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Based on interview and record review, the facility failed to follow their established policy to ensure physician consultation and supervision was documented in the medical records for 3 (#s 3, 11, and 14) of 3 sampled patients who were admitted by a mid-level provider. Findings include:

Review of the facility's policy titled, "Mid-level Supervision in CAH," dated 4/4/11, showed the following:

- "... 2.1.1 Consultation by phone or in person with the supervising physician ([Facility Name] on-staff attending physician or clinical consultant ...) for patients requiring such supervision in the Emergency Department and all hospital admissions ..., and
- 2.1.3 The hospital/emergency department records of the mid-level practitioner will reflect in writing in the hospital chart that consultation with the attending physician ... has occurred."

Review of patient #3's medical record, dated 8/6/23, showed the patient was cared for and admitted by a mid-level provider, and failed to show any documentation of attending physician consultation.

Review of patient #11's medical record, dated 4/23/23, showed the patient was cared for and admitted by a mid-level provider, and failed to show any documentation of attending physician consultation.

Review of patient #14's medical record, dated 7/30/22, showed the patient was cared for and admitted by a mid-level provider, and failed to show any documentation of attending physician consultation.

During an interview on 8/16/23 at 3:43 p.m., staff member P stated he was notified verbally of any admissions to the CAH by mid-level providers. Staff member P stated he did not co-sign the history and physical examination performed by a mid-level provider, but reviewed each of their medical charts during the peer review process. Staff member P stated the peer reviews were documented on a separate form which was not a part of the medical chart.

Based on interview and record review, the facility failed to ensure when a mid-level provider admitted a patient to the CAH, a physician was notified for 2 (#s 3 and 14) of 2 sampled patients. Findings include:

Review of the facility's policy titled, "Mid-level Supervision in CAH," dated 4/4/11, showed physician supervision consisted of consultation by phone or in person with the supervising physician for all hospital admissions.

Review of patient #3's acute CAH admission record, dated from 8/6/23 to 8/9/23, failed to show an MD or DO was notified when the patient was admitted to the hospital by a mid-level provider.

Review of patient #14's EHR, dated from 7/30/23 to 8/3/23, failed to show an MD or DO was notified when the patient was admitted to the hospital by a mid-level provider.

During an interview on 8/16/23 at 3:43 p.m., staff member P stated he was notified verbally of any admissions to the CAH by mid-level providers. Staff member P stated he did not co-sign the history and physical examination performed by a mid-level provider, but reviewed each of their medical charts during the peer review process. Staff member P stated the peer reviews were documented on a separate form which was not a part of the medical chart.

During an interview on 8/17/23 at 9:33 a.m., staff member Q stated the mid-level providers either told the supervising physician verbally or via text message when they (the mid-level providers) admitted someone to the hospital. Staff member Q stated he did not document the notification in the patient's medical record.

Based on observation, interview, and record review, the facility failed to follow their established policy for security of medications stored in the emergency department for 1 (#21) of 1 sampled emergency room patient. Findings include:

Review of the facility's policy titled, "Storage and Security of Medications," dated 7/2/23, showed, "The Emergency Department medications storage areas shall be behind a locked cabinet or door at all times." The policy also showed the RN and LPN on duty were authorized to carry the keys to the medication cabinet in the emergency department and were not to transfer possession of the keys to anyone other than another nurse on duty or the DON.

During an observation in the emergency department on 8/16/23 at 11:45 a.m., the medication cabinet was unlocked, and the doors were wide open. A covered plastic tray which contained a variety of medication vials was on the counter below the open medication cabinet. Patient #21 was lying on a gurney in an area adjacent to the medication cabinet. Staff member J left the emergency department while the medication cabinet remained open and unlocked. No other facility staff were present in the emergency department.

During an interview on 8/16/23 at 1:00 p.m., staff member K stated the facility expected the medication cabinet in the emergency department to be locked when an authorized staff member was not present to ensure security. Staff member K stated when staff member J left the emergency department with the medication cabinet doors open and unlocked, the medications were unsecured.

Based on observation, interview, and record review, the facility failed to develop and implement policies and procedures to include identifying hazardous radiation areas; and failed to ensure clear signage was posted on the entrance to the radiology department, identifying a hazardous radiation area. This deficient practice had the potential to affect all patients and staff utilizing the radiation services. Findings include:

A review of the facility's policy and procedure titled, "Radiation protection 3," last reviewed 7/7/23, showed,

- "Purpose: To establish policy, and procedure for the protection of employees, and patient.
- Policy: [Facility] will follow policy and procedures that are established to minimize the exposure of patient and technologist to radiation. ..." [sic]
- The policy and procedure did not address signage to be posted, identifying hazardous radiation areas.

