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Based on interview, and record review, the hospital failed to comply with the Condition of Participation for Nursing Services as evidenced by:

1. Failure to ensure the plan of care was implemented for 3 sampled patients (Patients 2, 3, and 12) (Refer to A-396);

2. Failure to ensure the nursing and respiratory staff followed the hospital policy and procedures for 3 sampled patients (Patients 2, 4, and 9) (refer to A-0398);

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



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Based on interview and record review, the facility failed to ensure their plan of care was implemented for 3 sampled patients (Patients 2, 3, and 12) when:

1. For Patient 2, the licensed nurses did not place a wound evaluation and treatment consult when a hospital-acquired wound was found on 11/29/2024;

2. For Patients 2 and 12, no documentation indicated nurses had notified the physician of newly identified hospital-acquired wounds;

3. The wound treatment plans and orders were not implemented for patients 2, 3, and 12.

These failures resulted in delayed wound healing, an increased risk of infection for Patients 2, 3, and 12, and the reopening of a previously healed wound for Patient 12.

Findings:

1. A review of Patient 2's clinical record indicated that he was admitted to Hospital A on 11/15/2024. His skin assessment upon admission indicated no skin issue on his nose.

A review of Patient 2's flowsheet indicated a wound on his nose on 11/29/2024. No documentation indicated a wound evaluation and treatment consult was ordered, and there was no photo of the wound.

A further review of Patient 2's flow sheet indicated a photo of Patient 2's nose wound uploaded on 11/30/24.

During an interview with Registered Nurse (RN) D on 1/28/2025 at 1:47 p.m., RN D stated when a new wound is found, the nurses needed to take photographs, complete a wound assessment, notify the physician, and place a wound evaluation and treatment consult. RN D confirmed that she saw a new wound identified on 11/29/24 on Patient 2's nose, but no photo. She took photos and uploaded them to the flowsheet. She also confirmed the wound consult was not ordered until 12/8/24.

A review of Patient 2's wound care consult notes dated 12/9/2024 indicated, a Bridge of nose-per staff, and the patient's wound was caused by the use of a BiPAP (a type of noninvasive ventilation that helps you breathe) mask. It appears to be a dry black and brown scab with flaky lifting edges. The hospital-acquired pressure injury (HAPI) is unstageable.

2. A review of Patient 2's flowsheet indicated a hospital-acquired wound on his nose on 11/29/2024.

During an interview and record review with Nurse Coordinator (NC) E on 2/5/024 at 1:43 p.m., NC E confirmed no documentation indicating that Patient 2's HAPI had been reported to physicians from 11/29/24 to Patient 2's discharge date of 12/11/2024.

A review of Patient 12's wound flowsheet on 1/15/2025 indicated hospital-acquired wound in the buttocks, right, left, and mid.

During an interview and record review with NC E on 2/5/024 at 3:09 p.m., NC E confirmed no documentation indicated Patient 12's hospital-acquired wound had been reported to physicians from 1/15/25 to 2/4/2025.

3.a). A review of Patient 2's wound care order dated 12/9/2024 indicated, bridge of nose-apply bacitracin (a polypeptide antibiotic. It is used to treat bacterial skin infections or to prevent infection of minor burns, cuts, or scrapes) to scabs. Daily PRN (as needed).

A review of Patient 2's wound flowsheet from 12/9/2024 to Patient 2's discharge date 12/11/2024, no documentation indicated that bacitracin had been applied.

During an interview with the wound care nurse (WCN) on 1/17/2025 at 4:00 p.m., he stated that for unstable HAPI, Bacitracin can provide moisture and help with wound healing. He also stated that the Bacitracin order for patient 2 should be daily and PRN.

During an interview and record review with Nurse Coordinator (NC) F on 2/4/024 at 3:35 p.m., NC F confirmed that there was no documentation indicating bacitracin had been applied since it was ordered on 12/9/2024.

3.b) A review of Patient 3's clinical record indicated he was admitted to Hospital B on 12/15/2024. Upon admission, the skin assessment indicated no pressure injury on his right ankle.

A record review of Patient 3's Flowsheet dated 12/23/24 indicated a pressure injury on Patient 3's right ankle.

A record review of Patient 3's wound care consult notes dated 12/25/24 indicated that the Right ankle unstageable pressure injury measures 2.2 x 2.0 x 0.4 cm.

A record review of Patient 3's wound care order dated 12/25/24 indicated that the wound should be cleaned with a wound cleanser and gauze. Thera honey should be applied to the wound bed, covered with petrolatum gauze, and secured with a silicone foam dressing. The dressing should be changed every two days.

