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

1. The facility failed to ensure the timely completion of one of 31 sampled patient's (Patient 10) Condition of Admission (COA, a contract that outlines the patient's obligations to the hospital, such as paying for services, providing informed consent (A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment), and understanding the hospital's arrangements) form, in accordance with the facility's policy and procedure regarding "Condition of Admission."

This deficient practice had the potential for Patient 10 and/or Patient 10's designated representative not being able to fully understand and exercise their rights as patient, which may lead to Patient 10's and/or Patient 10's designated representative's inability to effectively make decisions regarding own care and treatment in the facility. (Refer to A-0117)

2. The facility failed to ensure one of 31 sampled patients (Patient 13) was involved in the development and implementation of his (Patient 13) plan of care (a structured document that outlines the actions and interventions needed to address a patient's health or personal care needs) to ensure that Patient 13 received adequate pain management during repositioning (moving a patient into a different position to redistribute pressure from a particular part of the body) activities, in accordance with the facility's "Pain Management" and "Interdisciplinary Plan of Care" policy and procedure.

This deficient practice caused Patient 13 to feel unnecessary pain during routine repositioning and had the potential to increase anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), sensitivity to pain, and mistrust in caregivers. This deficient practice also had the potential for untreated pain that could worsen Patient 13's existing conditions, slow recovery, hinder mobility (the ability to move freely), and worsen bedsores (also known as pressure ulcers, are areas of skin damage that develop when pressure is applied to the same area of the body for an extended period) and reduced quality of life. (Refer to A-0130)

3. The facility failed to ensure its staff verified that the informed consent process (a process in which a health care providers educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) was completed for one of 31 sampled patients (Patient 3), in accordance with the facility's policy and procedure regarding informed consent prior to a surgical procedure (Incision and Drainage [I&D, a minor surgical procedure that releases pus or pressure that builds up under the skin]), when there was no informed consent form obtained and signed by Patient 3 for a bedside procedure performed on 12/16/2024.

This deficient practice had the potential to result in the physician not providing necessary information including the risks and benefits of a surgical procedure to Patient 3 and allows Patient 3 to make the informed decision. (Refer to A-0131)

4. The facility failed to provide physical privacy for one of 31 sampled patients (Patient 4) in accordance with the facility's policy and procedure regarding patient's rights, when the facility did not provide a privacy curtain in Patient 4's room.

This deficient practice resulted in Patient 4's privacy rights not being respected as people could see Patient 4's activities such as dressing, receiving medical treatment and nursing treatments. (Refer to A-0143)

5. The facility failed to ensure patient safety when the facility did not document a patient's adverse drug reaction (unintended, harmful events attributed to the use of medicines) to the medication Ativan (a benzodiazepine, commonly prescribed for anxiety [characterized by excessive fear, worry, and nervousness] and sedation [a state of drowsiness and relaxation]) for one of 31 sampled patients (Patient 27) during their (Patient 27's) first admission at the facility on December 2020, in accordance with the facility's policy and procedure regarding "Adverse Drug Reactions."

This deficient practice in documentation resulted in Patient 27 receiving Ativan again during a subsequent admission in December 2023. Consequently, Patient 27 experienced another negative adverse drug event associated with Ativan, including excessive sedation, further compromising Patient 27's health and recovery. (Refer to A-0144)

6. The facility failed to ensure one of 31 sampled patients (Patient 5), had proper documentation regarding the use of four siderails or evidence indicating that Patient 5 specifically requested all four side rails to be raised while in bed. There was also no physician order indicating the use of all four siderails.

This deficient practice had the potential to restrict Patient 5's freedom of movement and increase the risk of injury or harm due to potential entrapment, entanglement, or falls from a greater height should Patient 5 attempt to exit the bed. (Refer to A-0161)

7. The facility failed to ensure nursing staff obtained a physician order (orders written by physicians to direct care and treatment) for restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body), in a timely manner, for one of 31 sampled patients (Patient 7), in accordance with the facility's policy and procedure regarding restraints, when four (4) side rails were raised to prevent Patient 7 from getting out of bed.

This deficient practice had the potential for increased risk of injury or harm due to potential entrapment, entanglement, or falls from a greater height should Patient 7 attempt to exit the bed. (Refer to A-0168)

8. The facility failed to ensure nursing staff performed and documented restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) monitoring every two (2) hours for one of 31 sampled patients (Patient 2), in accordance with the facility's policy and procedure regarding restraints, when there was no documented restraints monitoring for eight (8) hours on 12/17/2024 from 6 a.m. to 2 p.m.

This deficient practice had the potential to put Patient 2 at risk for skin breakdown (damage to the skin and underlying tissue, usually caused by prolonged pressure which restricts blood flow to the area) and needs including hydration (the process of ensuring a patient has enough fluids in their body by drinking water and consuming foods with high water content) not being met while under restraints. (Refer to A-0175)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment, potentially placing patients at risk for a delay in care and treatment, injury, and/or death.

Based on interview, and record review, the facility failed to ensure the timely completion of one of 31 sampled patient's (Patient 10) Condition of Admission (COA, a contract that outlines the patient's obligations to the hospital, such as paying for services, providing informed consent [A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment], and understanding the hospital's arrangements) form, in accordance with the facility's policy and procedure regarding "Condition of Admission."

This deficient practice had the potential for Patient 10 and/or Patient 10's designated representative not being able to fully understand and exercise their rights as patient, which may lead to Patient 10's and/or Patient 10's designated representative's inability to effectively make decisions regarding own care and treatment in the facility.

Findings:

During a review of Patient 10's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 12/15/2024, the H&P indicated Patient 10 was admitted on 12/15/2024 for Acute Respiratory Failure (inadequate gas exchange in the lungs) and septic shock (a life-threatening medical condition where a severe infection causes a dangerously low blood pressure, leading to potential organ failure and requiring immediate medical attention).

During a review of Patient 10's Social Worker Notes, dated 12/15/2024, the notes indicated that Patient 10 had a Power of Attorney (a legal document that gives someone the authority to act on the patient's behalf).

During an interview on 12/16/2024 at 3:00 p.m. with Patient 10's designated representative, Patient 10's representative confirmed that she (Patient 10's designated representative) had not signed Patient 10's Condition of Admission (COA, a contract that outlines the patient's obligations to the hospital, such as paying for services, providing informed consent [A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment], and understanding the hospital's arrangements).

During a concurrent interview and record review on 12/20/2024 at 12:15 p.m. with the Manager for Quality and Training Patient Access (MQTP), MQTP stated he (MQTP) reviewed Patient 10's medical record and did not see a documentation regarding attempts to contact Patient 10's representative or designated family member regarding completion of the COA when Patient 10 was admitted on 12/15/2024.

During the same interview on 12/20/2024 at 12:15 p.m. with the Manager for Quality and Training Patient Access (MQTP), MQTP stated that Patient 10's representative's contact information was in Patient 10's record on admission since Patient 10 came from a Skilled Nursing Facility (SNF, a place where people can temporarily live and receive medical treatment and rehabilitation after an injury or illness). MQTP said the Patient Access staff should have contacted Patient 10's designated representative upon admission on 12/15/2024 regarding the COA. The COA was only completed on 12/19/2024 at 11:55 a.m.

During a review of the facility's policy and procedure (P&P) titled, "Conditions of Admission," effective date 3/20/2021, the P&P indicated the Facility was "committed to informing each patient or appropriate authorized patient representative of the patient's rights and obtain their consent to care and services in the conditions of admission (COA)." The P&P also indicated, "it is the responsibility of the patient access representative (PAR) to communicate with the patient or their representative when appropriate, to obtain an authorized consent evidenced by the patient signature on the condition of admission form."

Based on observation, interview, and record review, the facility failed to ensure one of 31 sampled patients (Patient 13) was involved in the development and implementation of his (Patient 13) plan of care (a structured document that outlines the actions and interventions needed to address a patient's health or personal care needs) to ensure that Patient 13 received adequate pain management during repositioning (moving a patient into a different position to redistribute pressure from a particular part of the body) activities, in accordance with the facility's "Pain Management" and "Interdisciplinary Plan of Care" policy and procedure.

This deficient practice caused Patient 13 to feel unnecessary pain during routine repositioning and had the potential to increase anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), sensitivity to pain, and mistrust in caregivers. This deficient practice also had the potential for untreated pain that could worsen Patient 13's existing conditions, slows recovery, hinders mobility (the ability to move freely), and worsens bedsores (also known as pressure ulcers, are areas of skin damage that develop when pressure is applied to the same area of the body for an extended period) and reduced quality of life.

Findings:

During a review of Patient 13's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 12/7/2024, the "H&P" indicated Patient 13 had "past medical history of alcoholism (a chronic disease in which a person craves drinks that contain alcohol and is unable to control his or her drinking) and bedbound state (when someone is unable to get out of bed independently, requiring assistance to move around or change positions) who presents to the Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries) for evaluation of back pain ... He (Patient 13) reports pain localized to his back and reports a history of sciatica (pain that radiates into one or both legs)." The H&P further indicated Patient 13 had osteomyelitis (an infection in a bone) with extensive cellulitis (a deep infection of the skin caused by bacteria) to the back, limbs, and right heel with visible bone exposure.

During an observation on 12/16/2024 at 3:41p.m., at the entrance hallway to 4 East (surgical unit, an area in the hospital where patients are cared for and treated before or after the surgery), screaming was heard from room ABC (Patient 13's room). Inside, two staff members (Certified Nursing Attendant [CNA], an entry-level role that provides vital support to both patients and nurses) 1 and Registered Nurse [RN], nurse who has graduated from a college's nursing program or from a school of nursing and has passed a national licensing exam) 4 were repositioning (moving a patient into a different position to redistribute pressure from a particular part of the body) Patient 13, who continued to scream during the procedure.

During an interview on 12/16/2024 at 3:50 p.m., Patient 13 stated, "I have pain in both legs when they move me." Patient 13 reported pain levels of 8/10 (on a scale of 0-10, with 0 representing no pain and 10 being the worst pain) to the legs and back during repositioning and cleaning.

During an interview on 12/16/2024 at 3:45 p.m. with Registered Nurse (RN) 8 outside the corridor of Patient 13's room, RN 8 stated that Patient 13 screamed each time staff repositioned Patient 13 due to pain. RN 8 indicated that Norco (a prescribed medication, a combination of hydrocodone [a drug used to treat moderate to severe pain] and acetaminophen [a drug used to relieve mild or chronic pain and to reduce fever] for pain relief) was administered five hours prior. RN 8 confirmed that since the medication for pain (Norco) was administered five hours ago, it (Norco) will not relieve Patient 13's pain during repositioning. RN 8 further stated that repositioning should have been paused when Patient 13 exhibited signs of pain. RN 8 stated Patient 13 may be aware of the pain medication ordered for him, but RN 8 confirmed that intervention for pain management was not discussed with Patient 13.

During a concurrent interview and record review on 12/16/2024 at 4:00 p.m. with the Nurse Manager (NM) 3, Patient 13's Electronic Medical Record (EMR, a digital version of the paper charts in hospitals) titled, "Medication Administration Report (MAR, a report detailing the drugs administered to a patient)," dated 12/8/2024 through 12/16/2024, was reviewed. NM 3 confirmed that Patient 13 had orders for pain medication as follows:

-Norco 10/325 mg (milliliters, a unit of measurement). one tablet every six hours as needed for severe pain (7-10).
-Tylenol 650 mg. tablet as needed for any pain level greater than zero when the patient refused other analgesics (also called painkillers, are medications that relieve different types of pain).

During the same interview on 12/16/2024 at 4:00 p.m. with the Nurse Manager (NM) 3, NM 3 stated that RN 8 administered one dose of the Norco 10/325 mg on 12/16/2024 at 10:02 a.m. (5 hours and 58 minutes) prior to repositioning Patient 13. NM 3 stated giving pain medication more than five hours before repositioning Patient 13 was not an adequate pain management. NM 3 stated that pain management should also align with patient-reported pain level. NM 3 stated, "Pain is what the patient says the pain is." NM 3 further stated it was important to follow prescribed orders, and if the prescribed order was not adequate for pain relief, the physician should be consulted for better pain management prior to repositioning Patient 13.

During a concurrent interview and record review on 12/19/2024 at 10:23 a.m. with the charge nurse (CN 1) for the 4 East unit, Patient 13's wound photos in the "Emergency Department Provider Notes," documented by MD 5, dated 12/7/2024, were reviewed. The ED provider notes of Patient 13's wounds with photos were as follows:

- A photo of the left foot and ankle showing denuded skin (a condition that results from the removal of the skin's surface layers), reddened skin, and an open wound at the heel with bone exposure. The photo was labeled: Multiple wounds of the left lower extremity as well as the right heel.

- A photo of the left hip and left back was labeled: Patient has raised erythematous (redness of the skin) rash on the left back.

During the same interview on 12/19/2024 at 10:23 a.m. with Charge Nurse (CN) 1, CN 1 confirmed that Patient 13 also had a pressure injury (a localized damage to the skin and underlying soft tissue) to the sacral region (region at the bottom of the spine that lies between the spine and tailbone) that required turning and repositioning to provide wound care and application of medication twice a day. CN 1 stated Patient 13 must be repositioned and turned every two hours to prevent worsening of the wound. CN 1 stated the physician should be called to advocate for the patient (Patient 13) to have IV (medication administered directly into the vein) pain medication to effectively relieve pain as the patient (Patient 13) required repositioning every two hours.

During an interview on 12/20/2024 at 10:40 p.m. with Medical Doctor (MD) 4, MD 4 stated that because the patient had multiple wounds and experienced pain during repositioning, nursing staff should assess the patient's level of pain and preferences for pain relief and make the provider aware so IV medication for pain could be ordered, as IV medication can provide faster pain relief. MD 4 also confirmed that IV pain medication was appropriate for Patient 13.

During a review of the facility's policy and procedure (P&P) titled, "Interdisciplinary Plan of Care (IPOC)," dated September 2020, the P&P indicated, "Ensure that the nursing staff develops, and keeps current, a nursing plan of care for each patient. The nursing plan of care is part of the interdisciplinary plan of care (lPOC). Each patient will receive care based on an individualized lPOC in collaboration with the interdisciplinary team. Ensure the patient's (or patient's representatives) right to participate in the development and implementation of his or her plan of care, inpatient treatment/care plan, outpatient treatment/care plan, and/or discharge plan. Aspects of patient care, such as, teaching, interventions, referrals, discharge planning, follow-up, changes in plan, etc. are linked with the interdisciplinary plan of care. Planning care includes planning the patient's care while in the hospital as well as planning for discharge to meet post-hospital needs. A nursing IPOC is developed based on assessing the patient's needs upon admission from all available sources of assessment to develop a comprehensive picture of the patients' condition (not solely those needs related to the admitting diagnosis) and develop-appropriate nursing interventions in response to those needs. Those sources may include: The Patient, the Patient's family, other patient caregivers as applicable ..."

During a review of the facility's policy and procedure (P&P) titled, "Pain Management," dated November 2022, the P&P indicated, "Pain is highly individual and variable and is one of the most feared aspects of illness, and one of the most common reasons for seeking healthcare interventions. The purpose of this policy is to provide guidelines for a collaborative interdisciplinary approach to pain management. The goals of pain management are:
Relief from physical suffering
Preservation or restoration of function
Sustained quality of life
Prevention of addiction
Pain management is a shared responsibility between the patient, providers, and nursing ... B. Initial and ongoing assessment of pain ...An initial pain assessment is done on admission. It includes: Pain Goal: This is set by the patient as is developmentally appropriate ... Continuing Pain Assessment (after Admission/Arrival Pain Assessment): Shift Assessment, Type of Assessment {Assessment or Post-Intervention Reassessment, Pain Goal (required each shift and pm any changes), Sedation Score (required), Location (required each shift and pm any change), Pain Rating (required) ..."

