8/28/24 at 2:05 p.m. with Assistant Nurse Manager (ANM), ANM stated the triage nurse would assess the pain level, and the physician would review the triage note and could implement an order for pain medication. ANM stated, severe pain (level 8-10) should be treated.

During an interview on 8/29/24 at 10:45 a.m. with Triage Registered Nurse (TRN), TRN stated patient pain level is assessed when patient assessments are completed. TRN stated if a patient is in pain, a physician's order can be obtained for a pain medication to be administered to the patient. TRN stated, once a pain medication order has been obtained, the patient would be administered the pain medication.

During a review of the hospital's policy and procedure (P&P) titled, "Pain Assessment and Reassessment, Standards for," dated 10/20/22, the P&P indicated, "[Hospital] recognizes and upholds the rights of patients to have pain safely and effectively managed and to include the patient the family and/or the patient's legal representative in the planning of the patient's care. The patient has the right to request or reject the use of any or all modalities to relieve their pain. The presence and intensity of pain will be based on the patient's self-report, physical examination and behavioral indicators in order to balance the need for pain control with the risk of over sedation. Patients will receive the best level of pain control that can be safety provided."

During a review of the hospital's P&P titled, "Patients' Rights and Responsibilities, and Non-Discrimination" dated 9/6/23, the P&P indicated, "1. Patient Rights . . . 9. Appropriate assessment and management of their pain, information about pain, pain relief measures and to participate in pain management decisions. The patient may request or reject the use of any or all modalities to relieve pain, including opiate medication, if they suffer from severe chronic intractable pain. The physician may refuse to prescribe the opiate [powerful pain reducing medication]." medication, but if so, the physician must inform the patient that there are physicians who specialize in the treatment of severe chronic pain with methods that include the use of opiates

Based on interview and record review, the hospital failed to develop and update individualized plans of care (IPOC- a plan to meet patient health care goals and needs) for one of 32 sampled patients (Patient 19). This failure had the potential for unmet care needs.

Findings:

During a review of Patient 19's "History and Physical (H&P)," dated 7/13/24, the H&P indicated Patient 19 was admitted to the hospital on 7/13/24 for an "acute hip fracture [break] requiring urgent surgical intervention."

During a review of Patient 19's " OPERATIVE NOTE (ORTHOPEDIC SURGERY) [OPN]," dated 7/14/24, the OPN indicated "OPERATION: Right proximal femur closed reduction and fixation [procedure to fix a broken thigh bone]."

During a review of Patient 19's "Encounter Tracking Sheet (ETS - dates and timespatients areetransferredd between departments)," undated, the ETS indicated Patient 19 was admitted as in patient to "1 E [east] on 7/13/24 at 4:02 a.m. and to "4 S [south]" (medical surgical unit) on 7/13/24 at 12:09 p.m. Patient 19 was transferred to pre operative unit on 7/14/24 at 8:36 a.m. and returned to 4 south on 7/14/24 at 12:24 p.m. post operatively.

During a concurrent interview and record review on 8/29/24 at 9:14 a.m. with Nurse Manager (NM), Patient 19's "H&P," dated 7/13/24 was reviewed. The H&P indicated Patient 19 was admitted to the hospital on 7/13/24 for an "acute hip fracture [break] requiring urgent surgical intervention." NM was unable to provide an IPOC for fall risk and pain management implemented on 7/13/24. NM stated an IPOC for fall risk and pain management should have initiated on 7/13/24 following her admission assessment on the medical surgical floor. NM was unable to provide an IPOC for impaired skin integrity implemented on 7/14/24. NM stated an IPOC for impaired skin integrity should have been initiated following Patient 19's surgery on 7/14/24.

During an interview on 8/29/24 at 9:25 a.m. with Director of Medical Surgical unit (DMS), DMS stated the policy stated Registered Nurses (RN) must initiate the IPOC by the end of their shift. DMS stated the IPOC's should be initiated at time of the patient's admission assessment or within four hours of the patient arrival to the unit.