During an interview and record with the Assistant nurse manager on 1/28/2025 at 3:05 p.m., she reviewed the wound flowsheet and confirmed that three wound dressing changes had not been documented.

During an interview with Quality Manager (QM) on 2/5/2025 at 5:26 p.m., she stated that the hospital nurse educator (NE) confirmed that nurses should document the wound dressing change on the LDA (Lines, Drains and Airway) wound flowsheet.

3.c) A record review indicated that Patient 12 was admitted to Hospital A on 12/24/2024. The skin assessment upon admission indicated that there was no skin issue on his buttock areas.

A review of Patient 12's wound flowsheet on 1/15/2025 indicated pressure injuries in the buttocks, right, left, and mid.

A review of Patient 12's wound care order dated 1/15/2025 indicated that for buttocks, gently cleanse the skin with saline and gauze, apply Z guard paste to press the gauze, and apply the Z-guard side to open areas. Secure with Mepilex border sacrum. Apply daily and PRN.

During a concurrent interview and record review with NC F, on 2/4/25 at 11:00 a.m., NC F confirmed no documentation indicating the dressing was changed on 1/23/25, 1/25/25, 1/26/25, and 1/28/25.
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During a concurrent interview and record review with NC E on 2/5/25 at 2:24 p.m., she confirmed the wound was open to air on 1/29/25, 1/30/25, 2/1/25, 2/2/25, and 2/3/25. She stated the nurses should have changed the Mepilex dressing daily instead of leaving it open to air, as per the wound care order.

A review of Patient 12's wound photo taken on 2/4/2025 indicated a skin opening on the buttock areas.

During a concurrent interview and record review with the WCN on 2/5/2025 at 3:42 p.m., he confirmed Patient 12's buttocks wound should not have been left open to the air and he did not discontinue the wound care order initiated on 1/15/2025. After reviewing the wound photo taken on 2/4/25, he confirmed the skin had re-opened in the same spot where Mepilex dressing should have been applied every day.

A review of the facility's policy and procedures, dated 5/29/24, titled "Skin Assessment and Interventions for Pressure Injury," indicated, " ...if a new wound or skin changes are discovered after 24 hours of admission, the nurse will take a photograph, open a wound template in the EHR [eletronic health records] (CWON or designee to label etiology), complete a wound assessment, notify physician, and place a Wound Evaluation and Treatment consult. Place an Incident/Occurrence Report for ALL hospital acquired injuries. Primary Nurse to document when patient, family, and /or provider is notified of hospital acquired injury ..."

A review of the facility's policy and procedures, dated 4/24/24, titled "Wound Care Procedure" indicated, " ...perform wound care/dressing change (using clean or sterile technique) as per provider order ..."

Based on observation, interview and record review, the hospital failed to ensure the nursing and respiratory staff followed the hospital policy and procedure (P&P) when:

1. In the Emergency Department (Hospital A) Patient 4 waited over seven hours for a primary RN (Registered Nurse) assessment completion (a process that evaluates a patient's health and well-being) and repeat vital signs (VS, measurements that indicate a person's basic bodily functions). There was no evidence of a current pain assessment prior to medication administration, and a complete set of VS were documented more than 2 hours prior to admission.
These failures in the Emergency Department had the potential of nursing and medical staff not detecting patients' health complications or needs and providing necessary treatment in a timely manner.

2. In the Emergency Department (Hospital C), Patient 9's fall was not documented in the medical record.
These failures in the Emergency Department had the potential of nursing and medical staff not detecting patients' health complications or needs and providing necessary treatment in a timely manner.

3. The facility failed to ensure their hospital Respiratory Procedure regarding non-invasive ventilatory support for one sampled patient (Patient 2) was followed by Respiratory therapists.
This failure resulted in Patient 2 developing an unstageable pressure injury on his nose.


FINDINGS:

1. During review of Patient 4's medical record, the Patient Care timeline dated 12/13/25 indicated, "Patient 4 arrived at the Emergency Department (ED) (Hospital A) on 12/13/25 at 1:53 p.m., Chief complaint: Post partum (the period of time after a woman gives birth, during which her body recovers from pregnancy and childbirth) complication (Pt is postpartum day 5 and sent by OBGYN (Obstetrics and Gynecology. It refers to a medical specialty that focuses on the health of women, particularly their reproductive systems) for c-section [(a surgical procedure used to deliver a baby through an incision (a surgical cut made in skin) in the mother's abdomen and uterus(womb)] incision infection. Temp 100 F this morning ... large area of redness to Abd (abdomen) ... triage VS (Vital Signs) BP 100/67, Heart rate 110, RR 18 Temp 98.1 F Pain assessment: pain score 4. Patient Acuity- Urgent. 8:34 p.m. Pain medication given without updated pain assessment documented . 9:38 p.m. A primary nursing assessment was completed by RN. 9:57 p.m. VS completed. 9:59 ED secondary assessment completed. 10:10 p.m. order placed for admission to hospital bed. 11:04 VS done. Pain score 4. 12:00 MN VS done no pain score. Pt admitted to floor at 2:17 a.m."