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights," dated November 2023, the P&P indicated, "To identify each client's rights while under treatment. Each client has all rights given to all citizens unless relieved of these rights by court action. Specifically, staff needs to assist in maintaining the client's rights to confidentiality, privacy, and dignity. Individualized treatment that is appropriate to the client's problems and needs ... Each client receives individualized treatment, including at least the following: ...The provision of an individualized treatment plan. The periodic review of the treatment plan. The active participation of the client and/or conservator in the planning of treatment. The provision of an adequate number of competent, qualified, and experienced professional clinical staff to implement the treatment plan and provide care ..."

During a review of the facility's policy and procedure (P&P) titled, "Hospital Plan for the Provision of Patient Care Services," dated 9/1/2020, the P&P indicated, "Overview of Discipline-Specific Policies for Assessment and Reassessment ... Nursing; Assessment time frame: Demographic, physical assessment, and care planning assessment within 2 hours of admission in critical care areas and 8 hours of admission in non-critical care areas. RN analyzes data/prioritizes care. Re-Assessment Time Frame: Every shift and/or unit-specific, as well as pre- and post-treatment, including diagnosis, pre- & post-treatment, and response to treatments ..."

Based on observation, interview and record review, the facility failed to ensure its staff verified that the informed consent process (a process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention), was completed for one of 31 sampled patients (Patient 3), in accordance with the facility's policy and procedure regarding informed consent prior to a surgical procedure (Incision and Drainage [I&D, a minor surgical procedure that releases pus or pressure that builds up under the skin]), when there was no informed consent form obtained and signed by Patient 3 for a bedside procedure performed on 12/16/2024.

This deficient practice had the potential to result in the physician not providing necessary information including the risks and benefits of a surgical procedure to Patient 3 and allows Patient 3 to make the informed decision.

Findings:

During a concurrent observation and interview on 12/16/2024 at 3:58 p.m. with Registered Nurse (RN) 13 at Patient 3's room, Patient 3 had a dressing covering the right lower leg. RN 13 stated Patient 3 had a bedside procedure earlier.

During a review of Patient 3's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 12/15/2024, the H&P indicated, Patient 3 was admitted to the facility with diagnoses of diabetes (high blood sugar), right lower leg abscess (a pocket of pus formed in any part of the body) with cellulitis (an infection of the deeper layers of skin and the underlying tissue). The H&P also indicated Patient 3 required surgical evaluation for possible debridement (a medical procedure that removed damaged, dead or infected tissue) and drainage (the process of removing fluid from a wound).

During a review of Patent 3's "Incision and Drainage (I&D, a minor surgical procedure that releases pus or pressure that builds up under the skin) Procedure Note (procedure note, operative report completed by a surgeon)," dated 12/16/2024, the procedure note indicated, physician (MD 8) performed right leg necrotizing (dead) soft tissue infection with abscess incision and drainage.

During an interview on 12/18/2024 at 10:28 a.m. with the Process Excellence Specialist (SRN), SRN stated there was no informed consent (a process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) form for the incision and drainage procedure done on 12/16/2024. SRN stated informed consent was required for every surgical procedure.

During an interview on 12/19/2024 at 10:29 a.m. with the Nurse Manager (NM 1) of Surgical Units (a hospital ward where patients are cared and treated before and after surgery) 1 and 2, NM 1 stated informed consent was the process to make sure patient was aware of what procedure he or she was having and understand its risk and benefits. NM 1 said patient was required to sign the informed consent form when he or she was agreeable with the procedure.

During an interview on 12/20/2024 at 8:33 a.m. with the Surgery Residency Program Director (MD 7), MD 7 stated MD 8 should have obtained an informed consent for the bedside incision and drainage procedure done on Patient 3 on 12/16/2024. MD 7 stated the team should make sure Patient 3 signed the informed consent form with the name of the procedure prior to the procedure.

During a review of the facility's policy and procedure (P&P) titled, "Informed Consent," dated 10/2021, the P&P indicated, "the 'Informed Consent' ... the patient's physician is responsible for providing the information the patient needs in order to make an informed decision and for obtaining the patient's informed consent or refusal for the recommended procedure ... the hospital's role in the informed consent process is to verify that the physician obtained the patient's informed consent before the physician is permitted to perform the procedure ... the doctors will provide the procedures to be performed ... so the 'Authorization for and Consent to Surgery, Care, Treatment, Special Diagnostic or Therapeutic Procedures' consent form can be completed ... If the 'Authorization and Consent to Surgery, Care, Treatment, Special Diagnostic or Therapeutic Procedure' consent form has not been completed or the informed consent attestation is not documented in the medical record prior to the procedure, the nurse must contact the physician providing the service to obtain documentation. Non-emergency procedures will be delayed or canceled until the informed consent process had been completed ... Nursing verifies that an executed 'Authorization for and Consent to Surgery, Care, Treatment, Special Diagnostic or Therapeutic Procedures' form is in the record or completes the form using information provided by doctors in his or her orders and has the patient or a surrogate decision-maker sign the form. Any doubt or confusion expressed by the patient regarding the procedure or operation must be immediately referred to the treating physician. The patient will not be asked to sign the form until satisfactory clarification is supplied by the physician."

Based on observation, interview and record review, the facility failed to provide physical privacy to one of 31 sampled patients (Patient 4) in accordance with the facility's policy and procedure of patient's rights when the facility did not provide a privacy curtain to Patient 4's room.

This deficient practice had resulted in Patient 4's privacy rights not being respected as people could see Patient 4's activities such as dressing, receiving medical treatment and nursing treatments.

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 12/11/2024, the H&P indicated, Patient 4 was admitted to the facility with diagnoses of suicide (killing self) attempt and diabetes (high blood sugar).

During a concurrent observation and interview on 12/16/2024 at 4:02 p.m. with Registered Nurse (RN) 13 outside Patient 4's room in Surgical Unit (a hospital ward where patients are cared and treated before and after surgery) 1, the door was closed, and there was a glass window on the door. Through the glass window, Patient 4 was observed sitting in bed holding two pillows. There was a bedside sitter with the door closed. RN 13 stated Patient 4's privacy was not respected because everyone passing by could see through the window to see what Patient 4 was doing. RN 13 also stated the staff should cover the window on the door to give Patient 4 some privacy.

During an interview on 12/16/2024 at 4:10 p.m. with the Nurse Manager (NM 1) of Surgical Unit 1 and 2, NM 1 stated there should be a privacy curtain in Patient 4's room to provide privacy for Patient 4.

During a review of the facility's policy and procedure (P&P) titled, "Patient Non-Discrimination, Rights and Responsibilities," dated 8/2021, the P&P indicated, "You have the right to have your personal privacy respected."

Based on interview and record review, the facility failed to ensure patient safety when the facility did not document a patient's adverse drug reaction (unintended, harmful events attributed to the use of medicines) to the medication Ativan (a benzodiazepine, commonly prescribed for anxiety [characterized by excessive fear, worry, and nervousness] and sedation [a state of drowsiness and relaxation]) for one of 31 sampled patients (Patient 27) during their (Patient 27's) first admission to the facility in December 2020, in accordance with the facility's policy and procedure regarding "Adverse Drug Reactions."

This deficient practice in documentation resulted in Patient 27 receiving Ativan again during a subsequent admission in December 2023. Consequently, Patient 27 experienced another negative adverse drug event associated with Ativan, including excessive sedation, further compromising Patient 27's health and recovery.

Findings:

During a review of Patient 27's History and Physical (H&P, a comprehensive medical document that summarizes a patient's medical history, current symptoms, and physical examination findings upon admission), dated 12/04/2020, the H&P indicated that Patient 27 was admitted due to hypertensive urgency (a medical condition characterized by a severe and sudden increase in blood pressure that requires prompt medical attention to prevent organ damage) and visual hallucinations (visual hallucinations, seeing objects, people, or shapes that are not actually present). The H&P further indicated Patient 27 had a Past Medical History (PMH, a record of a patient's previous health conditions) of possible memory impairment (refers to difficulties in remembering information), white coat hypertension (a phenomenon where a patient's blood pressure readings are elevated in a clinical setting but remain normal in other environments, often due to anxiety experienced during medical visits), and possible depression (a mental health disorder characterized by persistent feelings of sadness, loss of interest in activities, and a range of emotional and physical problems that can affect a person's daily functioning).

During a review of Patient 27's medical record (MR) titled, "History and Physical (H&P)," dated 12/04/2020, the MR indicated that Patient 27 had no known medication allergies documented in the H&P.

During further review of Patient 27's medical record (MR) titled, "Medication Administration Record (MAR, a document that tracks all medications administered to a patient)," dated 12/05/2020, the MR indicated that on 12/05/2020, Patient 27 received 1 milligram (mg, a unit of measurement) of Ativan (lorazepam [Ativan], a medication used to treat anxiety [a feeling of fear and uneasiness) at 6:16 p.m. prior to undergoing a Magnetic Resonance Imaging (MRI, a medical imaging procedure that uses magnetic fields and radio waves to create detailed images of the brain) ordered by a neurologist (neurologist, a medical doctor specializing in the diagnosis and treatment of disorders of the nervous system, including the brain, spinal cord, and nerves) on 12/04/2020 for sedation (induces a state of drowsiness or relaxation) to be administered prior to the procedure.

During further review of Patient 27's medical record (MR) titled, "Nursing Note," dated 12/05/2020, the MR indicated the following:

-At 8:00 p.m. - "Patient (Patient 27) was disoriented, not making sense, and experiencing visual hallucinations (sensing things such as visions, sounds, or smells that seem real but are not). Registered Nurse (RN) expressed to Medical Doctor (MD) that Patient 27 was not safe for discharge. MD agrees to keep Patient 27 overnight."

-At 8:30 p.m. - "It was decided to move patient (Patient 27) closer to the nurses' station for safety ... Patient (Patient 27) got tangled in a cord and fell. This incident was witnessed by an RN who was walking in patient's (Patient 27) room to assist. Patient (Patient 27) was assessed, and no injury was noted. MD and patient's (Patient 27) family were notified."

-At 10:50 p.m. - "Patient (Patient 27) was disoriented, agitated (feeling of restlessness and irritability), wandering the halls, unsteady at times, attempting to enter other patients' rooms, and trying to find the exit ... Patient (Patient 27) was placed on 4-point soft restraints (4-point soft restraints, a type of physical restraint that secures a patient's arms and legs to limit movement). MD was consulted, and an order for restraints was received."

During a review of Patient 27's medical record (MR) titled, "Initial Psychiatric Consultation (an evaluation conducted by a psychiatrist to assess a patient's mental health status), dated 12/06/2020, the MR indicated the following:

-" ...Per the nurse on duty this evening, the patient (Patient 27), post (after)-Ativan for MRI, became more psychotic (a mental state characterized by a loss of contact with reality, including delusions (false beliefs that are firmly held despite clear evidence to the contrary) and hallucinations), experiencing sundowning (a pattern of increased confusion and agitation that occurs in the late afternoon and evening hours), and confused. This condition is slowly resolving; however, in the evening, Patient 27 appears to sundown and become confused ..."

-"Diagnosis of MDD (Major Depressive Disorder, a mood disorder characterized by persistent feelings of sadness and loss of interest), single severe, with psychotic features, with recent delirium (an acutely disturbed state of mind characterized by restlessness, illusions, and incoherence) secondary to Ativan, with 12-24 hours of confusion/agitation/wandering that is now resolved."

During a review of Patient 27's medical record (MR) titled, "Discharge Summary," dated 12/07/2020, the MR indicated that the discharging physician (MD 1) documented that Patient 27 "was agitated by Lexapro (Lexapro, an antidepressant used to treat depression and anxiety disorders) and the Ativan made them (Patient 27) worse."

During a review of Patient 27's History and Physical (H&P), dated 11/30/2023, the H&P indicated that Patient 27 was admitted to the facility on 11/30/2023 (second admission after 12/04/2020) due to a fall (an incident in which a person unintentionally comes to rest on the ground or a lower level) at home and elevated troponin (elevated troponin, an increased level of troponin in the blood indicative of heart muscle injury) with no symptoms. The H&P further indicated that Patient 27 had a Past Medical History (PMH) of Alzheimer's (Alzheimer's, a progressive disease that causes memory loss and cognitive decline), depression, white coat hypertension, and anxiety.

During a review of Patient 27's medical record (MR) titled, "Allergy Review History (a detailed record of a patient's known allergies and adverse reactions to medications), dated 11/30/2023, the MR indicated that on 11/30/2023, an allergy to Xanax (a medication containing alprazolam, used to treat anxiety and panic disorders) with a recorded unspecified reaction (unspecified reaction, an allergic response where the specific symptoms or type of reaction are not documented or unavailable) was documented in Patient 27's electronic medical record (EMR, digital version of paper charting).

During a review of Patient 27's medical record (MR) titled, "Physician's Orders," dated 12/02/2023, the MR indicated that 1 mg of Ativan IV push (Ativan IV push, an intravenous administration of lorazepam given rapidly through a vein to provide immediate relief) was ordered for Patient 27 on 12/02/2023 at 6:36 p.m., to be administered every 12 hours as needed for agitation and anxiety.

During a review of Patient 27's medical record (MR) titled, "Allergy Review History," dated 12/2/2023, the MR indicated that Patient 27's primary nurse reviewed Patient 27's allergy record on 12/2/2023 at 6:35 p.m.

During a review of Patient 27's medical record (MR) titled, "Warning Override History for Lorazepam (Ativan) injection 1 mg," dated 12/02/2023, the MR indicated that on 12/02/2023 at 6:36 p.m., the warning for allergy/contraindication (a condition in which a medication should not be used due to a documented allergy or other medical reason) for administration of Ativan (Ativan, a benzodiazepine medication used to manage anxiety and seizures) due to a documented allergy to alprazolam (Xanax, a benzodiazepine used to treat anxiety and panic disorders) was overridden (bypass a warning) by a primary nurse (Patient 27's nurse) by the order of a physician (MD 1). The MR contained the following comment: "Physician (MD 1) aware [of an allergy/contraindication], Benadryl (an antihistamine medication used to treat allergic reactions and provide sedation) ordered."

During a review of Patient 27's Medical Administration Record (MAR), dated 12/2/2023, the MAR indicated that on 12/2/2023 Patient 27 was administered 1 mg of Ativan at 7:57 p.m.

During a review of Patient 27's medical record (MR) titled, "Physician-Internal Medicine Progress Note," dated 12/03/2023, the MR indicated that the physician (MD 1) documented the following: "[Patient 27] agitated last night, got Ativan, and now over-sedated" (a condition where a patient experiences excessive sedation, potentially causing decreased responsiveness, slowed breathing, and impaired motor function). "Discontinue Ativan."

During a review of Patient 27's medical record (MR) titled, "Physician-Internal Medicine Progress Note," dated 12/04/2023, the MR indicated that the physician (MD 1) documented the following: "[Patient 27] more awake. Nearer at baseline. It's Ativan ..."