During a review of the hospital's policy and procedure (P&P) titled "Assessment and Documentation, Nursing: Acute Patient Care" dated 3/20/23, the P&P indicated, "Procedure: I. Nursing Assessment. . . D. Initial assessment and Admission History. . . 1. The function of the initial nursing assessment is to identify the assessment parameters and responsibilities needed to plan and deliver appropriate, individualized care to the patient. 2. Each patient undergoes an initial assessment by an RN [registered nurse] as soon as possible upon admission to the assigned unit, transfer from a higher level of care or post anesthesia care unit (PACU). 3. The admission history is completed within 24 hours upon admission to the assigned unit unless otherwise specified by department procedure. . . 5. The RN analyzes the data collected from the initial assessment and admission history to formulate a nursing diagnosis and individualized plan of care (IPOC) in collaboration with the patient and the interdisciplinary team. . . C. Shift Assessment and Interdisciplinary Plan of Care (iPOC): minimum frequencies. . . 2. Minimally, the plan of care is reviewed and revised as needed with documentation of outcomes conducted each shift."

Based on interview and record review, the Hospital failed to ensure their procedure titled, "Wound Care RN [Registered Nurse] [WN] Consult Priority Workflow (WCWF)" was implemented for one of 32 sampled patients (Patient 21) when WN consultation orders were not implemented timely. This failure had the potential for Patient 21's pressure injuries to worsen.

Findings:

During a review of Patient 21's "History and Physical (H&P)," dated 7/18/24, the "H&P" indicated Patient 21 was brought to the hospital due to unresponsive altered mental status. The assessment included sepsis (infection in the blood), hypothermia (low body temperature), hypoglycemia (low blood sugar), toxic metabolic encephalopathy (alteration in consciousness due to brain dysfunction), sacral decubitus ulcer (pressure ulcer that appear on skin over a bony region of the spine), stage III (wound to the lower back), history of CVA (cerebral vascular accident - stroke).

During a review of Patient 21's "Order Information (OI)," dated 7/18/24, the "OI" indicated, "Consult to Wound Care RN with follow up as needed."

During a review of Patient 21's "Wound Care Progress Notes (WCPN)," dated 7/26/24 at 12:33 p.m. (six business days after initial wound care consultation order was placed) the WCPN indicated, "2. Sacrococcygeal (buttock) - Left Buttock Stage 4 [a full skin thickness skin loss that may extent to the muscle, bone, tendon, or joint]."

During an interview on 8/27/24 at 1:04 p.m. with Wound Nurse (WN), WN stated She identified Patient 21's stage 4 pressure injuries during the WN consultation on 7/26/24. WCN 1 stated the process for prioritization of wound care patients was coordinated each morning from a list of patients with wound care consultant orders. WN stated there are two to three wound nurses at the facility, therefore we must prioritize which patients are seen by the WN each day. WN stated patients with pressure injuries on admission should be seen within one to two days. WN stated patients with pending discharges or patients with urgent needs would be seen as next priority. WN stated patients with any wound care orders should be seen within five days.

During a concurrent interview and record review on 8/27/24 at 1:30 p.m. with WN, the hospitals "Multiple Patient Task List - Wound Care (MPLWC)" dated 7/19/24 was reviewed. The MPLWC indicated, 54 patients were on the list to be seen for wound care and 32 patients were overdue for their wound care consultations. WN stated the MPLWC identified which patients had wound care consultant orders and through this list the WN prioritized which order patients would be seen.

During a review of the Hospital's procedure titled, "Wound Care RN Consult Priority Workflow" dated 7/19/24, the WCWF indicated, "1. Orders received for a wound consult. 2. Patients are auto placed on multi-task list. 3. Wound consults are reviewed on the Wound team's multi-task list 4. Depending on priority selected on the wound consult order, the wound care RN will respond to wound consult orders in the following order: a. ASAP orders b. Pending discharge/Pressure injuries c. Urgent/Emergent phone calls/messages received d. Oldest consult date on multi-task list e. Requests while rounding on floors. 5. Wound Care RNs will attempt to consult on patients within 1-5 business days depending on the priority established in # 4."