During an interview on 1/28/25 at 3:10 p.m. with the Emergency Department Nurse Manager (EDNM), the EDNM stated reassessment is based on severity, there is no recommended time, "the hope is to reassess patients every few hours".

During a review of the facility's policy and procedure (P&P) titled, "Triage Process", dated 2/2023, the P&P indicated, "the triage nurse will prioritize patient problems and complete the patient's assessment in order of urgency. The complete assessment will include the collection of subjective and objective data, description of pain and documentation of the medications and allergies. Patients' reassessments, which may include a focused assessment and/or repeat set of vital signs will be repeated based on the patient's clinical status as determined by the triage nurse."

During a review of the facility's policy and procedure (P&P) titled, Department of Emergency Medicine, Standards Manual, dated 2/2023, the P&P indicated, "Patient assessment/reassessment is conducted by a Registered Nurses. This assessment /reassessment may include, (but is not limited to), a primary and /or focused assessment, vital signs, patient desire for treatment and /or patients' response to treatment provided. The emergency department develops standards of patient care and standards of nursing practice in relation to important aspects of care. A patient assessment is one of those aspects.... Continuing care needs are assessed .... "Complete vital signs (Blood pressure (BP), temperature (T), pulse (P) and respiratory rate (R) and pain scale should be obtained on all patients, unless the patient declines. After being placed in an in a bed, a patient reassessment is performed every two hours or more often as necessary, based on acuity and or change in patient status and values recorded in the medical record at appropriate. A full set of vitals must be obtained on all patients prior to admission to an inpatient unit, ideally within 30 minutes of admission."

During a review of the facility's policy and procedure (P&P) Pain Management, dated 9/30/24, the P&P indicated in the Emergency Department, pain is assessed with the initial set of vital signs, ongoing as needed, and/or after an intervention has been initiated.

2. During a review of Patient 9's medical records, the ED (Emergency Department) Provider Notes, dated 1/6/2025 1140 p.m. indicated, "Patient 9 presented to the Emergency Department (Hospital C) on 1/6/25 at 6:51 p.m. with the chief complaint: generalized weakness. ...Pt states he woke up this morning feeling generally weak. Unable to ambulate secondary to weakness. Denies any abdominal pain nausea, vomiting, denies any fevers. Denies any numbness tingling. Pt presents jaundice ...Medical Decision Making: ...Patient is weak, had mechanical fall in the emergency department without any evidence of injury or trauma. Patient was reevaluated immediately after fall. ...Diagnosis 1. Cholelithiasis with choledocholithiasis (the condition of having a gallstone (or stones) in your common bile duct (The common bile duct connects to your liver to your gallbladder) 2. Cholecystitis (inflammation of the gallbladder, a pear-shaped organ located beneath the liver that stores bile)., dated ..."

During review of Patient 9's Physical Therapy (PT) Evaluation, dated 1/9/25 at 11:32 a.m., the PT evaluation indicated..." fell just prior to admission and required two persons assist to get up... Patient reports numbness and or tingling in left hand was reason for coming to hospital".

During review of Patient 9's Occupational Therapy (OT) Evaluation, dated 1/9/25 at 12:40, the OT evaluation indicated "demonstrates left side weakness with left arm drift and impaired coordination. Patient noted to be leaning to left side. Patient also appears to have left neglect and slow to respond and required repeated clues for one step commands. RN and MD notified."

During a review of Patient 9's significant event document dated 1/9/25 at 5:39 p.m., the significant event document indicated, " patient was noted to have left sided weakness. On further questioning, patients father states, that he fell at home and had left side at weakness on Monday. He again fell in the ER. He was noted to have generalized weakness with frequent vomiting and elevated blood pressure.... Post procedure, he remained weak on the left side with left pronator drift and some confusion. He was seen and evaluated this morning.... MRI showed acute right intraparenchymal hemorrhage with edema and leftward midline shift ...."