During a review of Patient 27's medical record (MR) titled, "Discharge Summary," dated 12/05/2023, the MR indicated the following: Patient (Patient 27) had an allergy to Xanax on the MAR (Medication Administration Record, a document that tracks all medications administered to a patient) but was given a small amount of Ativan due to agitation. The patient was agitated and almost fell out of bed. The agitation caused by benzodiazepines (a class of psychoactive drugs used to treat anxiety, insomnia (difficulty sleeping), seizures (a temporary episode of abnormal electrical activity in the brain that causes physical and mental changes), which can also cause side effects like sedation, confusion, and agitation) is quite severe, leading to confusion, agitation, and almost comatose-like symptoms (a state of deep unconsciousness). No benzodiazepines whatsoever ..."

During an interview on 12/18/2024 at 10:15 a.m. with the Medication Safety Pharmacy Compliance officer (MSPC, a pharmacist responsible for ensuring compliance with pharmacy regulations, medication safety, and adherence to organizational policies), the MSPC reviewed Patient 27's "Warning Override History for Lorazepam (Ativan) injection 1 mg" and stated the following:
-The ordering user for 1 mg of Ativan was [Patient 27's] registered nurse (RN), and the ordering provider was medical doctor (MD 1). It was a telephone order with readback, signed on 12/02/2023. The allergy/contraindication warning was overridden by the nurse due to a comment: "MD 1 aware, PRN (PRN, an abbreviation for "pro re nata," meaning "as needed") Benadryl ordered." Every medication ordered comes into a queue (a system where medication orders are temporarily held for review by the pharmacy before being dispensed) for the pharmacy to review. There was an allergy contraindication alert, but it was bypassed because of what the physician said and as documented by the nurse. The pharmacist released the order for 1 mg Ativan after reviewing the order and the comment.

During the same interview on 12/18/2024 at 10:15 a.m. with the Medication Safety Pharmacy Compliance Officer (MSPC), the MSPC reviewed Patient 27's medical records and stated the following: Patient 27's adverse reaction to Ativan administration in December 2020 was not entered under the Allergy section in the patient's (Patient 27) electronic medical record. Had this information been entered, it would have transitioned to the new electronic medical record platform when the patient (Patient 27) was admitted (back) to the facility in 2023.

During an interview on 12/18/2024 at 3:20 p.m. with medical doctor (MD 1), MD 1 stated the following after reviewing Patient 27's records from the first admission to the facility in 2020 [11/30/2020]: "In the discharge summary, I documented that the patient (Patient 27) got worse after receiving Ativan. The patient (Patient 27) was not allergic to Ativan then [in 2020]." MD 1 also stated, "Documentation of allergies and drug reactions should be done by nurses. It's their job to document this information. I don't typically document reactions to medications [in the allergy section] in medical records."

During the same interview on 12/18/2024 at 3:30 p.m. with medical doctor (MD 1), MD 1 stated the following: "Since the facility transitioned to a different platform for electronic medical records a few years ago, there is no way to read previous records. The information available for review is only what is accessible through the new platform. I reviewed the allergy for Xanax (during Patient 27's admission on 11/30/2023), but there was no reaction documented for Ativan. I ordered Benadryl to be administered in case there is a reaction. I think the patient (Patient 27) was very agitated when the nurse called me for orders, and I wanted to use the least restrictive measures (interventions that limit a patient's freedom as minimally as possible while ensuring safety and addressing clinical needs) possible, so I ordered Ativan and Benadryl." The MD 1 also stated, "If there was a documented allergy to Ativan and it was flagged, I would have tried a different medication [not Ativan]."

During an interview on 12/19/2024 at 1:02 p.m. with the Chair of Medicine (COM), the COM stated the following: "Everybody in the facility should be aware of the process of assessing a patient's allergies. It starts with the emergency room; the intake person pulls up the information and clarifies it. Nurses perform medication reconciliation (the process of comparing a patient's current medications to their medication orders to identify and resolve discrepancies), and as part of that process, they assess allergies. Once this is done, the physician would also clarify if there is a significant issue with any medications. Before I perform a procedure, 'allergy' would be the first question I ask. I would ensure that what the patient says matches what the chart indicates. As far as documentation of allergies or reactions in patients' records, anybody can document an allergy in the chart when they identify a reaction."

During a review of the facility's policy and procedure (P&P) titled, "Adverse Drug Reaction Reporting," dated 3/2018, the P&P indicated the following: An adverse drug reaction (ADR) is defined as one which is noxious and unintended, and which occurs in doses normally used in humans for the prophylaxis, diagnosis, or therapy of disease or for modification of physiological functions. An ADR reaction is an unexpected, unintended, undesired, or excessive response to a drug that prolongs a stay in a health care facility, requires changing the drug therapy, or requires discontinuing the drug. Verified drug reactions shall be entered into the patient's chart in the Allergy section of the electronic medical record (EMR).

Based on observation, interview, and record review, the facility failed to ensure one of 31 sampled patients (Patient 5), had proper documentation regarding the use of four siderails or evidence indicating that Patient 5 specifically requested all four side rails to be raised while in bed. There was also no physician order indicating the use of all four siderails.

This deficient practice had the potential to restrict Patient 5's freedom of movement and increase the risk of injury or harm due to potential entrapment, entanglement, or falls from a greater height should Patient 5 attempt to exit the bed.

Findings:

During a review of Patient 5's History and Physical (H&P, a formal document summarizing the patient's medical history and current condition), dated 12/9/2024, the H&P indicated that Patient 5 was admitted to the facility following a "robotic-assisted total gastrectomy reconstruction converted to open (a surgical procedure where the stomach is completely removed, initially performed using robotic assistance but later converted to an open surgery due to complexity or complications)." The H&P also indicated a past medical history (PMH, a record of previous diagnoses and medical treatments) of recurrent gastric cancer (a return of cancer in the stomach following prior treatment).

During a review of Patient 5's medical record (MR) titled, "Operative Report," dated 12/9/2024, the MR indicated that Patient 5 underwent a partial transverse colectomy (a surgical procedure involving the removal of part of the 'transverse' colon, typically to treat conditions like cancer, polyps [small, non-cancerous (benign) growths that can develop on the lining of various body organs, such as the colon, uterus, bladder, and nose], or obstruction) and a total gastrectomy reconstruction on 12/9/2024.

During a concurrent observation and interview on 12/16/2024 at 4:47 p.m. with Registered Nurse (RN 5), Patient 5 was observed in bed sleeping with all four side rails raised (positioned upright to provide a barrier). RN 5 stated that Patient 5 had walked the previous day with a walker and further indicated that Patient 5 was identified as high risk for falls (an unintentional event that results in a person coming to rest on the ground or a lower level). RN 5 confirmed that all four side rails were up at the time of observation (12/16/2024 at 4:47 p.m.) and stated that the patient (Patient 5) preferred to have all four side rails up. However, RN 5 was unable to demonstrate documentation or evidence of a safety assessment in the medical record regarding Patient 5's preference and safety for having all four side rails raised.

During a review of Patient 5's medical record (MR) titled, "Flowsheets: Fall Prevention Intervention," dated 12/16/2024, it was noted that all four bed side rails were documented as being raised.

During a concurrent interview and record review on 12/18/2024 at 3:31 p.m. with the Professional Development Nurse (PDN), the PDN reviewed Patient 5's nursing progress notes and nursing care plans (structured plans that outline the individualized nursing interventions, goals, and assessments to address a patient's specific healthcare needs), dated 12/16/2024. The PDN stated that there was no record indicating that Patient 5 had expressed a preference to have all side rails raised on 12/16/2024.

During a review of the facility's policy and procedure (P&P) titled "Restraints and Seclusions (the involuntary confinement of a patient alone in a designated room or area, where they are physically prevented from leaving)," dated 2/2022, the P&P indicated the following: Side rails are considered a restraint (restraint, any device or intervention that restricts a patient's voluntary movement to ensure safety or prevent harm) only when:
A. Used to prevent a patient from getting out of bed.
B. Used to create a barrier with other furniture to prevent a patient from voluntarily exiting the bed.

Based on observation, interview and record review, the facility failed to ensure nursing staff obtained a physician order (orders written by physicians to direct care and treatment) for restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) in a timely manner for one of 31 sampled patients (Patient 7), in accordance with the facility's policy and procedure regarding restraints, when four (4) side rails were raised to prevent Patient 7 from getting out of bed.

This deficient practice had the potential for increased risk of injury or harm due to potential entrapment, entanglement, or falls from a greater height should Patient 7 attempt to exit the bed.

Findings:

During a review of Patient 7's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 12/14/2024, the H&P indicated, Patient 7 was admitted to the facility with the diagnoses of right lower leg cellulitis (an infection of the deeper layers of skin and the underlying tissue), end stage renal disease (ESRD, a stage where the kidneys can no longer support the body's needs for waste removal and fluid balance) and atrial fibrillation (an irregular, often rapid heart rate that can cause poor blood flow, leading to blood clots, stroke [occurs when blood flow to the brain is interrupted and causing brain cells to die], or heart failure [a condition where the heart cannot pump enough blood to meet the body's needs]).

During an interview on 12/16/2024 at 3:12 p.m. with the Registered Nurse (RN) 7, RN 7 stated raising four (4) side rails up to prevent patient from getting out from bed would be considered as a form of restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body).

During a concurrent observation and interview on 12/17/2024 at 10:31 a.m. with Registered Nurse (RN) 11 at Patient 7's room, Patient 7 was observed in bed with all four (4) side rails up. RN 11 stated the following: Patient 7 had bilateral (both) ankles and mittens restraints due to being combative and pulling lines. Restraints were removed about twenty (20) minutes ago. She (RN 11) was keeping four (4) side rails up for now to monitor and prevent Patient 7 from getting out of bed.

During a review of Patient 7's "Nonviolent restraints flowsheet," dated 12/17/2024, the "Nonviolent restraint flowsheet" indicated bilateral ankles and bilateral mittens were discontinued on 12/17/2024 at 10:08 a.m. The restraints flowsheet also indicated Patient 7's orientation level as confused and disoriented.

During a concurrent interview and record review on 12/17/2024 at 2:52 p.m. with the Process Excellence Specialist (SRN), Patient 7's physician order for restraints dated 12/16/2024, was reviewed. The physician order indicated, primary restraint type with bilateral mittens and bilateral ankles with primary reason due to repeated attempts to remove/tamper with lines, tubes, equipment, dressing and unintentional behavior that could compromise self/medical treatment. SRN stated the following: there was no physician order for use of four (4) side rails. Using four (4) side rails as restraints could be a safety issue because patient might try to climb out of bed and hurt himself or herself. It was also violation of patient's rights to restrain someone without a physician order.

During an interview on 12/19/2024 at 10:55 a.m. with Nurse Manager (NM) 1 of Surgical Unit (a hospital ward where patients are cared and treated before and after surgery) 1 and 2, NM 1 stated there should be a physician order when using four (4) side rails up as a restraints to prevent patient from getting out of bed.

During a review of the facility's policy and procedure (P&P) titled, "Restraints and Seclusion," dated 2/2022, the P&P indicated, "Side Rails are considered a restraint only when a. used to prevent a patient from getting out of bed ... restraint(s) is/are used in accordance with the order the of a physician or other licensed independent practitioner who is responsible for the care of the patient ... if the attending or treating physician did not order the restraint, the attending physician (or treating physician) is notified as soon as possible."

Based on interview and record review, the facility failed to ensure nursing staff performed and documented restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) monitoring every two (2) hours for one of 31 sampled patients (Patient 2), in accordance with the facility's policy and procedure regarding restraints, when there was no documented restraints monitoring for eight (8) hours on 12/17/2024 from 6 a.m. to 2 p.m.

This deficient practice had the potential to put Patient 2 at risk for skin breakdown (damage to the skin and underlying tissue, usually caused by prolonged pressure which restricts blood flow to the area) and needs including hydration (the process of ensuring a patient has enough fluids in their body by drinking water and consuming foods with high water content) not being met while under restraints.

Findings:

During a review of Patient 2's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 12/3/2024, the H&P indicated, Patient 2 was admitted to the facility with diagnoses of acute intracranial (inside the brain) hemorrhage (bleeding). The H&P also indicated Patient 2 was intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) with mechanical ventilation (an appliance for artificial respiration).

During an interview on 12/16/2024 at 3:12 p.m. with the Registered Nurse (RN) 7, RN 7 stated nursing staff needed to check restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) site for skin integrity (the state of the skin being intact or undamaged) and pulse, assess patients for hygiene and provide comfort measures while patients were being restrained. RN 7 stated the monitoring should have been done and documented every two (2) hours.

During a concurrent interview and record review on 12/17/2024 at 2:39 p.m. with the Process Excellence Specialist (SRN), Patient 2's "Nonviolent Restraints Flowsheet," dated 12/17/20024, was reviewed. The "Nonviolent Restraints Flowsheet indicated, Patient 2 had right mitten (a large, soft glove that covers a patient's hand to prevent them from dislodging medical equipment) and four (4) side rails as restraints. The "Nonviolent Restraints Flowsheet" also indicated last restraint monitoring was completed on 12/17/2024 at 6 a.m. SRN stated the following: nursing staff need to perform assessment every two (2) hours to monitor if patient still met criteria for restraints and check for skin integrity, pulse, offer hydration, toileting and allow range of motion while being restrained.The assessment should be documented every two (2) hours, and it should be real time charting. The last entry was made at 6 a.m. so there was eight (8) hours (from 6 a.m. to 2 p.m.) with no assessment/documentation of restraints monitoring. Patient 2 would be at risk for skin breakdown (damage to the skin and underlying tissue, usually caused by prolonged pressure which restricts blood flow to the area), not being fed, not being cleaned and at risk for circulation problem if the restraint applied was too tight.

During a review of the facility's policy and procedure (P&P) titled, "Restraints and Seclusion," dated 2/2022, the P&P indicated, "monitoring is accomplished by observation, interaction with the patient, or related direct examination of the patient by qualified staff ...monitoring frequency and parameters ... c. monitor and document the following at least every two (2) hours as appropriate ...1. The licensed vocational nurse (LVN) may assist with the data collection of these components: a. restraints status/ evaluation of continued need, b. restraint site assessment, c. orientation/ level of consciousness, d. behavioral status ... the LVN or Patient Care Assistant (PCA) may assist with the data collection of these components: a. respiratory rate, b. nutrition/hydration, c. activity/position, d. toileting, e. range of motion (to restrained limbs)."

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 provide a competent Registered Nurse (trained in accessing a central line) for one of 31 sampled patients (Patient 1), to access Patient 1's Hickman central line (a type of central venous catheter [long, flexible tube inserted into a large vein to provide access to the heart] inserted into vein under the collarbone and tunneled under the skin of the chest wall) in a timely manner, in accordance with the facility's policy and procedure regarding central venous catheter and access devices, when there was a physician order to access Patient 1's Hickman central line on 11/25/2024.

This deficient practice resulted in Patient 1's Hickman central line not accessed until the next day 11/26/2024 and caused delay in medication administration which included an ordered Dilaudid (type of opioid to treat severe pain) Patient Controlled Analgesia (PCA, a pain management method that allows patients to control when they receive pain medication by pressing a button from a machine). (Refer to A-0392)

2. The facility failed to:
2.a. Ensure one of 31 sampled patients (Patient 13), had a consistent wound care documentation and assessment completed and the appropriate wound region identified and documented correctly, in accordance with the facility's policy and procedure regarding "Wound Care Assessment & Treatment" and "Documentation."