During an observation on 8/15/23 at 10:27 a.m., the entrance door to the radiology department had a sign, turned toward the door, which showed, "In use." An "X-ray in use" sign, with the capability of being illuminated, was on the wall, positioned above the upper left corner of the door frame. No signage had been posted on the entrance door identifying a hazardous radiation area.

During an interview on 8/16/23 at 9:30 a.m., staff member G stated he was unaware signage identifying a hazardous radiation area was to be posted on the door of the radiology department. Staff member G stated the signage documentation would be added to the radiology policy and procedure.

Based on observation, interview, and record review, the facility failed to ensure staff member C followed the facility's established policies and procedures during the administration of insulin for 1 (#18); failed to display professional standards of practice related to the safe handling of used needles; failed to follow the facility's established policies and procedures and physician's orders for the timely administration of medications for 2 (#s 9 and 18); failed to ensure staff member K displayed professional standards of practice related to the transfusion of blood products for 1 (#22); and failed to ensure staff member J followed the facility's established policy related to the security of medications in the emergency department for 1 (#14) of 22 sampled patients. Findings include:

1. Administration of insulin

Review of the facility's policy and procedure titled, Nursing Procedures Standard of Care, last revised 7/8/23, and best practice from Lippincott Nursing Procedures showed:

- "Purpose: [Facility] Licensed Nursing staff need to know and follow best practice recommendations for stand of care for nursing services/procedures performed. This Policy and Procedure will outline that standard of care to be followed.
- Policy Nursing staff at [Facility] will follow Lippincott Nursing Procedures book for all nursing procedures performed. For example: catheter care, IV insertion and care, checking blood sugars, administering insulin ..., and
- ...disinfect the vial's rubber stopper with an antiseptic pad using friction, and then allow it to dry. ..." [sic]

During an observation on 8/15/23 at 11:20 a.m., staff member C was preparing to give patient #18 his 11:00 a.m. Humalog injection. While in the medication room, staff member C removed patient #18's Humalog insulin pen from the refrigerator, placed an unused needle onto the pen, and dialed the pen to 12 units of insulin, per the physician's order. Staff member C failed to clean the insulin pen prior to attaching the needle and failed to prime the insulin pen with 2 units of insulin, to clear any air from the pen/needle prior to the administration of the insulin.

During an interview on 8/15/23 at 11:25 a.m., staff member C stated she was supposed to prime the insulin pen with 2 units of insulin before dialing the pen to the correct dose. She stated she usually primed the insulin pen. Staff member C stated she was unsure of cleaning an insulin pen prior to attaching a new needle to the pen.

2. Safe handling of used needles

Review of the facility's policy and procedure titled, Nursing Procedures Standard of Care, last revised 7/8/23, and best practice from Lippincott Nursing Procedures showed, "...Handle used needles and other sharp instruments carefully. Don't bend or break them, reinsert them into their original sheaths..." [sic]

During an observation on 8/15/23 at 11:24 a.m., staff member C had administered patient #18's dose of Humalog insulin. After the administration of the insulin, staff member C re-capped the used needle by placing the original needle sheath back onto the insulin pen needle.

During an interview on 8/15/23 at 11:25 a.m., staff member C stated she re-capped the used needle and did not dispose of the needle into the sharps container in patient #18's room. Staff member C stated she did not want to carry the insulin pen down the hallway, back into the medication room, without the needle attached. She stated this would expose the end of the insulin pen to "dirty" air in the hallway.

3. Timely administration of medication

Review of the facility's policy and procedure titled, Administration of Medication, last revised 7/2/23, showed:

- "Purpose Guidelines have been established to assure that medication administration is done safely and with optimal efficiency.
- ...3.3 Medication administration is done by licensed nurses only and under the five rights of medication administration.
- ...3.8 Appropriate medication administration schedules are observed. Acute and skilled patients have medications given within thirty minutes before or after the scheduled time. Swing bed patients will have medications given within one hour before or after the scheduled time. ..."

a. During an observation on 8/16/23 at 8:42 a.m., staff member C prepared medications for administration to patient #9. One of the medications prepared for patient #9 was levothyroxine sodium 175 mcg. The label on the medication bubble pack showed one tab was to be given by mouth, every day, "on an empty stomach."

During an observation on 8/16/23 at 8:46 a.m., staff member C approached patient #9's dining room table to administer his medications. Patient #9 was eating his breakfast when the levothyroxine sodium 175 mcg, metformin 1,000 mg, sertraline 200 mg, magnesium oxide 400 mg, and aspirin-dipyridamole extended release 25 mg-200 mg were administered.