During a review of the hospital's policy and procedure (P&P) titled, "Wound: Prevention & Treatment of Wounds," dated 4/05/24, the P&P indicated, "I. All patients are screened by a Licensed Nurse to determine the risk potential for pressure injury development and/or the presence of an existing pressure injury(s) and/or wound(s)."

The facility failed to meet the regulatory requirements for the Condition of Participation: CFR §482.51 Surgical Services as evidenced by:

1. Based on interview and record review, the Hospital failed to follow their policy and procedure, "Surgical/Procedural Site Verification [a pause before a procedure to confirm the correct patient, procedure, and site]," for one of 32 sampled patients (Patient 32) when the signed informed consent (IC - process for health care provider to educate patient about the risks, benefits, and alternatives of a procedure) did not match the procedure performed. (Refer to A-0951)

This failure resulted in Patient 32's wrong site surgical procedure and had the potential for development of infection due to untreated abscesses (pockets of pus in tissues).

2. Based on interview and record review, the Hospital failed to ensure the correct informed consent (process for health care providers to educate patient about the risks, benefits, and alternatives of the planned procedure) was obtained for one of 32 sampled patients (Patient 32)'s prior to surgical procedure. (Refer to A-0955)

This failure resulted in Patient 32 being unable to make informed medical decisions regarding the surgical procedure.

The cumulative effect of these systemic problems resulted in the hospitals inability to ensure safe quality health care, in compliance with Conditions of Participation for Surgical Services.

Based on interview and record review, the Hospital failed to follow their policy and procedure, "Surgical/Procedural Site Verification [TO - a pause before a procedure to confirm the correct patient, procedure, and site]," for one of 32 sampled patients (Patient 32) when the signed informed consent (IC - process for health care provider to educate patient about the risks, benefits, and alternatives of a procedure) did not match the procedure performed.

This failure resulted in Patient 32's wrong site surgical procedure and had the potential for development of infection due to untreated abscesses (pockets of pus in tissues).

Findings:

During a concurrent interview and record review on 8/28/24 at 11:32 a.m. with Surgeon, Patient 32's "Surgical Progress Note" (SPN), dated 8/22/24 was reviewed. The SPN indicated Patient 32's computed tomography (CT - special x-ray that produces 3D images) of abdomen and pelvis showed fluid in abdominal wall. Surgeon stated there were two suspected abscesses (pocket of pus in tissues or spaces inside the body), one in the left abdominal wall and one in the pelvis. Surgeon stated after reviewing the CT results, the surgical team decided to prioritize treatment of the left abdominal wall abscess. Surgeon stated she placed an order for a left abdominal wall abscess CT guided drain placement to be performed by an interventional radiologist (IR - a doctor who performs minimally invasive procedures guided by x-ray imaging).

During a review of Patient 32's "Order Information" (OI), dated 8/22/24 at 5:46 a.m. the OI indicated Surgeon placed an order for "stat [now] CT Percutaneous [through the skin] Drain of left abdominal wall abscess."

During a concurrent interview and record review on 8/28/24 at 11:49 a.m. with Registered Nurse (RN) 1, Patient 32's "Informed Consent for Surgical, Diagnostic or Therapeutic Procedure" (IC) was reviewed. The IC indicated the procedure to be performed was "Imagining [sic] Guided Percutaneous Left abdominal wall abscess drain placement with procedural sedation [medications given to relax and calm the patient]." The IC indicated Patient 32 signed the IC on 8/22/24. RN 1 witnessed Patient 32's signature and signed the IC on 8/22/24. IR 1 signed Patient 32's IC on 8/22/24. RN 1 stated she created the IC form based on the order that was placed by the Surgeon. RN stated IR 1 did not inform her of any changes to the ordered procedure.