This deficient practice could result in improper wound care management for Patient 13, potentially causing delayed healing, an increased risk of infection, a worsening of the wound condition, and subsequent health complications. (Refer to A-0395)

2.b. Ensure the PICC (Peripherally Inserted Central Venous Catheter, nurses who are specialized in central line care) team performed proper assessment and accessed the central line catheter (CVC, long, flexible tube inserted into a large vein to provide access to the heart), in a timely manner, for one of 31 sampled patients (Patient 1) per physician's order.

This deficient practice resulted in the delay of care when Dilaudid (type of opioid to treat severe pain) PCA (PCA, a pain management method that allows patients to control when they receive pain medication by pressing a button from a machine), was not administered on time due to delay in accessing and utilizing Patient 1's central line catheter. (Refer to A-0395)

3. The facility failed to:
3.a. Ensure Nursing staff developed and maintained a current nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for one of 31 sampled patients (Patient 29), for Influenza A (a contagious viral infection of the respiratory tract that can cause fever, cough, sore throat, and potentially severe complications in vulnerable populations) and dialysis (dialysis, a medical procedure to remove waste products and excess fluids from the blood when the kidneys are no longer functioning adequately), in accordance with the facility's policy regarding nursing care plans.

This deficient practice had the potential for Patient 29's needs, risks and treatment goals not being met, negatively affecting Patient 29's effectiveness of care and treatment outcomes. (Refer to A-0396)

3.b. Implement and revise interventions in the pain care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for one of 31 sampled patients (Patient 13), in accordance with the facility's "Interdisciplinary Plan of Care" policy and procedures.

This deficient practice resulted in Patient 13 experiencing pain when being repositioned every two hours, leading to heightened discomfort and emotional distress. This persistent pain can also limit Patient 13's ability to move and refusal to be moved, resulting in decreased physical activity and potential complications such as muscle atrophy (wasting or thinning of muscle mass) and worsening pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time), negatively impacting Patient 13's quality of life. (Refer to A-0396)

4. The facility failed to ensure that the clinical alarms for telemetry monitor (a medical device that continuously monitors the heart activity, and/or oxygen saturations [the amount of oxygen in the blood]) were appropriately set, according to the facility's "Cardiac Monitoring Guidelines and Clinical Alarm Management" policy and procedure, for two of 31 sampled patients (Patients 14 and Patient 15).

This deficient practice had the potential to delay the detection of life-threatening changes. For Patient 14, this could have led to uncontrolled high blood pressure, increasing the risk of stroke (occurs when blood flow to the brain is interrupted and causing brain cells to die) or other cardiac (relating to the heart) emergencies. For Patient 15, improper oxygen monitoring can lead to undetected hypoxia (low oxygen levels), which can cause brain damage or death. (Refer to A-0398)

5. The facility failed to ensure Nursing personnel reported a suspected adverse drug reaction (unintended, harmful events attributed to the use of medicines) to Ativan (Ativan, a benzodiazepine [class of medication] used to treat anxiety) and/or Benadryl (Benadryl, an antihistamine [class of medication] used to treat allergic reactions, reduce itching, and provide sedation) for one of 31 sampled patients (Patient 27), in accordance with the facility's policy and procedure regarding adverse drug reaction reporting.

This deficient practice had the potential to compromise Patient 27's health and recovery due to delayed recognition and management of adverse drug reactions and repeated exposure to medications that Patient 27 may be allergic to. (Refer to A-0398)

6. The facility failed to ensure Nursing personnel entered the isolation precautions (infection control measures designed to prevent the spread of contagious diseases, such as placing the patient in a designated isolation room and using protective equipment like masks and gowns) information for Influenza A (a contagious viral infection of the respiratory tract that can cause fever, cough, sore throat, and severe complications in vulnerable populations) into the Patient Care System (PCS, an electronic system used to document and communicate patient care needs and treatment plans) for one of 31 sampled patients (Patient 29), in accordance with the facility's policy and procedure regarding "Initiation of Infection Control Precautions for Staff and Visitors."

This deficient practice had the potential to delay the implementation of infection control measures for Patient 29, thereby increasing the risk of spreading Influenza A to other patients, visitors, and staff due to uncommunicated isolation precautions. (Refer to A-0398)

7. The facility failed to implement complete seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness [a state where a person is not aware of their environment or themselves]) precautions for one of 31 sampled patients (Patient 21), when there was no readily available suction set-up (a medical device that essentially acts like a vacuum cleaner for a person's airway, removing excess mucus, saliva, blood, or other fluids that they can't clear on their own, helping them breathe properly, especially when they are unconscious or unable to cough effectively) for Patient 21 in the event of a seizure episode, in accordance with the facility's policy and procedure regarding "Seizure Precautions and Guidelines."

This deficient practice had the potential for Patient 21 to aspirate (inhale) during a seizure activity, which may result in complications such as aspiration pneumonia (infection of the lung) and may prolong Patient 21's recovery. (Refer to A-0398)

8. The facility failed to ensure side rails were padded for one of 31 sampled patients (Patient 2) for seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness) precaution, in accordance with the facility's policy and procedure regarding "Seizure Precaution and Guidelines." This deficient practice had the potential to result in Patient 2 getting injured when having seizures. (Refer to A-0398)

9. The facility failed to ensure Nursing staff completed the pre-procedure check list (steps taken to verify the patient, procedure, and consent form) and follow the time-out (a pause before a medical procedure to confirm that the correct patient, procedure, and site are being used) process for two of 31 sampled patients (Patient 2 and Patient 3), in accordance with the facility's policy and procedure regarding "Universal Protocol (a set of standardized procedures in healthcare, primarily used in surgical settings, designed to prevent wrong-site, wrong-procedure, and wrong-patient surgeries by requiring a pre-procedure verification process, surgical site marking, and a "time-out" before starting the procedure).

This deficient practice had the potential to result in Patient 2 and Patient 3 having the wrong procedure, wrong site and/or having the procedure without informed consent (a process in which a health care providers educates a patient about the risks, benefits, and alternatives of a given procedure or intervention). (Refer to A-0398)

10. The facility failed to ensure Nursing staff followed the chain of command (provides a clear structure for reporting concerns, escalating issues, and making decisions related to patient care) to manage one of 31 sampled patient's (Patient 1) pain, in accordance with the facility's policy and procedure regarding "Chain of Command."

This deficient practice resulted in Patient 1 remaining in severe pain for 3.5 hours on 12/3/2024 and had the potential to result in Patient 1 not being able to move, talk or perform activities of daily living (basic self-care tasks that people perform everyday such as hygiene) due to severe pain. (Refer to A-0398)

11. The facility failed to ensure one of 31 sampled patient's (Patient 13) prescribed medication, Desitin (medication used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and skin irritations), was administered in accordance with prescribed instruction.

This deficient practice could result in improper wound care management for Patient 13, potentially causing delayed healing, an increased risk of infection, a worsening of the wound condition, and subsequent health complication. (Refer to A-0405)

12. The facility failed to ensure nursing staff gave pain medications, per physician order, for one of 31 sampled patients (Patient 3), in accordance with the facility's policy and procedure regarding "Medication Use, Administration, Routes and High Alert Medications," when Norco (opioid medication to treat and relieve pain) 5/325 milligrams (mg, a unit of measure) by mouth and Morphine (opioid medication to treat and relieve moderate to severe pain) 2 mg intravenous (IV - administered into a vein), were administered to Patient 3 at the same time.

This deficient practice had the potential to overmedicate Patient 3 and put Patient 3 at risk for oversedation (excessive drowsiness) and respiratory distress (difficulty breathing). (Refer to A-0405)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on interview and record review, the facility failed to provide a competent Registered Nurse (trained in accessing a central line) for one of 31 sampled patients (Patient 1), to access Patient 1's Hickman central line (a type of central venous catheter [long, flexible tube inserted into a large vein to provide access to the heart] inserted into vein under the collarbone and tunneled under the skin of the chest wall) in a timely manner, in accordance with the facility's policy and procedure regarding central venous catheter and access devices, when there was a physician order to access Patient 1's Hickman central line on 11/25/2024.

This deficient practice resulted in Patient 1's Hickman central line not accessed until the next day 11/26/2024 and caused delay in medication administration which included an ordered Dilaudid (type of opioid to treat severe pain) Patient Controlled Analgesia (PCA, a pain management method that allows patients to control when they receive pain medication by pressing a button from a machine).

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 11/25/2024, the H&P indicated, Patient 1 was admitted to the facility for left shoulder diagnostic arthroscopy (a minimally invasive surgical procedure that allows a surgeon to examine and treat the joint). The H&P also indicated Patient 1 had a Hickman central line (a type of central venous catheter [CVC, long, flexible tube inserted into a large vein to provide access to the heart] inserted into vein under the collarbone and tunneled under the skin of the chest wall).

During a concurrent interview and record review on 12/19/2024 at 9:43 a.m. with the PICC (Peripherally Inserted Central Venous Catheter, nurses who are specialized in central line care) nurse (PICC 1), Patient 1's "Physician Order," dated 11/25/2024, was reviewed. The "Physician Orders (orders written by physicians to direct care and treatment)" indicated, "IV (Intravenous) Team Request to insert peripheral intravenous (IV, a thin, flexible that is inserted into a vein to administer fluid or medications) right arm only, also assess Hickman access." PICC 1 stated the PICC nurse receiving this physician order should insert peripheral IV to Patient 1's right arm and assess Patient 1's Hickman central line including checking the site, getting a chest X ray (an imaging procedure that uses X-rays to create picture of the structures in the chest) to confirm placement, checking the ports for blood return, flushing the line and changing the dressing to make sure the central line was good to use. PICC 1 also stated the nursing staff could then follow up with the physician to obtain order for "okay to use" the central line.

During a concurrent interview and record review on 12/19/2024 at 9:47 a.m. with PICC 1, Patient 1's "Progress Note - Nursing (nurses notes)," dated 11/25/2024 at 3:17 p.m., was reviewed. The nurses notes indicated, "PICC team [name] Registered Nurse (RN) (PICC 2) inserted a right antecubital (the area on the front of the elbow joint) 20-gauge (G, a unit of measure) peripheral IV ... Placed an order got PICC team to assess Hickman central line. Per the PICC team, the PICC team does not evaluate or access the Hickman central line. PICC team stated that the Hickman central line is tunneled and sutured in the chest and does not need placement confirmation." PICC 1 stated PICC 2 provided incorrect information. PICC 1 stated Patient 1's Hickman central line needed to be assessed and accessed by PICC team.

During a concurrent interview and record review on 12/19/2024 at 9:51 a.m. with PICC 1, Patient 1's "LDA (line, drains and airways) Flowsheet," dated from 11/25/2024 to 11/26/2024, was reviewed. The "LDA Flowsheet" indicated, Patient 1 had a double lumen central line at right subclavian (beneath the collarbone) present on admission (11/25/2024) and a peripheral IV 20 gauge to right antecubital (the area in front of the elbow joint) placed on 11/25/2024 at 3:15 p.m. PICC 1 stated the following: the PICC nurse (PICC 2) inserted a peripheral IV for Patient 1 only. PICC 2 did not follow physician order to assess Patient 1's Hickman central line. The nursing staff would not be able to use the Hickman central line without being assessed and accessed by PICC team or other trained staff. Nurses from Oncology unit (a hospital ward that is specialized in providing care to patients with cancer) 1 were trained to access central lines (CVC) as well. PICC 1 stated Patient 1's Hickman central line was accessed by another PICC nurse on 11/26/2024 at 11:45 a.m.

During a review of Patient 1's "Physician Orders," dated 11/25/2024, the "Physician Orders" indicated the following:

-Ketamine (name of medication to treat pain) 500 milligrams (mg, a unit of measure) in 0.9 percent (%, a unit of measure) Normal Saline (type of fluid) 250 milliliters (ml, a unit of measure) infusion with scheduled start date/time on 11/25/2024 at 11 p.m. and Dilaudid (type of opioid to treat severe pain) 1 mg/ml 30 ml adult standard Patient-controlled analgesia (PCA, a pain management method that allows patients to control when they receive pain medication by pressing a button from a machine) with scheduled start date/time on 11/25/2024 at 11 p.m.

During a review of Patient 1's "Pain Flowsheet (record of patient's pain level, location, intervention and response to pain intervention)," dated from 11/26/2024, the "Pain flowsheet" indicated Patient 1 had aching left shoulder pain with the following pain rating:

-12:11 a.m., 10/10 on numeric pain scale (0-10, a pain scale used in rating the severity of pain with 0 being no pain, 1-3 for mild pain, 4-6 for moderate pain and 7-10 for severe pain)
-1:47 a.m., 7/10
-3:14 a.m., 8/10
-3:44 a.m., 6/10
-4:30 a.m., 7/10

During a review of Patient 1's "Medication Administration Record (MAR, record of medications given to patients)," dated 11/26/2024, the MAR indicated, Dilaudid 0.5 mg intravenous push (IVP, administered into a vein) was given on 11/26/2024 at 1:32 a.m., 3:14 a.m. and 3:44 a.m.

During a review of Patient 1's "Progress note - Nursing," dated 11/26/2024 at 5:53 a.m., the nurses notes indicated, Patient 1 was transferred to Surgical Unit (a hospital ward where patients are cared and treated before and after surgery) 2 around 12:45 a.m. Registered Nurse (RN) 18 was told by Patient Flow Coordinator (charge nurse) and the house supervisor that on Surgical Unit 2, they were unable to use Patient 1's Hickman central line. Patient 1 had one peripheral IV that was infusing Ketamine ... Patient 1 also wanted Dilaudid PCA ... Another IV was placed via ultrasound (no documented time when the second peripheral IV was started) ... Patient (Patient 1) repeatedly asked RN 18 if RN 18 could use Patient 1's Hickman line ... RN 18 placed a PICC team consult for another line.

During a review of Patient 1's "Medication Administration Record," dated from 11/25/2024 to 11/26/2024. The MAR indicated, Dilaudid 1mg/ml Adult Standard PCA was administered on 11/26/2024 at 5:17 a.m. through the second peripheral IV started by an Emergency Department (ED) nurse.

During an interview on 12/19/2024 at 10:40 a.m. with the Nurse Manger (NM) 1 of Surgical Unit 1 and 2, NM 1 stated the following: there was miscommunication among the staff. They were under the impression that nurses on Surgical Unit 2 could not use Patient 1's Hickman central line until nurses from Oncology Unit 1 access it. NM 1 stated he (NM1) did not know why the nursing staff from Surgical Unit 2 did not call nurses from Oncology Unit 1 to access the Hickman central line for Patient 1. NM 1 stated there was a delay in care in managing Patient 1's pain due to delay in accessing Patient 1's Hickman central line. Patient 1's Hickman central line was accessed by another PICC line nurse on 11/26/2024 at 11:45 a.m.

During an interview on 12/20/2024 at 9:06 a.m. with the Nurse Manager (NM) 5 of Post-Anesthesia Care Unit (PACU, a recovery area in hospital where patients are monitored after surgery), NM 5 stated the following: Hickman central line was a type of central venous catheter (CVC) in which only certain nurses at the facility could access. PACU nurses should refer to the facility's policy and procedure to find out who the nurses were allowed to access the CVC. It was not acceptable to wait until the next morning for the PICC team to access Patient 1's Hickman central line.

During an interview on 12/20/2024 at 10 a.m. with the Director of Nursing Operation (DIR 3), DIR 3 stated all nursing staff was oriented with the facility's policy and procedure regarding CVC including the nursing supervisor. The nursing supervisor should have made arrangement to have nurses from Oncology Unit 1 to come down to access Patient 1's Hickman central line. It was not acceptable to wait for PICC team to access the Hickman central line in the morning. It was Patient 1's right to receive pain medication and have pain managed in a timely manner.