During review of Patient 9's Plan of Care, dated 1/9/25 at 6:58 p.m., the plan of care indicated Patient transferred to ICU. Pt 9 was identified as a fall risk in the ICU.

During review of Patient 9's "Patient Care Timeline" dated 1/6/25 -1/7/25, the Timeline indicated no evidence documented that Patient 9 had a fall in the Emergency Department.

During an interview on 1/29/25 at 9:56 a.m. with Emergency Department (ED) Assist Nurse Manager (EDANM), the EDANM stated, "Pt 9 was standing when the lab tech went to draw blood, the lab tech requested patient to lay down, he went into the gurney and rolled off the other side of the bed. The day of the incident there was no report filed, there was no nursing documentation in the ED chart. Follow up documentation via email from nursing staff dated 1/16/25 from Registered Nurse (RN) J indicated, prior to the fall RN J had no interaction with the patient, he heard the lab tech asking for help. The NP (Nurse Practitioner) was at the bedside, the patient was back in the bed. Another email from RN K dated 1/28/25 indicated, ...the lab tech yelled for assistance. Stating that the Pt was lying in bed and slid off. ...Pt denied any pain or head injury during fall."

During an interview on 1/29/25 at 10:22 a.m. with the EDANM, the EDANM stated Patient 9 did not have a primary nurse at the time of the fall, Patient 9 had a team of nurses. EDANM confirmed there was no nursing documentation about a fall, and there was no fall assessments completed.

During an interview on 1/29/25 at 10:25 with Hospital C's Quality Manager (QM) H, the QMH stated, "Any of them, all of them could have reported a patient fall, during an investigation it was discovered the lab tech witnessed the fall."

During an interview on 1/29/25 at 11:19 a.m. with the Medical Doctor (MD) I, MDI stated "PT (Physical Therapist) informed him about the weakness and that prompted the evaluation, neurology consults and MRI. The MRI showed a massive bleed, and multiple strokes. The patients father told him about the fall in the ED, said the weakness has been going on since the beginning. Prior to 1/9/25 he was not aware of the fall, MDI stated if he was alerted of the fall, he would have evaluated the patient."

During an interview on 1/29/25 at 12:35 p.m. with Emergency Department Medical Director (ED MD), the EDMD stated "on arrival Patient 9 had non focal weakness (a problem that affects the brain or nervous system in a way that is not specific to a certain area)."

During an interview on 1/29/24 at 2:44 p.m. with the Medical Lab Assistant (MLA), the MLA stated, she asked Patient 9 to lay down to draw blood, he tried to crawl into bed, fell off the other side hit the stuff on the side of the tent. He did not say anything. She called for help, the Nurse Practitioner (NP) came and asked if he hit his head, asked if he could get up. MLA told two nurses what happened when they arrived in the room. She did not do a report about the fall until she was notified by her supervisor.

During review of the facility's policy and procedure titled, "Fall Prevention Guidelines", dated 2/23/22 indicated, ...Patients who have been identified as a fall risk shall be monitored by nursing staff according to the care guidelines .... Reporting of patient falls.... is based on reports entered in the Occurrence Reporting System. ... Fall: any sudden unintentional change in position that causes an individual to land at a lower level, on an object, on the floor, or on the ground. Post fall: Registered nurses shall comprehensively assess patient to ensure it is safe before moving a patient after a fall ... Observe for presence of injury such as fracture, bleeding, concussion, etc. Vital signs monitored vital signs every 15 minutes times one hour, presence of pain, level of consciousness and basic neurological assessment including pupil size, change of strength in extremity, comparison of left to right movement and strength, range of motion of extremities, and bruising. ... Registered nurses will document all pertinent information in the electronic health record. Date and time, how the patient fell, what the patient said about the fall.; What were they doing prior to the fall, presence of injury, location, and description, What preventative measures were in place at the time of the fall and update care plan with additional measures to prevent repeat fall, any witness, responding MD, family Medicare vacation and who notified the family, post fall assessment and condition, Any additional interventions necessary .... Procedure assisted/Intercept/ witness falls: A RN will assess the patient and interview the staff with the patient during the fall to determine the presence of risk for injury to the patient. If the RNC determines the patient is not injured and there is no suspicion that injury may have occurred, the RN will document the assessment, indicating the patient was not injured, and no further post fall assessments are required. If the RN's determined the patient was injured or suspected to be injured, post fall monitoring. And assessment documentation will commence per protocol. The RN will notify the provider and report the fall per policy.


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3. A review of Patient 2's clinical record indicated that he was admitted to Hospital A on 11/15/2024. His skin assessment upon admission indicated no skin issue on his nose.