During a concurrent interview and record review on 8/28/24 at 11:49 a.m. with RN 1, Patient 32's "Preprocedure Time-Out Universal Protocol" (PTO), dated 8/22/24 at 12:15 p.m., was reviewed. The PTO indicated IR 1, RN 1, RN 2 and Certified Radiological Technologist (CRT) were present for the procedure time out. The PTO indicated:
"Procedure Category Other: Abdominal drain"
"Full Procedure Team Present for Timeout Yes"
"Correct Patient Name and Date of Birth Yes"
"Spoken Procedure Matches Written Cons [Consent] ... Yes"
"Procedure SIDE Verified Yes"
"Procedure SITE Verified Yes"
"Procedure Site Marked & Visible PostDrape [after surgical field is prepared] Yes"
"Relevant documentation reviewed Yes"
"Proc. [procedure] Consent accurate/complete/Signed Yes"
"Correct Patient Position Yes"
"Diagnostic or radiology studies reviewed Yes"
"All members involved in the proc [procedure] agree Yes"
"Procedure Comments Site marked, draped and cleansed"
RN 1 stated she read the procedure from the order (CT Percutaneous Drain Left Abdominal Wall Abscess). RN 1 stated IR 1 was present during the TO but was preparing for the procedure and not giving his full attention during the TO.

During an interview on 8/28/24 at 2:58 p.m. with CRT, CRT stated he recalled the TO during Patient 32's procedure was read as "left abdominal wall mass" thought it was odd, but did not think he (CRT) needed to clarify.

During a concurrent interview and record review on 8/29/24 at 1:30 p.m. with IR 1, Patient 32's "CT Percutaneous Drain Exam Report" (CTER) was reviewed. The CTER indicated reason for exam was "left abdominal wall abscess . . . Impression: Successful CT guided right transgluteal [buttock] approach perirectal [tissue around the buttocks] abscess drainage catheter placement . . ." signed by IR 1 on 8/22/24. IR 1 stated after he reviewed Patient 32's CT results, IR 1 decided Patient 32's pelvic abscess was of more concern. IR 1 stated he did not contact the ordering surgeon to discuss the change in planned procedure and did not place a new order for the perirectal drain placement. IR 1 stated he did not review the IC form prior to signing. IR 1 stated he did not notify RN 1 of change to Patient 32's planned procedure (from left abdominal wall abscess drain placement to perirectal abscess drain placement)

During an interview on 8/28/24 at 12:10 p.m. with Imaging Services Manager (ISM), ISM stated during the TO process, the procedure should be read from the IC form signed by the patient and the physician performing the procedure. ISM stated any member of the team should stop and ask questions when something does not seem right. ISM stated she had observed the TO process and there were opportunities for improvement. Team members should be "present", use actively listening, and communicate during procedure time outs.

During a review of the hospital's policy and procedure (P&P) titled, "Surgical/Procedural Site Verification (Universal Protocol)" dated 1/10/20, the P&P indicated, "Procedure: . . . IV. Conduct final "Time Out" verification immediately before starting the procedure. A. . . Note: this includes at a minimum; a review of the patient (using two identifiers), signed informed consent, verifying the correct procedure(s), laterality [right or left], and site(s). . . C. Interactive verbal communication between all team members includes a verbal statement of "I agree" at the end of the Time Out. If anyone on the team is not in agreement with the information stated during the time out, or if there is a concern or question, the team member must express their concerns without hesitation. D. Any discrepancy is discussed and reconciled prior to starting the intended surgery or procedure. E. During the "Time Out," other activities are suspended and all members of the team are focused on the active verification of the correct patient, procedure, site, and other critical elements. . . All areas within Surgical Services will also include the following elements in the time-out: 1. Reading from a verified, accurate procedure consent form."

2. Based on interview and record review, the Hospital failed to ensure the correct informed consent (process for health care providers to educate patient about the risks, benefits, and alternatives of the planned procedure) was obtained for one of 32 sampled patients (Patient 32)'s prior to surgical procedure.

This failure resulted in Patient 32 being unable to make informed medical decisions regarding the surgical procedure.