During a review of the facility's policy and procedure (P&P) titled, "Central Venous Catheters and Access Devices Adult and Pediatrics," dated 9/2023, the P&P indicated, "Accessing Subcutaneous Venous Access Ports (SCVAP, type of central venous catheter) 1. Must have a physician's order to access the port 2. Registered Nurses (RNs) from 6 West/Oncology, Critical Care Unit, Definitive Observation Unit Patient Flow Coordinators, Emergency Room, Interventional Radiology, Endoscopy, and the PICC Team ... a consult to PICC Team is entered for all patients with an accessed port on any unit other than those listed in. If a patient with an accessed port from one of these areas is being transferred to another unit, the receiving unit is responsible for entering the PICC Team consult. The PICC Team will follow the patient and assure the needle and dressing are changed per policy ... Patients admitted to Central Venous Catheter (CVC) ... A. Patient may be admitted with a CVC in place B. Call the physician for a chest X ray (CXR) order to confirm placement before using or accessing the device C. Once the CXR is taken, confirm appropriate placement with the physician and obtain an order to access/use the device. D. Notify PICC team of any PICC, Midline or SCVAP."

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

1. Ensure one of 31 sampled patients (Patient 13), had a consistent wound care documentation and assessment completed and the appropriate wound region identified and documented correctly, in accordance with the facility's policy and procedure regarding "Wound Care Assessment & Treatment" and "Documentation."

This deficient practice could result in improper wound care management for Patient 13, potentially causing delayed healing, an increased risk of infection, a worsening of the wound condition, and subsequent health complications.

2. Ensure the PICC (Peripherally Inserted Central Venous Catheter, nurses who are specialized in central line care) team performed proper assessment and accessed the central line catheter (CVC, long, flexible tube inserted into a large vein to provide access to the heart), in a timely manner, for one of 31 sampled patients (Patient 1) per physician's order.

This deficient practice resulted in the delay of care when Dilaudid (type of opioid to treat severe pain) PCA (PCA, a pain management method that allows patients to control when they receive pain medication by pressing a button from a machine), was not administered on time due to delay in accessing and utilizing Patient 1's central line catheter.

Findings:

1. During a review of Patient 13's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 12/7/2024, the "H&P" indicated Patient 13 was admitted with "past medical history of alcoholism (a chronic disease in which a person craves drinks that contain alcohol and is unable to control his or her drinking) and bedbound state a (person is confined to their bed, unable to get up or move around without assistance, usually due to a significant health issue that limits their mobility, such as a severe injury) who presents to the Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries) for evaluation of back pain ... He (Patient 13) reports pain localized to his back and reports a history of sciatica (pain that radiates into one or both legs)." The H&P further indicated Patient 13 had osteomyelitis (an infection in a bone) with extensive cellulitis (a deep infection of the skin caused by bacteria) to the back, limbs, and right heel with visible bone exposure.

During a concurrent interview and record review on 12/17/2024 at 3:10 p.m. with the Quality Coordinator (QC) 1, Patient 13's "Medication Administration Report," with a start date on 12/11/2024 indicated, "Zinc oxide-cod liver oil (Desitin, medication used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and skin irritations) 40% ointment, apply 2 times daily."

During a concurrent interview and record review on 12/18/2024 at 11:45 a.m. with the Quality Coordinator (QC) 1, Patient 13's Electronic Medical Record (EMR, a digital version of the paper charts in hospitals) titled, "Skin/Wound/PI (pressure injury, a localized damage to the skin and underlying soft tissue)," dated 12/7/2024 through 12/16/2024, was reviewed. The record indicated as follows:

-On 12/7/2024, the Skin/Wound/PI record indicated the wound's location is at the "ischial tuberosity (an anatomical term for the V-shaped bone at the bottom of the pelvis that makes contact with a surface when a person is sitting down)," but the photo attached to the record showed the wound was actually located at the coccyx (the last bone at the base of the spine) area. QC 1 confirmed that the documentation was incorrect and stated the photo clearly indicated the wound was on the coccyx.

-On 12/14/2024, the Skin/Wound/PI records indicated that for both an a.m. shift (7 a.m. to 7 p.m.) and a p.m. shift (7 p.m. to 7 a.m.), there was no wound assessment and wound care medication (Desitin) documented. QC 1 stated that Patient 13 remained on the unit on 12/14/2024. Thus, wound assessment and treatment should be completed and documented. OC 1 also confirmed that on 12/14/2024 there were no documentation indicating that Patient 13 refused wound assessment and treatment.

-On 12/15/2024, the Skin/Wound/PI record indicated that for the a.m. shift (7 a.m. to 7 p.m.), there was no assessment and wound care medication (Desitin) documented. QC 1 stated that Patient 13 remained on the unit on 12/15/2024. Thus, wound assessment and treatment should be completed and documented. OC 1 also confirmed that on 12/15/2024, there were no documentation indicating that Patient 13 refused wound assessment and treatment.

During an interview on 12/19/2024 at 12:15 p.m. with Nursing Supervisor and Wound Care (NSW), NSW stated skin and wound assessment must be completed every shift especially for Patient 13, who had a pressure injury that required wound treatment two (2) times a day.

During a review of the facility's policy and procedure (P&P) titled, "Wound Care Assessment & Treatment," dated February 2021, the P&P indicated, "Patient Assessment: All patients admitted to [Name of Facility] will have their skin integrity assessed by a RN within eight (8) hours of admission. Skin integrity assessment will be performed by an RN at least once a shift ..."

During a review of the facility's policy and procedure (P&P) titled, "Documentation," dated January 2023, the P&P indicated, "To establish general guidelines for documentation in the medical record. The medical record facilitates communication between members of the health care delivery team. Documentation is to be concise and pertinent to the clinical condition of the patient ... Filing an electronic document signifies that you have reviewed the information contained within the fields and that all information is accurate and up to date for your patient ..."

During a review of the facility's policy and procedure (P&P) titled, "Hospital Plan for the Provision of Patient Care Services," dated 9/1/2020, the P&P indicated, "Overview of Discipline-Specific Policies for Assessment and Reassessment ... Nursing; Assessment time frame: Demographic, physical assessment, and care planning assessment within 2 hours of admission in critical care areas and 8 hours of admission in non-critical care areas. RN analyzes data/prioritizes care. Re-Assessment Time Frame: Every shift and/or unit-specific, as well as pre- and post-treatment, including diagnosis, pre- & post-treatment, and response to treatments ..."

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 11/25/2024, the H&P indicated, Patient 1 was admitted to the facility for left shoulder diagnostic arthroscopy (a minimally invasive surgical procedure that allows a surgeon to examine and treat the joint). The H&P also indicated Patient 1 had a Hickman central line (a type of central venous catheter [CVC, long, flexible tube inserted into a large vein to provide access to the heart] inserted into vein under the collarbone and tunneled under the skin of the chest wall).

During a concurrent interview and record review on 12/19/2024 at 9:43 a.m. with the PICC (Peripherally Inserted Central Venous Catheter, nurses who are specialized in central line care) nurse (PICC 1), Patient 1's "Physician Order," dated 11/25/2024, was reviewed. The "Physician Orders (orders written by physicians to direct care and treatment)" indicated, "IV (Intravenous) Team Request to insert peripheral intravenous (IV, a thin, flexible that is inserted into a vein to administer fluid or medications) right arm only, also assess Hickman access." PICC 1 stated the PICC nurse receiving this physician order should insert peripheral IV to Patient 1's right arm and assess Patient 1's Hickman central line including checking the site, getting a chest X ray (an imaging procedure that uses X-rays to create picture of the structures in the chest) to confirm placement, checking the ports for blood return, flushing the line and changing the dressing to make sure the central line was good to use. PICC 1 also stated the nursing staff could then follow up with the physician to obtain order for "okay to use" the central line.

During a concurrent interview and record review on 12/19/2024 at 9:47 a.m. with PICC 1, Patient 1's "Progress Note - Nursing (nurses notes)," dated 11/25/2024 at 3:17 p.m., was reviewed. The nurses' notes indicated, "PICC team [name] Registered Nurse (RN) (PICC 2) inserted a right antecubital (the area on the front of the elbow joint) 20-gauge (G, a unit of measure) peripheral IV ... Placed an order, got PICC team to assess Hickman central line. Per the PICC team, the PICC team does not evaluate or access the Hickman central line. PICC team stated that the Hickman central line is tunneled and sutured in the chest and does not need placement confirmation." PICC 1 stated PICC 2 provided incorrect information. PICC 1 stated Patient 1's Hickman central line needed to be assessed and accessed by PICC team.

During a concurrent interview and record review on 12/19/2024 at 9:51 a.m. with PICC 1, Patient 1's "LDA (line, drains and airways) Flowsheet," dated from 11/25/2024 to 11/26/2024, was reviewed. The "LDA Flowsheet" indicated, Patient 1 had a double lumen central line at right subclavian (beneath the collarbone) present on admission (11/25/2024) and a peripheral IV 20 gauge to right antecubital placed on 11/25/2024 at 3:15 p.m. PICC 1 stated the following: the PICC nurse (PICC 2) inserted a peripheral IV for Patient 1 only. PICC 2 did not follow physician order to assess Patient 1's Hickman central line. The nursing staff would not be able to use the Hickman central line without being assessed and accessed by PICC team or other trained staff. Nurses from Oncology unit (a hospital ward that is specialized in providing care to patients with cancer) 1 were trained to access central lines (CVC) as well. PICC 1 stated Patient 1's Hickman central line was accessed by another PICC nurse on 11/26/2024 at 11:45 a.m.

During a review of Patient 1's "Physician Orders," dated 11/25/2024, the "Physician Orders" indicated the following:

-Ketamine (name of medication to treat pain) 500 milligrams (mg, a unit of measure) in 0.9 percent (%, a unit of measure) Normal Saline (type of fluid) 250 milliliters (ml, a unit of measure) infusion with scheduled start date/ time on 11/25/2024 at 11 p.m. and Dilaudid (type of opioid to treat severe pain) 1 mg/ml 30 ml adult standard Patient-controlled analgesia (PCA, a pain management method that allows patients to control when they receive pain medication by pressing a button from a machine) with scheduled start date/time on 11/25/2024 at 11 p.m.

During a review of Patient 1's "Pain Flowsheet (record of patient's pain level, location, intervention and response to pain intervention)," dated from 11/26/2024, the "Pain flowsheet" indicated Patient 1 had aching left shoulder pain with the following pain rating:

-12:11 a.m., 10/10 on numeric pain scale (0-10, a pain scale used in rating the severity of pain with 0 being no pain, 1-3 for mild pain, 4-6 for moderate pain and 7-10 for severe pain)
-1:47 a.m., 7/10
-3:14 a.m., 8/10
-3:44 a.m., 6/10
-4:30 a.m., 7/10

During a review of Patient 1's "Medication Administration Record (MAR, record of medications given to patients)," dated 11/26/2024, the MAR indicated, Dilaudid 0.5 mg intravenous push (IVP, administered into a vein) was given on 11/26/2024 at 1:32 a.m., 3:14 a.m. and 3:44 a.m.

During a review of Patient 1's "Progress note - Nursing," dated 11/26/2024 at 5:53 a.m., the nurses notes indicated, Patient 1 was transferred to Surgical Unit (a hospital ward where patients are cared and treated before and after surgery) 2 around 12:45 a.m. Registered Nurse (RN) 18 was told by Patient Flow Coordinator (charge nurse) and the house supervisor that on Surgical Unit 2, they were unable to use Patient 1's Hickman central line. Patient 1 had one peripheral IV that was infusing Ketamine ... Patient 1 also wanted Dilaudid PCA ... Another IV was placed via ultrasound ... Patient (Patient 1) repeatedly asked RN 18 if RN 18 could use Patient 1's Hickman line ... RN 18 placed a PICC team consult for another line.

During a review of Patient 1's "Medication Administration Record," dated from 11/25/2024 to 11/26/2024. The MAR indicated, Dilaudid 1mg/ml Adult Standard PCA was administered on 11/26/2024 at 5:17 a.m.

During an interview on 12/19/2024 at 10:40 a.m. with the Nurse Manger (NM) 1 of Surgical Unit 1 and 2, NM 1 stated the following: there was miscommunication among the staff. They were under the impression that nurses on Surgical Unit 2 could not use Patient 1's Hickman central line until nurses from Oncology Unit 1 access it. NM 1 stated he (NM1) did not know why the nursing staff from Surgical Unit 2 did not call nurses from Oncology Unit 1 to access the Hickman central line for Patient 1. NM 1 stated there was a delay in care in managing Patient 1's pain due to delay in accessing Patient 1's Hickman central line.

During a review of the facility's policy and procedure (P&P) titled, "Central Venous Catheters and Access Devices Adult and Pediatrics," dated 9/2023, the P&P indicated, "Accessing Subcutaneous Venous Access Ports (SCVAP) 1. Must have a physician's order to access the port 2. Registered Nurses (RNs) from 6 West/Oncology, Critical Care Unit, Definitive Observation Unit Patient Flow Coordinators, Emergency Room, Interventional Radiology, Endoscopy, and the PICC Team ... a consult to PICC Team is entered for all patients with an accessed port on any unit other than those listed in. If a patient with an accessed port from one of these areas is being transferred to another unit, the receiving unit is responsible for entering the PICC Team consult. The PICC Team will follow the patient and assure the needle and dressing are changed per policy ... Patients admitted to Central Venous Catheter (CVC) ... A. Patient may be admitted with a CVC in place B. Call the physician for a chest X ray (CXR) order to confirm placement before using or accessing the device C. Once the CXR is taken, confirm appropriate placement with the physician and obtain an order to access/use the device. D. Notify PICC team of any PICC, Midline or SCVAP."

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

1. Ensure Nursing staff developed and maintained a current nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for one of 31 sampled patients (Patient 29), for Influenza A (a contagious viral infection of the respiratory tract that can cause fever, cough, sore throat, and potentially severe complications in vulnerable populations) and dialysis (dialysis, a medical procedure to remove waste products and excess fluids from the blood when the kidneys are no longer functioning adequately), in accordance with the facility's policy regarding nursing care plans.

This deficient practice had the potential for Patient 29's needs, risks and treatment goals not being met, negatively affecting Patient 29's effectiveness of care and treatment outcomes.

2. Implement and revise interventions in the pain care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for one of 31 sampled patients (Patient 13) in accordance with the facility's "Interdisciplinary Plan of Care" policy and procedures.

This deficient practice resulted in Patient 13 experiencing pain when being repositioned every two hours, leading to heightened discomfort and emotional distress. This persistent pain can also limit Patient 13's ability to move and refusal to be moved, resulting in decreased physical activity and potential complications such as muscle atrophy (wasting or thinning of muscle mass) and worsening pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time), negatively impacting Patient 13's quality of life.

Findings:

1. During a review of Patient 29's History and Physical (H&P, a formal document summarizing the patient's medical history and current condition), dated 12/14/2023, the H&P indicated that Patient 29 had a past medical history (PMH, a record of prior diagnoses and treatments), including but not limited to end-stage renal disease (ESRD, a chronic condition where the kidneys fail to function effectively), currently on hemodialysis (HD, a treatment that filters waste and excess fluids from the blood), diabetes (a chronic disease that affects the body's ability to regulate blood sugar levels due to insufficient insulin production [helps the body manage blood sugar levels] or utilization), and a history of cardiac transplant (a surgical procedure to replace a diseased heart with a healthy donor heart). The H&P further indicated that Patient 29 was admitted on 12/14/2023 due to respiratory failure (a serious condition where the lungs cannot adequately oxygenate the blood) and Influenza A (a contagious viral infection of the respiratory tract that can cause fever, cough, sore throat, and potentially severe complications in vulnerable populations).