The correct time for the administration of medications for patient #9, listed in the electronic health record, showed 7:00 a.m. Patient #9's levothyroxine sodium 175 mcg was given while eating and not on an empty stomach.

b. During an observation on 8/16/23 at 9:00 a.m., patient #18 was administered the following 7:00 a.m. medications:

- olanzapine 10 mg,
- gabapentin 600 mg,
- meloxicam 15 mg,
- lisinopril 40 mg,
- hydrochlorothiazide 25 mg,
- duloxetine 60 mg,
- finasteride 5 mg,
- amlodipine 5 mg,
- metformin 1,000 mg,
- carvedilol 25 mg,
- acetaminophen 1,000 mg,
- docusate/senna 50 mg-8.6 mg, and
- polyethylene glycol 17 gm.

During an interview on 8/16/23 at 9:00 a.m., staff member C stated she was unsure of the policy and procedure for the timely administration of medications, "I just know I'm late."

During an interview on 8/16/23 at 2:00 p.m., staff member B stated it was the expectations of nurses to clean an insulin pen with an alcohol wipe prior to attaching the needle and then priming the insulin pen. Staff member B stated it was not best practice to re-cap a used needle.

During an interview on 8/17/23 at 8:42 a.m., staff member B stated a new traveling nurse's orientation timeframe depended on their nursing roll and length of time (prn vs. 13-week full time). She stated the goal was to have a specific binder for orientation of travelers.

During an interview on 8/17/23 at 8:47 a.m., staff member B stated the facility did not have an official skills checklist for travelers.


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4. Transfusion of blood products

Review of the facility's policy titled, Administration of Blood, dated 7/11/23, showed a second verification check between the RN performing the transfusion and another RN or LPN. The purpose of the check was to verify the blood to be transfused was being given to the correct patient.

Review of patient #22's Blood Bank Report, dated 4/18/23, showed the Infusion section of the form was blank except for the signature of staff member B. The areas left blank were the patient blood band #, the unit blood band #, the donor unit #, the expiration date on the blood product, the unit ABO and RH type, the patient name on the unit, the patient name on the hospital band, the patient ABO and RH type, and the signature of the first RN were blank. Results of the visual inspection of the appearance of the bag and the blood product were also blank.

During an interview on 8/16/23 at 1:04 p.m., staff member K stated she was the nurse who administered the blood transfusion to patient #22. Staff member K stated she did confirm the information from the Blood Bank Report which was left blank. Staff member K stated she did not complete the form because the information was already present in another area on the form, and she felt it was unnecessary. When asked, staff member K stated she was aware the facility's policy was to complete all parts of the Blood Bank Report form when transfusing blood products to patients.

5. Security of medications in the emergency department

Review of the facility's policy titled, Storage and Security of Medications, dated 7/2/23, showed, "The Emergency Department medications storage areas shall be behind a locked cabinet or door at all times." The policy also showed the RN and LPN on duty were authorized to carry the keys to the medication cabinet in the Emergency Department and were not to transfer possession of the keys to anyone other than another nurse on duty or the DON.

During an observation in the emergency department on 8/16/23 at 11:45 a.m., the medication cabinet was unlocked, and the doors were wide open. A covered plastic tray which contained a variety of medication vials was on the counter below the open medication cabinet. Patient #21 was lying on a gurney in an area adjacent to the medication cabinet. Staff member J left the emergency department while the medication cabinet remained open and unlocked. No other facility staff were present in the emergency department during the time staff member J was gone from the area.

During an interview on 8/16/23 at 1:00 p.m., staff member K stated the facility expected the medication cabinet in the emergency department to be locked when an authorized staff member was not present to ensure security. Staff member K stated when staff member J left the emergency department with the medication cabinet doors open and unlocked, the medications were unsecured.

Based on observation, interview, and record review, staff member C failed to follow standard infection control practices related to hand hygiene for 1 (#18) of 22 sampled patients. Findings include:

Review of the facility's policy and procedure titled, Nursing Procedures Standard of Care, last revised 7/8/23, and best practice from Lippincott Nursing Procedures showed:

- "Purpose: [Facility] Licensed Nursing staff need to know and follow best practice recommendations for stand of care for nursing services/procedures performed. This Policy and Procedure will outline that standard of care to be followed.
- ...Perform hand hygiene before and after patient care and before and after putting on and removing gloves. ..." [sic]

During an observation on 8/15/23 at 11:24 a.m., staff member C knocked on patient #18's room door and entered. Staff member C was in patient #18's room to give him his 11:00 a.m. dose of Humalog 12 units. Staff member C donned gloves, administered patient #18's insulin, doffed her gloves, then sanitized her hands. Staff member C did not sanitize her hands before she entered patient #18's room or before she donned the gloves to perform insulin administration.

During an interview on 8/15/23 at 11:30 a.m., staff member C stated she did not sanitize her hands before entering patient #18's room or before she donned gloves. She stated she should have performed these tasks.

During an interview on 8/16/23 at 2:00 p.m., staff member B stated hand hygiene should be performed before entering and after exiting a patient's room, before donning gloves, and after doffing gloves.