Findings:

During a review of Patient 32's "ED [emergency department] Note Physician" (EDNP), dated 8/11/24, the EDNP indicated Patient 32 was brought to the ED after a motor vehicle accident on 8/11/24, where he received an abdominal contusion (bruise due to direct blow or impact).

During a concurrent interview and record review on 8/28/24 at 11:32 a.m. with Surgeon, Patient 32's "Surgical Progress Note" (SPN), dated 8/22/24 was reviewed. The SPN indicated Patient 32's computed tomography (CT - special x-ray that produces 3D images) of abdomen and pelvis showed fluid in abdominal wall. Surgeon stated there were two suspected abscesses (pocket of pus in tissues or spaces inside the body), one in the left abdominal wall and one in the pelvis. Surgeon stated after reviewing the CT results, the surgical team decided to prioritize treatment of the left abdominal wall abscess. Surgeon stated she placed an order for a left abdominal wall abscess CT guided drain placement to be performed by an interventional radiologist (IR - a doctor who performs minimally invasive procedures guided by x-ray imaging).

During a review of Patient 32's "Order Information" (OI), dated 8/22/24 at 5:46 a.m. the OI indicated Surgeon placed an order for "stat [now] CT Percutaneous [through the skin] Drain of left abdominal wall abscess."

During a concurrent interview and record review on 8/28/24 at 11:49 a.m. with Registered Nurse (RN) 1, Patient 32's "Informed Consent for Surgical, Diagnostic or Therapeutic Procedure" (IC) was reviewed. The IC indicated the procedure to be performed was "Imagining [sic] Guided Percutaneous Left abdominal wall abscess drain placement with procedural sedation [medications given to relax and calm the patient]." The IC indicated Patient 32 signed the IC on 8/22/24. RN 1 witnessed Patient 32's signature and signed the IC on 8/22/24. IR 1 signed Patient 32's IC on 8/22/24. RN 1 stated she created the IC form based on the order that was placed by the Surgeon. RN stated IR 1 did not inform her of any changes to the ordered procedure.

During a concurrent interview and record review on 8/29/24 at 1:30 p.m. with IR 1, Patient 32's "CT Percutaneous Drain Exam Report" (CTER) was reviewed. The CTER indicated reason for exam was "left abdominal wall abscess . . . Impression: Successful CT guided right transgluteal [buttock] approach perirectal [tissue around the buttocks] abscess drainage catheter placement . . ." signed by IR 1 on 8/22/24. IR 1 stated after he reviewed Patient 32's CT results, IR 1 decided Patient 32's pelvic abscess was of more concern. IR 1 stated he did not contact the ordering surgeon to discuss the change in planned procedure and did not place a new order for the perirectal drain placement. IR 1 stated he did not review the IC form prior to signing. IR 1 stated he did not notify RN 1 of change to Patient 32's planned procedure (from left abdominal wall abscess drain placement to perirectal abscess drain placement)

During an interview on 8/28/24 at 12:10 p.m. with Imaging Services Manager (ISM), ISM stated the expectation was for IR 1 to discuss the changes made to the procedure with the ordering physician and change the IC to reflect procedure to be performed.

During an interview on 8/29/24 at 1:00 p.m. with IR 2, IR 2 stated the expectation was for IR 1 to contact the ordering physician and discuss the proposed changes to the procedure, have the ordering physician change the order and obtain a new IC form for the planned procedure.

During a review of the hospital's policy and procedure (P&P) titled, "Informed Consent for Surgical, Diagnostic, or Therapeutic Procedure," dated 11/23/21, the P&P indicated "Policy: . . . 3. It is the provider's responsibility to obtain informed consent and to document this consent in the patient's hospital medical record before the provider is permitted to perform any procedure that requires consent. 4. The hospital's role in the consent process is to verify the patient's informed consent was obtained by the provider before the provider is permitted to perform the procedure. . . Procedure: . . . 2. The provider is responsible to document that this discussion occurred by signing the "Informed Consent for Surgical, Diagnostics or Therapeutic Procedure" (Informed Consent form) form prior to the procedure. 3. The hospital's role is to verify that the informed consent discussion occurred.