During a review of Patient 29's medical record (MR) titled, "Care Plan (CP, a structured, individualized plan created by healthcare providers to address a patient's specific medical and nursing needs)," dated 12/14/2023-12/18/2023, the MR indicated that the following CPs were initiated for Patient 29 during the admission stay [12/14/2023-12/18/2023]:
i. Mobility-Impaired: A condition where physical movement or coordination is limited, impacting the patient's ability to perform daily activities independently.
ii. Risk for Falls: A state where a patient is at increased risk of falling due to factors like impaired balance, weakness, or medications.
iii. Pain: An unpleasant sensory and emotional experience associated with actual or potential tissue damage, requiring management and intervention.
iv. Ineffective Breathing Pattern: A condition where the patient's respiratory rhythm, depth, or rate is insufficient to meet physiological needs.
v. Risk for Pressure Injury: A situation where prolonged pressure on the skin may lead to tissue damage, especially in immobile patients.
vi. Discharge Planning: A process that begins on admission and involves preparing the patient for a safe transition from the hospital to home or another care setting, ensuring continuity of care.
vii. Impaired Skin Integrity-Pressure Injury: Damage to the skin or underlying tissues caused by sustained pressure, often seen in bedridden or immobile patients, requiring specialized care and prevention strategies.

During a concurrent interview and record review on 12/18/2024 at 10:58 a.m. with Professional Development Nurse (PDN), the PDN reviewed Patient 29's medical record (MR) titled, "Care Plan," dated 12/14/2023-12/18/2023, and stated the following: Nurses did not develop a care plan to address Patient 29's medical conditions of dialysis and Influenza A infection.

During a concurrent interview and record review on 12/18/2024 at 10:58 a.m. with Professional Development Nurse (PDN), the PDN reviewed the available nursing care plans for patients with kidney and dialysis conditions and stated the following: A renal failure care plan and an excess fluid volume care plan could be added for Patient 29 to address the medical diagnoses of kidney disease [End-Stage Renal Disease (ESRD)] and dialysis. Additionally, a Risk/Management of Infection care plan could be added to Patient 29's plan of care to address Patient 29's needs associated with a diagnosis of Influenza A.

During an interview on 12/19/2024 at 10:20 a.m. with the Nurse Manager (NM 1), the NM 1 stated that care plans (CPs) should be initiated for patients as soon as possible after admission. The NM 1 said the following: This [initiation of individualized care plans] allows the care team to assess what's working, what is not, and how the patient is progressing. For dialysis patients, for example, the nurse can initiate a fluid and electrolyte (the regulation of and minerals with an electrical charge (electrolytes) within the body) imbalance CP (a care plan addressing imbalances in the body's essential minerals and fluids that can affect organ function), which prompts nurses to perform daily weights and establish appropriate interventions to meet the treatment goals for the patient. It's important to have a CP so we can track progress, check in with the patient, and determine if additional education is needed: what they already know and what they need to learn.

During the same interview on 12/19/2024 at 10:20 a.m. with the Nurse Manager (NM 1), NM 1 said that for Influenza A, the nurse should initiate a respiratory CP (focused on managing breathing difficulties and lung health) and an infection control/management CP (designed to prevent the spread of infection and address specific patient needs). The patient should also be placed on droplet isolation precautions (infection control measures to prevent the spread of respiratory droplets). This is a nurse-driven intervention and does not require a physician's order.

During a review of the facility's policy and procedure (P&P) titled, "Interdisciplinary Care Plan (IPOC)," dated 9/20/2024, the P&P indicated that nursing staff is responsible for developing and maintaining a current nursing plan of care for each patient. Plan of care: A communication tool that identifies and prioritizes patient care and treatment needs, including outcomes, interventions, indicators, and goals. A nursing IPOC is developed by assessing the patient's needs upon admission from all available sources, creating a comprehensive picture of the patient's condition (not just those related to the admitting diagnosis) to establish appropriate nursing interventions. The Registered Nurse is responsible for setting mutually agreed-upon goals with the patient (or family/significant other) and the interdisciplinary team as needed. These goals align with the medical plan of care.

2. During a review of Patient 13's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 12/7/2024, the "H&P" indicated Patient 13 was admitted with "past medical history of alcoholism (a chronic disease in which a person craves drinks that contain alcohol and is unable to control his or her drinking) and bedbound state (when someone is unable to get out of bed independently, requiring assistance to move around or change positions) who presents to the Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries) via paramedics (a person trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) for evaluation of back pain ... He (Patient 13) reports pain, localized to his back and reports a history of sciatica (pain that radiates into one or both legs)." The H&P further indicated Patient 13 had osteomyelitis (an infection in a bone) with extensive cellulitis (a deep infection of the skin caused by bacteria) to the back, limbs, and right heel with visible bone exposure.

During an observation on 12/16/2024 at 3:41 p.m., at the entrance hallway to 4 East (surgical unit, an area in the hospital where patients are cared for and treated before or after the surgery) screaming was heard from room ABC (Patient 13's room). Inside, two staff members (Certified Nursing Attendant [CNA], an entry-level role that provides vital support to both patients and nurses) 1 and Registered Nurse [RN], nurse who has graduated from a college's nursing program or from a school of nursing and has passed a national licensing exam) 4 were repositioning (moving a patient into a different position to redistribute pressure from a particular part of the body) Patient 13, who continued to scream during the procedure.

During an interview on 12/16/2024 at 3:50 p.m., Patient 13 stated, "I have pain in both legs when they move me." Patient 13 reported pain levels of 8/10 (on a scale of 0-10, with 0 representing no pain and 10 being the worst pain) to the legs and back during repositioning and cleaning.

During an interview on 12/16/2024 at 3:45 p.m. with Registered Nurse (RN) 8, outside the corridor of Patient 13's room, RN 8 stated that patient (Patient 13) screamed each time staff repositioned them (Patient 13) due to pain. RN 8 indicated that Norco (a prescribed medication, a combination of hydrocodone [a drug used to treat moderate to severe pain] and acetaminophen [a drug used to relieve mild or chronic pain and to reduce fever for pain relief]), one dose of 10/325 mg (milligram, a unit of measurement) was administered five hours prior (to repositioning Patient 13). RN 8 confirmed that since the medication for pain (Norco) was administered five hours ago; it (Norco) will not relieve the Patient 13's pain during repositioning. RN 8 further stated that repositioning should have been paused when Patient 13 exhibited signs of pain. RN 8 stated Patient 13 may be aware of the pain medication ordered for them (Patient 13), but RN 8 confirmed that intervention for pain management was not discussed with Patient 13. RN 8 stated Another intervention to relieve pain for Patient 13 was rest.

During an interview on 12/16/2024 at 4:00 p.m. with the Nurse Manager (NM) 3, NM 3 stated that pain management should align with patient-reported pain level. NM stated, "Pain is what the patient says the pain is." NM 3 further stated it was important to follow prescribed orders, and if the prescribed order was not adequate for pain relief, the physician should be consulted for better pain management prior to repositioning Patient 13. NM 3 verified that RN 8 did not notify the physician that Patient 13 is experiencing pain upon repositioning and may require changes to pain medication regimen or additional pain medication.

During a concurrent interview and record review on 12/18/2024 at 10:45 a.m. with the Quality Coordinator (QC) 1, Patient 13's Electronic Medical Record (EMR, a digital version of the paper charts in hospitals) titled, "Vascular Surgery (surgery that can be used to treat a wide range of heart and blood flow issues) Progress Note," dated 12/17/2024, indicated Patient 13 underwent right above-knee amputation (surgically removing a body part, like a limb) on 12/10/2024.

During a concurrent interview and record review on 12/18/2024 at 10:50 a.m. with the Quality Coordinator (QC) 1, Patient 13's EMR titled, "Care Plan," dated from 12/7/2024 through 12/16/2024, was reviewed. QC 1 confirmed that there was no revision to the care plan for pain's interventions throughout Patient 13 length of stay (from 12/7/2024 through 12/16/2024). The care plan for pain indicated intervention were as follows:

1. Assessment and preservation of baseline functional status or physical
2. Assessment and preservation of baseline functional status or Psychosocial
3. Opioid analgesic side-effect assessment
4. Pain characteristic assessment
5. appropriate form of analgesia
6. Cognitive-emotional support
7. Comfort promotion.
8. Patient family participation promotion

During a concurrent interview and record review on 12/18/2024 at 11:00 a.m. with the Quality Coordinator (QC) 1, Patient 13's EMR titled, "Pain Assessment," dated from 12/7/2024 through 12/16/2024, was reviewed. QC 1 confirmed that from 12/7/2024 through 12/16/2024 when pain rating was documented, there was no documentation of the characteristics of pain, such as quality of pain, pain onset, and pain duration. QC 1 confirmed that pain characteristic assessment is part of the intervention listed in Patient 13's pain care plan.

During a review of the facility's policy and procedure (P&P) titled, "Interdisciplinary Plan of Care (IPOC)," dated September 2020, the P&P indicated, "Ensure that the nursing staff develops, and keeps current, a nursing plan of care for each patient. The nursing plan of care is part of the interdisciplinary plan of care (lPOC). Each patient will receive care based on an individualized lPOC in collaboration with the interdisciplinary team. Ensure the patient's (or patient's representatives) right to participate in the development and implementation of his or her plan of care, inpatient treatment/care plan, outpatient treatment/care plan, and/or discharge plan. Aspects of patient care, such as, teaching, interventions, referrals, discharge planning, follow-up, changes in plan, etc. are linked with the interdisciplinary plan of care. Planning care includes planning the patient's care while in the hospital as well as planning for discharge to meet post-hospital needs. A nursing IPOC is developed based on assessing the patient's needs upon admission from all available sources of assessment to develop a comprehensive picture of the patients' condition (not solely those needs related to the admitting diagnosis) and develop-appropriate nursing interventions in response to those needs. Those sources may include: The Patient, the Patient's family, other patient caregivers as applicable ... The IPOC is kept current by ongoing assessments of the patient's needs and the patient's response to goals or outcomes, interventions, and updating or revising the patient's IPOC in response to assessments ..."

During a review of the facility's policy and procedure (P&P) titled, "Pain Management," dated November 2022, the P&P indicated, "Pain is highly individual and variable and is one of the most feared aspects of illness, and one of the most common reasons for seeking healthcare interventions. The purpose of this policy is to provide guidelines for a collaborative interdisciplinary approach to pain management. The goals of pain management are:

Relief from physical suffering
Preservation or restoration of function
Sustained quality of life
Prevention of addiction
Pain management is a shared responsibility between the patient, providers, and nursing ... B. Initial and ongoing assessment of pain ...An initial pain assessment is done on admission. It includes: Pain Goal: This is set by the patient as is developmentally appropriate ... Continuing Pain Assessment (after Admission/Arrival Pain Assessment): Shift Assessment, Type of Assessment {Assessment or Post-Intervention Reassessment, Pain Goal (required each shift and pm any changes), Sedation Score (required), Location (required each shift and pm any change), Pain Rating (required) ..."

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights," dated November 2023, the P&P indicated, "To identify each client's rights while under treatment. Each client has all rights given to all citizens unless relieved of these rights by court action. Specifically, staff needs to assist in maintaining the client's rights to confidentiality, privacy, and dignity. Individualized treatment that is appropriate to the client's problems and needs ... Each client receives individualized treatment, including at least the following: ...The provision of an individualized treatment plan. The periodic review of the treatment plan. The active participation of the client and/or conservator in the planning of treatment. The provision of an adequate number of competent, qualified, and experienced professional clinical staff to implement the treatment plan and provide care ..."

During a review of the facility's policy and procedure (P&P) titled, "Hospital Plan for the Provision of Patient Care Services," dated 9/1/2020, the P&P indicated, "Overview of Discipline-Specific Policies for Assessment and Reassessment ... Nursing; Assessment time frame: Demographic, physical assessment, and care planning assessment within 2 hours of admission in critical care areas and 8 hours of admission in non-critical care areas. RN analyzes data/prioritizes care. Re-Assessment Time Frame: Every shift and/or unit-specific, as well as pre- and post-treatment, including diagnosis, pre- & post-treatment, and response to treatments ..."

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

1. Ensure that the clinical alarms for telemetry monitor (a medical device that continuously monitors the heart activity, and/or oxygen saturations [the amount of oxygen in the blood]) were appropriately set, according to the facility's "Cardiac Monitoring Guidelines and Clinical Alarm Management" policy and procedure, for two of 31 sampled patients (Patients 14 and Patient 15).

This deficient practice had the potential to delay the detection of life-threatening changes. For Patient 14, this could have led to uncontrolled high blood pressure, increasing the risk of stroke (occurs when blood flow to the brain is interrupted and causing brain cells to die) or other cardiac (relating to the heart) emergencies. For Patient 15, improper oxygen monitoring can lead to undetected hypoxia (low oxygen levels), which can cause brain damage or death.

2. Ensure Nursing personnel reported a suspected adverse drug reaction (unintended, harmful events attributed to the use of medicines) to Ativan (Ativan, a benzodiazepine [class of medication] used to treat anxiety) and/or Benadryl (Benadryl, an antihistamine [class of medication] used to treat allergic reactions, reduce itching, and provide sedation) for one of 31 sampled patients (Patient 27), in accordance with the facility's policy and procedure regarding adverse drug reaction reporting.

This deficient practice had the potential to compromise Patient 27's health and recovery due to delayed recognition and management of adverse drug reactions and repeated exposure to medications that Patient 27 may be allergic to.

3. Ensure Nursing personnel entered the isolation precautions (infection control measures designed to prevent the spread of contagious diseases, such as placing the patient in a designated isolation room and using protective equipment like masks and gowns) information for Influenza A (a contagious viral infection of the respiratory tract that can cause fever, cough, sore throat, and severe complications in vulnerable populations) into the Patient Care System (PCS, an electronic system used to document and communicate patient care needs and treatment plans) for one of 31 sampled patients (Patient 29), in accordance with the facility's policy and procedure regarding "Initiation of Infection Control Precautions for Staff and Visitors."

This deficient practice had the potential to delay the implementation of infection control measures for Patient 29, thereby increasing the risk of spreading Influenza A to other patients, visitors, and staff due to uncommunicated isolation precautions.

4. Implement complete seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness [a state where a person is not aware of their environment or themselves]) precautions for one (Patient 21) of 31 sampled patients, when there was no readily available suction set-up (a medical device that essentially acts like a vacuum cleaner for a person's airway, removing excess mucus, saliva, blood, or other fluids that they can't clear on their own, helping them breathe properly, especially when they are unconscious or unable to cough effectively) for Patient 21 in the event of a seizure episode, in accordance with the facility's policy and procedure regarding "Seizure Precautions and Guidelines."

This deficient practice had the potential for Patient 21 to aspirate (inhale) during a seizure activity, which may result in complications such as aspiration pneumonia (infection of the lung) and may prolong Patient 21's recovery.

5. Ensure side rails were padded for one of 31 sampled patients (Patient 2) for seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness) precaution, in accordance with the facility's policy and procedure regarding "Seizure Precaution and Guidelines." This deficient practice had the potential to result in Patient 2 getting injured when having seizures

6. Ensure Nursing staff completed the pre-procedure check list (steps taken to verify the patient, procedure, and consent form) and follow time-out (a pause before a medical procedure to confirm that the correct patient, procedure, and site are being used) process for two of 31 sampled patients (Patient 2 and Patient 3), in accordance with the facility's policy and procedure regarding "Universal Protocol (a set of standardized procedures in healthcare, primarily used in surgical settings, designed to prevent wrong-site, wrong-procedure, and wrong-patient surgeries by requiring a pre-procedure verification process, surgical site marking, and a "time-out" before starting the procedure).

This deficient practice had the potential to result in Patient 2 and Patient 3 having the wrong procedure, wrong site and/or having the procedure without informed consent (a process in which a health care providers educates a patient about the risks, benefits, and alternatives of a given procedure or intervention).

7. Ensure Nursing staff followed chain of command (provides a clear structure for reporting concerns, escalating issues, and making decisions related to patient care) to manage one of 31 sampled patient's (Patient 1) pain, in accordance with the facility's policy and procedure regarding "Chain of Command."

This deficient practice resulted in Patient 1 remaining in severe pain for 3.5 hours on 12/3/2024 and had the potential to result in Patient 1 not being able to move, talk or perform activities of daily living (basic self-care tasks that people perform everyday such as hygiene) due to severe pain.

Findings:

1. During a review of Patient 14's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 12/16/2024, the "H&P" indicated, Patient 14s past medical history included hypertension (abnormally high blood pressure), and premature ventricular contractions (PVCs, are extra, abnormal heartbeats). The H&P further indicated Patient 14 was brought in by ambulance (a special vehicle used to take sick or injured people to the hospital) after "developing acute vertigo (a sensation of motion or spinning that is often described as dizziness), patient (Patient 14) also had nausea (a feeling of sickness with an inclination to vomit) and vomiting. She (Patient 14 was hypertensive (having high blood pressure) to 211 (systolic blood pressure, the pressure in the artery when the heart contracts and pumps blood out)/92 (diastolic blood pressure, the pressure in the arteries when the heart is relaxed between beats)." The H&P indicated the blood pressure of 211/92 was treated.

During a concurrent observation and interview on 12/16/2024 at 3:00 p.m. with the registered nurse (RN) 3 in Patient 14's room, the telemetry monitor was set to trigger systolic blood pressure (the top number in a blood pressure reading) alarms only if readings reached 170 or above and heart rate alarms only if readings were 170 beats per minute or higher. RN 3 stated they (the nursing staff) did not address and set the high limits alarm to go off for SBP and the heart rate. RN 3 further stated, "It is important to check the alarm settings." RN 3 also stated they (the nursing staff) should follow policy and procedure to set the alarm in accordance with the default standard limits if the patient does not have a specific order for alarm setting.

During a concurrent interview and record review on 12/16/2024 at 3:16 p.m. with the charge nurse (CN) 1, the facility's policy and procedure (P&P) titled, Cardiac Monitoring Guidelines and Clinical Alarm management," dated February 2021, was reviewed. CN 1 stated the default standard alarm setting for heart rate high limits was 120, and for SBP high limits was 150. CN 1 stated if the patient (Patient 14) does not have an order for a heart rate setting, then the HR high limits should be set to 120.

During a concurrent interview and record review on 12/17/2024 at 2:16 p.m. with Quality Coordinator (QC) 1, Patient 14's Electronic Medical Record (EMR, a digital version of the paper charts in hospitals) titled, "Medication Administration Record (MAR, report of patient's medication including special instructions and date and time)," dated 12/16/2024 at 9:39 a.m. was reviewed. The MAR indicated that Patient 14's medication order included hydralazine (a drug that lowers blood pressure) 10 mg (milligram, a unit of measurement) with instructions to "give for SBP greater than 150." QC 1 confirmed that the appropriate high limits alarm setting for SBP should be set at 150 to activate the alarm and thus administer the hydralazine as ordered.

During a concurrent interview and record review on 12/17/2024 at 2:20 p.m. with Quality Coordinator (QC) 1, Patient 14's EMR titled, "Order Report," was reviewed. The report indicated that on 12/16/2024 at 3:05 a.m., Patient 14 was ordered to start "48-Hour Cardiac Monitoring until discontinued." QC 1 verified that Patient 14 does not have a specific heart rate high limit order by the physician; thus, the HR's alarm setting should be set to the standard default setting, at 120 for the high limits.

During a review of the facility's policy and procedure (P&P) titled, "Cardiac Monitoring Guidelines and Clinical Alarm management," dated February 2021, the P&P indicated, "In order to promote patient safety, this policy provides Guidelines for RNs related to cardiac monitoring ... Alarms are set and adjusted as described under Procedure in this policy. Default Alarm Settings: Determination of default settings is based on risk analysis and each area provides input to safe default settings. For current Defaults See Appendix C., Alarm Default Settings Adults: Heart rate high 120 and SBP high 150 ..."

2. During a review of Patient 15's "History and Physical (H&P)," dated 12/16/2024, the "H&P" indicated, Patient 15 medical history included DM II (diabetes mellitus type 2, a disease that occurs when your blood sugar is too high), cerebral accident (CVA, or stroke; a loss of blood flow to part of the brain), and pulmonary embolism (PE, a blood clot in the lungs).

During a concurrent observation and interview on 12/16/2024 at 2:20 p.m. with the charge nurse (CN) 2 in Patient 15's room, the telemetry monitor displayed that the oxygen saturation alarm was set to activate only if levels dropped below 85%. CN 2 stated it should be set at default setting of 88 % unless the patient has an order by the physician for setting of 85%.

During a review of Patient 15's electronic medical record titled "Notify Physician Vitals," dated 12/16/2024 at 7:00 a.m., a physician order indicated the need to notify the physician if oxygen saturation levels fell below 88%.

During a review of the facility's policy and procedure (P&P) titled, "Cardiac Monitoring Guidelines and Clinical Alarm management," dated February 2021, the P&P indicated, "In order to promote patient safety, this policy provides Guidelines for RNs related to cardiac monitoring ... Alarms are set and adjusted as described under Procedure in this policy. Default Alarm Settings: Determination of default settings is based on risk analysis and each area provides input to safe default settings. For current Defaults See Appendix C., Alarm Default Settings Adults: 02 (oxygen) saturation low at 88."

3. During a review of Patient 27's History and Physical (H&P), dated 11/30/2023, the H&P indicated that Patient 27 was admitted to the facility on 11/30/2023 due to a fall (fall, an incident in which a person unintentionally comes to rest on the ground or a lower level) at home and elevated troponin (elevated troponin, an increased level of troponin in the blood indicative of heart muscle injury) with no symptoms. The H&P further indicated that Patient 27 had a Past Medical History (PMH) of Alzheimer's (Alzheimer's, a progressive disease that causes memory loss and cognitive decline), depression, white coat hypertension (blood pressure is higher at a healthcare professional's office than in other settings, such as at home), and anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).

During a review of Patient 27's medical record (MR) titled. "Allergy Review History (a detailed record of a patient's known allergies and adverse reactions to medications), dated 11/30/2023, the MR indicated that on 11/30/2023, an allergy to Xanax (a medication containing alprazolam, used to treat anxiety and panic disorders) with a recorded unspecified reaction (unspecified reaction, an allergic response where the specific symptoms or type of reaction are not documented or unavailable) was documented in Patient 27's electronic medical record (EMR).

During a review of Patient 27's medical record (MR) titled, "Physician's Orders," dated 12/02/2023, the MR indicated that 1 mg of Ativan IV push (Ativan IV push, an intravenous administration of lorazepam given rapidly through a vein to provide immediate relief) was ordered for Patient 27 on 12/02/2023 at 6:36 p.m., to be administered every 12 hours as needed for agitation (a feeling of restlessness and irritability) and anxiety.

During a review of Patient 27's medical record (MR) titled, "Allergy Review History," dated 12/2/2023, the MR indicated that Patient 27's primary nurse reviewed Patient 27's allergy record on 12/2/2023 at 6:35 p.m.

During a review of Patient 27's medical record (MR) titled, "Warning Override History for Lorazepam (Ativan) injection 1 mg," dated 12/02/2023, the MR indicated that on 12/02/2023 at 6:36 p.m., the warning for allergy/contraindication (a condition in which a medication should not be used due to a documented allergy or other medical reason) for administration of Ativan (Ativan, a benzodiazepine medication used to manage anxiety and seizures) was due to a documented allergy to alprazolam (Xanax, a benzodiazepine used to treat anxiety and panic disorders) was overridden (to bypass) by a primary nurse (Patient 27's nurse) by the order of a physician (MD 1). The MR contained the following comment: "Physician (MD 1) aware [of an allergy/contraindication], Benadryl (an antihistamine medication used to treat allergic reactions and provide sedation) ordered."

During an interview on 12/18/2024 at 10:15 a.m. with Medication Safety Pharmacy Compliance officer (MSPC, a pharmacist responsible for ensuring compliance with pharmacy regulations, medication safety, and adherence to organizational policies), the MSPC reviewed Patient 27's "Warning Override History for Lorazepam (Ativan) injection 1 mg" and stated the following: The ordering user for 1 mg of Ativan was [Patient 27's] registered nurse (RN), and the ordering provider was medical doctor (MD 1). It was a telephone order with readback, signed on 12/02/2023. The allergy/contraindication warning was overridden by the nurse due to a comment: "MD 1 aware, PRN (PRN, an abbreviation for "pro re nata," meaning "as needed") Benadryl ordered." Every medication ordered comes into a queue (a system where medication orders are temporarily held for review by the pharmacy before being dispensed) for the pharmacy to review. There was an allergy contraindication alert, but it was bypassed because of what the physician said and as documented by the nurse. The pharmacist released the order for 1 mg Ativan after reviewing the order and the comment.

During a review of Patient 27's Medical Administration Record (MAR), dated 12/2/2023, the MAR indicated that on 12/2/2023 Patient 27 was administered 1 mg of Ativan at 7:57 p.m.

During a review of Patient 27's medical record (MR) titled, "Nursing Note," dated 12/03/2023, the MR indicated that on 12/03/2024 at 6:00 a.m., the night shift nurse (RN 1) documented the following: Benadryl IV (an intravenous (IV) formulation of diphenhydramine (Benadryl) given through a vein and used to treat allergic reactions and provide sedation) and Ativan (IV) given for agitation. Patient (Patient 27) started to have occasional jerky movements afterwards, which seem like restless leg syndrome (legs jerking) and whole-body myoclonus (myoclonus, a rapid, involuntary muscle jerk affecting the entire body). Severity and frequency decreased over this shift [12/02/23-12/03/23, 7 p.m.-7 a.m.], but still present intermittently.

During a review of Patient 27's medical record (MR) titled, "Physician Notification," dated 12/2/2024 through 12/3/2024, the MR indicated that no record of physician notification was entered during the night shift (7 p.m. to 7 a.m.) regarding the observed occasional jerky movements following the administration of Ativan and Benadryl.

During a review of Patient 27's medical record (MR) titled, "Provider Notification," dated 12/03/2023, the MR indicated that Patient 27's primary RN (RN, Registered Nurse) documented the following on 12/03/2023 at 9:00 a.m.: "Incomprehensible speech (speech that cannot be understood by others), tongue swelling/dryness (tongue swelling/dryness, a condition where the tongue becomes enlarged and lacks moisture) and fatigue. MD (MD, Medical Doctor) putting in orders."

During an interview on 12/19/2024 at 1:50 p.m. with Medication Safety Pharmacy Compliance Officer (MSPC), the MSPC stated the following: "Anybody can go on the intranet and access the event reporting system for any unsafe event, including medication-related events. They can also call the hotline to report. The nurse should have reported the adverse event associated with the medication administration [Ativan and/or Benadryl]. The event was not reported. The night shift nurse should have documented the adverse reactions. Both nurses should have documented in the reporting system. They take care of the patient, and when they see something, they should say something. If it is not reported, there is no way to intervene and identify the issues."

During the same interview on 12/19/2024 at 1:50 p.m., the MSPC stated, "Adverse medication reactions are tracked. I maintain a spreadsheet, and I track reactions, then report them to the Medication Safety Committee. I would have investigated the incident right away, documented it in the allergy section, and ensured that the next time the physician orders the medication, if coded correctly with the severity, we could follow up with the physician. We could then put a hard stop on the medication or discuss it with the MD."

During an interview on 12/20/2024 at 7:46 a.m. with registered nurse (RN 1), regarding Patient 27's documented response to administration of Ativan and Benadryl on 12/03/2023, RN 1 provided the following response:

-RN 1 recalled observing jerky movements in Patient 27, describing them as resembling a seizure (uncontrolled electrical disturbance in the brain that can cause changes in behavior, movements, sensations, or consciousness) but not an actual seizure. RN 1 stated that she (RN 1) did not find the movements concerning at the time and considered them a potential side effect of Benadryl based on information looked up online. RN 1 said that if she (RN 1) had notified the physician about the movements, it would have been documented in the notification in the patient's (Patient 27) medical record. However, she (RN 1) believed the movements were most likely a side effect of the medication and reported her observations to the oncoming nurse during the shift handoff instead of escalating them further.

-RN 1 further said that, in cases of suspected adverse medication reactions, the usual practice would be to call the physician and document the event in the progress notes. RN 1 said that adverse reactions should also be reported in the facility's adverse event reporting system but stated that she (RN 1) thought the jerky movements were an expected reaction to Benadryl, as the medication was ordered to address a potential reaction (to Ativan). RN 1 did not recall any instances of tongue swelling during her (RN 1) shift (12/2/2024 through 12/3/2024, 7 p.m. to 7 a.m. shift) and described the patient (Patient 27) as responsive, occasionally waking up to say a word before falling back asleep.

During a review of the facility's policy and procedure (P&P) titled, "Adverse Drug Reaction Reporting," dated 3/2018, the P&P indicated the following: A. Nursing personnel play a critical role in adverse drug reaction (ADR) reporting, as they are often the first to observe a suspected drug reaction and are required to report it immediately. B. An adverse drug reaction (ADR) is defined as a reaction that is noxious and unintended and occurs in doses normally used in humans for prophylaxis, diagnosis, therapy, or modification of physiological functions. C. An ADR is further defined as an unexpected, unintended, undesired, or excessive response to a drug that prolongs a hospital stay, requires changing drug therapy, or necessitates discontinuing the drug.
Procedure:

A. There are three methods of reporting ADRs:
1. Internal Reporting System.
2. Federal Reporting System.
3. Hospital Adverse Drug Reaction Hotline.

B. Reporting Process:
1. All suspected ADRs must be reported in the internal reporting system.
4. ADRs that result in insignificant or no harm to the patient must also be documented in the electronic health record (EHR) but do not require immediate physician notification. Documentation should be completed as soon as practical but without undue delay.

C. The nurse and/or pharmacist must report any suspected ADRs to the physician for verification and initiate event reporting.
D. Pharmacy tracks ADR data
E. A physician, Medication Safety Committee, and the Pharmacy Therapeutics and Diet Committee review reports quarterly.
F. Verified drug reactions must be entered into the patient's chart in the Allergy section of the electronic medical record (EMR).

4. During a review of Patient 29's History and Physical (H&P), dated 12/14/2023, the H&P indicated that Patient 29 had a past medical history (PMH, a record of prior diagnoses and treatments), including but not limited to end-stage renal disease (ESRD, a chronic condition where the kidneys fail to function effectively), currently on hemodialysis (HD, a treatment that filters waste and excess fluids from the blood), diabetes (a chronic disease that affects the body's ability to regulate blood sugar levels due to insufficient insulin [helps to lower blood sugar level] production or utilization), and a history of cardiac transplant (a surgical procedure to replace a diseased heart with a healthy donor heart). The H&P further indicated that Patient 29 was admitted on 12/14/2023 due to respiratory failure (a serious condition where the lungs cannot adequately oxygenate the blood) and Influenza A (a contagious viral infection of the respiratory tract that can cause fever, cough, sore throat, and potentially severe complications in vulnerable populations).

During a concurrent interview and record review on 12/18/2024 at 10:58 a.m. with the Professional Development Nurse (PDN), the PDN reviewed Patient 29's medical record (MR), titled, "Care Plan (a structured, individualized plan created by healthcare providers to address a patient's specific medical and nursing needs)," dated 12/14/2023-12/18/2023. The PDN stated that nurses did not develop a care plan to address Patient 29's medical condition of Influenza A infection.

During the same interview on 12/18/2024 at 10:58 a.m. with the Professional Development Nurse (PDN), the PDN reviewed Patient 29's medical chart and stated that there was no record or documentation of isolation precautions (infection control measures implemented to prevent the spread of contagious diseases, including actions like placing the patient in a designated isolation room and using appropriate protective equipment such as masks and gowns) in Patient 29's medical record.

During a review of the facility's built-in nursing care plans titled, "Infection - Risk/Management of," the following interventions (actions or measures taken by nursing staff to address specific patient care needs and promote positive outcomes) were identified as part of standard nursing practices upon initiation of an Infection Management care plan:
-Isolation Appropriateness Assessment: Evaluating whether isolation precautions are necessary based on the patient's condition, diagnosis, and potential risk of infection transmission to others.
-Patient Isolation: Implementing measures to physically separate the patient to prevent the spread of infection, which may include placing the patient in a designated isolation room and applying appropriate precautions such as droplet, contact, or airborne protocols.

During an interview on 12/19/2024 at 10:20 a.m. with the Nurse Manager (NM 1), the NM 1 stated that care plans (CPs) should be initiated for patients as soon as possible after admission. The NM 1 said the following: For Influenza A, the nurse should initiate a respiratory CP (focused on managing breathing difficulties and lung health) and an infection control/management CP (designed to prevent the spread of infection and address specific patient needs). The patient should also be placed on droplet isolation precautions (infection control measures to prevent the spread of respiratory droplets) and document it (placement in droplet isolation precaution) in the Patient Care System (PCS, an electronic system used to document and communicate patient care needs and treatment plans). This is a nurse-driven intervention and does not require a physician's order.

During a review of the facility's policy and procedure (P&P) titled, "Initiation of Infection Control Precautions for Staff and Visitors," dated 11/2022, the P&P indicated the following: A registered nurse to place a patient on precautions without a physician's order to minimize the spread of infection to the patient, staff, and the community at large. The P&P further stated that the registered nurse is responsible for educating the patient and visitors about the need for precautions and expectations and for entering the type of precautions into the Patient Care System (PCS, an electronic system used to document and communicate patient care needs and treatment plans) and TeleTracking (a software system designed to optimize hospital operations by monitoring and managing patient flow, bed assignments, and resource utilization).

During a review of the facility's policy and procedure (P&P) titled, "Interdisciplinary Care Plan (IPOC)" dated 9/20/2024, the P&P indicated that nursing staff is responsible for developing and maintaining a current nursing plan of care for each patient. Plan of care: A communication tool that identifies and prioritizes patient care and treatment needs, including outcomes, interventions, indicators, and goals. A nursing IPOC is developed by assessing the patient's needs upon admission from all available sources, creating a comprehensive picture of the patient's condition (not just those related to the admitting diagnosis) to establish appropriate nursing interventions.

5. During a review of Patient 21's History and Physical (H&P), dated 11/22/2024, the H&P indicated that Patient 21 was admitted to the facility on 11/22/2024 for bilateral (both) lower extremity (legs) cellulitis (bacterial infection of the skin) and had a history of seizures (a sudden uncontrolled electrical disturbances in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness [a state where a person is not aware of their surroundings or themselves]).

During a review of Patient 21's electronic medical record titled, "Precaution Orders," dated 11/22/2024 at 5:56 p.m., a physician order indicated continuous seizure precautions (safety measures taken before someone experiences a seizure activity).

During a concurrent observation and interview on 12/17/2024 at 10:23 a.m. with Registered Nurse (RN) 11 in Patient 21's room, RN 11 stated that Patient 21 was on seizure precautions and that the side rails should be padded and a suction machine (a medical device that essentially acts like a vacuum cleaner for a person's airway, removing excess mucus, saliva, blood, or other fluids that they can't clear on their own, helping them breathe properly, especially when they are unconscious or unable to cough effectively) should be set up at bedside. RN 11 stated that Patient 21 does not have a suction set-up because Patient 21 was on a safety hold (when someone is involuntarily detained for up to 72 hours for evaluation and treatment) and no cords were allowed in the room for safety. RN 11 stated that suction set-up could be placed outside in the hallway as standby. RN 11 confirmed that there was no portable suction in the hallway for Patient 21.

During an interview on 12/17/2024 at 2:12 p.m. with the Process Excellence Specialist (SRN), the SRN stated that nurses should make sure that side rails were padded for safety, preventing patients from injuring themselves during a seizure episode, and suction should be set up at bedside to prevent aspiration (the accidental inhalation of foreign materials, such as food, liquid, or other substances, into the lungs).

During an interview on 12/19/2024 at 1:28 p.m., with Nurse Manager (NM) 4, NM 4 stated seizure precautions could be determined by the neurologist (physician who specializes in the diagnosis, treatment, and management of disorders affecting the brain and spinal cord) and entered as an order. It could also be nursing driven for patients who had history of or with active seizures. NM 4 said Seizure precaution interventions included: applying padded side rails, keeping head of bed at appropriate elevation to prevention aspiration and have suction set up in the room.

During a review of the facility's policy and procedure (P&P) titled, "Seizure Precautions and Guidelines," dated 1/21, indicated seizure precautions guideline "to help protect the patient from injury and maintain a patent airway if a seizure should occur. Equipment includes padding for side rails, suction setup with yankauer (a medical tool used to remove secretions from the mouth and throat, oropharynx, to prevent aspiration and maintain an open airway) and to ensure oxygen and suction is set up."

6. During a review of Patient 2's History and Physical (H&P) dated 12/3/2024, the H&P indicated, Patient 2 was admitted to the facility with diagnoses of acute intracranial (inside the brain) hemorrhage (bleeding). The H&P also indicated Patient 2 had seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and a loss of consciousness) on 12/3/2024.

During a review of Patient 2's "Neurology Consult Note," dated 12/6/2024, the "Neurology Consult Note" indicated, Neurology was consulted for seizure control with recommendation to continue Phenobarbital (medication to treat seizure), Lamictal (medication to treat seizure), and Vimpat (medication to treat seizure) and seizure precaution (safety measures taken before an individual experiences seizure).

During a concurrent observation and interview on 12/16/2024 at 3:03 p.m. with Registered Nurse (RN) 6 at Patient 2's room, Patient 2 was observed in bed with no padded side rails. There was a communication board in the room with written "Seizure Precaution and monitor for seizure." RN 6 stated there was no padded side rails applied on Patient 2.

During an interview on 12/16/2024 at 3:12 p.m. with RN 7, RN 7 stated seizure precaution was considered prophylaxis (to prevent) measures to protect the patient when he or she seized, there should be padded side rails. RN 7 also stated the seizure precaution measures should be uniform throughout the hospital.

During an interview on 12/17/2024 at 10:23 a.m. with RN 11, RN 11 stated nursing staff should make sure bed side rails were padded and there was a suction set up (a medical device that essentially acts like a vacuum cleaner for a person's airway, removing excess mucus, saliva, blood, or other fluids that they can't clear on their own, helping them breathe properly, especially when they are unconscious or unable to cough effectively) for seizure precaution.

During a concurrent interview and record review on 12/17/2024 at 2:12 p.m. with the Process Excellence Specialist (SRN), Patient 2's "Daily Care Flowsheet," dated 12/16/2024, was reviewed. The Daily Care Flowsheet indicated, Patient 2 was placed on seizure precaution and seizure precaution intervention with "suction set up" from 8 a.m. to 6 p.m. SRN stated there was no documentation that padded side rails

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

1. Ensure one of 31 sampled patient's (Patient 13) prescribed medication, Desitin (medication used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and skin irritations), was administered in accordance with prescribed instruction.

This deficient practice could result in improper wound care management for Patient 13, potentially causing delayed healing, an increased risk of infection, a worsening of the wound condition, and subsequent health complication.

2. Ensure nursing staff gave pain medications, per physician order, for one of 31 sampled patients (Patient 3), in accordance with the facility's policy and procedure regarding "Medication Use, Administration, Routes and High Alert Medications," when Norco (opioid medication to treat and relieve pain) 5/325 milligrams (mg, a unit of measure) by mouth and Morphine (opioid medication to treat and relieve moderate to severe pain) 2 mg intravenous (IV - administered into a vein), were administered to Patient 3 at the same time.

This deficient practice had the potential to overmedicate Patient 3 and put Patient 3 at risk for oversedation (excessive drowsiness) and respiratory distress (difficulty breathing).

Findings:

1. During a review of Patient 13's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 12/7/2024, the "H&P" indicated Patient 13 was admitted with "past medical history of alcoholism (a chronic disease in which a person craves drinks that contain alcohol and is unable to control his or her drinking) and bedbound state (when someone is unable to get out of bed independently, requiring assistance to move around or change positions) who presents to the Emergency Department (ED, a department within a hospital where someone is treated for life-threatening or limb-threatening illnesses or injuries) for evaluation of back pain ... He (Patient 13) reports pain localized to his back and reports a history of sciatica (pain that radiates into one or both legs)." The H&P further indicated Patient 13 had osteomyelitis (an infection in a bone) with extensive cellulitis (a deep infection of the skin caused by bacteria) to the back, limbs, and right heel with visible bone exposure.

During a concurrent interview and record review on 12/17/2024 at 3:10 p.m. with the Quality Coordinator (QC) 1, Patient 13's "Medication Administration Report," with a start date on 12/11/2024, indicated Zinc oxide-cod liver oil (Desitin, medication used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and skin irritations) 40% ointment. Instruction: Apply 2 times daily. QC verified that Desitin was not applied on 12/14/2024 for the a.m. shift (7 a.m. to 7 p.m.). QC stated if the medication was not given, there should be documentation of the reason that the medication was omitted. Additionally, QC confirmed that there was no documentation indicating the reason that the Desitin was not administered. On 12/14/2024, the Skin/Wound/PI (Pressure Injury, a localized damage to the skin and underlying tissue caused by prolonged pressure on a specific area of the body, usually over a bony prominence, which restricts blood flow and can lead to tissue breakdown and open sores if left untreated) records indicated that for both an a.m. shift (7 a.m. to 7 p.m.) and a p.m. shift (7 p.m. to 7 a.m.), there was No wound assessment and wound care medication (Desitin) documented. QC 1 stated that Patient 13 remained on the unit on 12/14/2024. Thus, wound assessment and treatment should be completed and documented. QC 1 also confirmed that on 12/14/2024 there were no documents indicating that Patient 13 refused wound assessment and treatment.

During an interview on 12/19/2024 at 12:15 p.m. with Nursing Supervisor and Wound Care (NSW), NSW stated skin and wound assessment must be completed every shift especially for Patient 13, who had pressure injury that required wound treatment 2 times a day.

During a review of the facility's policy and procedure (P&P) titled, "Medication Use, Administration, Routes and High Alert Medications," dated September 2024, the P&P indicated, "Provide guidelines to ensure the safe administration of medications to patients at [Name of Facility]. Ensure regulatory compliance in the prescribing, dispensing, administration, and documentation of medication by authorized [name of the facility] employees ... Medication Use, Administration and routes: Meds ordered more frequently than daily but no more frequently than every scheduled time 4 hours, Administer up to 1 hour before or after the scheduled time.

During a review of the facility's policy and procedure (P&P) titled, "Wound Care Assessment & Treatment" dated February 2021, the P&P indicated, "Patient Assessment: All patients admitted to [Name of Facility] will have their skin integrity assessed by a RN within eight (8) hours of admission. Skin integrity assessment will be performed by an RN at least once a shift ..."

2. During a review of Patient 3's History and Physical (H&P), dated 12/15/2024, the H&P indicated, Patient 3 was admitted to the facility with diagnoses of diabetes (high blood sugar), right lower leg abscess (a pocket of pus formed any part of the body) with cellulitis (an infection of the deeper layers of skin and the underlying tissue). The H&P also indicated Patient 3 required surgical evaluation for possible debridement (a medical procedure that removed damaged, dead or infected tissue) and drainage (the process of removing fluid from a wound).

During a review of Patient 3's "Pain Flowsheet," dated 12/15/2024, the pain flowsheet indicated, on 12/15/2024 at 8 p.m., Patient 3 had pain rating of six (6) on numeric pain scale (0-10, a pain scale used in rating the severity of pain with 0 being no pain, 1-3 for mild pain, 4-6 for moderate pain and 7-10 for severe pain) at right ankle.

During a concurrent interview and record review on 12/18/2024 at 10:57 a.m. with the Process Excellence Specialist (SRN), Patient 3's "Medication Administration Record (MAR, record of medications given to patients)," dated 12/15/2024, was reviewed. The MAR indicated Norco (opioid medication to treat and relieve pain) 5/325 milligrams (mg, a unit of measure) 1 tablet by mouth was given on 12/15/2024 at 10:10 p.m. and Morphine (opioid medication to treat and relieve moderate to severe pain) 2 mg intravenous (IV - administered into a vein) was given on 12/15/2024 at 10:10 p.m. by Registered Nurse (RN) 14. SRN stated the two medications were given for Patient 3's pain level 6/10.

During a review of Patient 3's "Physician orders," dated 12/15/2024, the physician orders indicated the following:

-Diabetic Diet (a special diet for patients with high blood sugar);
-Norco 5/325 mg one tablet every four (4) hours as needed for moderate pain (6-10);
-Morphine injection 2 mg intravenous push (IVP) every four (4) hours as needed for moderate pain (4-6) if NPO or patient cannot tolerate PO.

During an interview on 12/19/2024 at 11 a.m. with the Nurse Manager (NM) 1 at Surgical Unit (a hospital ward where patients are cared and treated before and after surgery) 1 and 2, NM 1 stated RN 14 should only give either Norco 3/325 mg or Morphine 2 mg to Patient 3 but not both medications. NM 1 stated RN 14 did not follow physician order. NM 1 stated giving both medications could over medicate Patient 3 and could put Patient 3 at risk for over sedation (excessive drowsiness) and result in respiratory distress (difficulty breathing).

During a review of the facility's policy and procedure (P&P) titled, "Medication Use, Administration, Routes and High Alert Medications," dated 9/2024, the P&P indicated, "Purpose: Provide guidelines to ensure the safe administration of medications to patients at [the facility] ... Six rights of medication administration ... the licensed caregiver reviews the six rights prior to administering medication: 1. Right patient 2. Right medication 3. Right dose 4. Right route 5. Right time and/or frequency 6. Right reason/ indication and the right monitoring following administration."