A review of Patient 2' Respiratory Therapy Assessment Flowsheet (RTAF) from 11/27 to 11/28/2024 indicated that he was wearing a BiPAP (a type of noninvasive ventilation that helps you breathe) mask. His nasal bridge skin was checked once on 11/27/24 and three times on 11/28/2024.

A review of Patient 2's RTAF dated 11/28/2024 indicated Nasal bridge reddened and indentation.

A review of Patient 2's wound care consult notes dated 12/9/2024 indicated " bridge of nose-per staff, and the patient's wound was caused by the use of a BIPAP mask. no longer in use...appears to be a dry black and brown scab with flaky lifting edges. hosptial acquired pressure injury (HAPI) unstageable..."

During a concurrent interview and record review with the Respiratory Manager (RM) on 1/28/2025 at 1:09 p.m., the RM reviewed the RTAF and confirmed that there was no documentation indicating Respiratory Therapists (RT) had assessed Patient 2's nose skin under BiPAP mask every four hours. He stated that the RT should have assessed his nasal bridge every four hours.

A review of the facility's policy and procedures, revised on 12/23, titled "... Health System Enterprise Respiratory Procedure, non-invasive ventilatory support," indicated, "Routine assessment of skin needs to be done and documented in EMR. ...Assessment should be done every 3-4 hours, assessment to be done with all interfaces, mask, Nasal prongs/pillows ..."

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

1. For one sampled patient (Patient 1), the Physician accurately documented the discharge summary. (Hospital B)

2. For one patient (Patient 9), staff documented a significant event in an Emergency Department (ED) patients medical record. (Hospital C)

3. For one sampled patient (Patient 13), the After Visit Summary provided the patients accurate discharge information. (Hospital A)

4. For one sampled patient (Patient 12), documentation of the accurate identification of wounds on the buttocks. (Hospital A)

These failures had the potential to result in pertinent patients care, observations, treatment and outcomes, including compliance and claims processing to be missed and to provide accurate communication to other health care providers and impacted the integrity and accuracy of those patients' electronic health records.

Findings:

1. During a review of Patient (Pt) 1's "Discharge Summary", dated 4/30/24, the Discharge Summary indicated Pt 1 was admitted (Hospital B) on 3/19/2024 and Discharged 5/9/2024. Discharge diagnosis included Acute Respiratory failure ( lungs cannot get enough oxygen into your blood), Non traumatic lung collapse, ... Discharge exam indicated, BP (Blood Pressure) 0/0, Pulse 75, Temp (temperature) 37.3 (Axillary), Resp (Respirations) 0, GEN: (General appearance) well appearing, NAD (No apparent distress), ...Resp: CTA (Clear to auscultation) B/L (Bilateral lungs), SKIN: Warm/dry, NEURO/PSYCH: (Neurological/Psychological) AA+Ox3 (Awake, alert and orient to person, place, time), interactive. Disposition: Expired.

During a review of Pt. 1's "Death Discharge Summary", dated 4/30/24, the Death Summary indicated " ... I was called to patients' bedside to pronounce that the patient has died". " ...Patient pronounced d on 4/30/24 at 7:05 p.m. due to acute respiratory failure 2/2 lung collapse". "Death exam: The patient was lying in bed, still, unresponsive to verbal or physical stimuli. No spontaneous movement was observed. Eyes closed. Pupils fixed and not reactive, no corneal reflex. No heart or breath sounds heard. No pulse. No gag reflex (a natural reaction that prevents choking and swallowing harmful substances).

During an interview on 10/15/24 at 10:30 a.m. with Medical Doctor (MD) G, MD G stated, "I did not check the discharge summary to edit it, some information is part of the template, I would go and edit it for the exam".

Review of the facility's Policy and Procedure titled, "Medical Record Documentation Guidelines -Providers", dated 6/26/24, indicated ... documentation must have sufficient and accurate information to 1) support the diagnosis, 2) justify the treatment procedures, 3) document the course of care, 4) identified treatment/ diagnostic test results, and 5) promote continuity of care among health care providers.

Review of the facility's Policy and Procedure titled, "Medical Records- Delinquent; Automatic Suspension of Privileges", dated 10/26/22-last reviewed 10/15/23, indicated, "Complete Medical Record means a legible, accurate and quality medical record that: Contain the following: ...Discharge summary including final diagnosis, Complications, Procedures performed, deliveries, consultations and a summary that includes condition on discharge and patient instruction for follow up care....


2. During review of Patient 9's medical record, the ED (Emergency Department) Provider Notes, dated 1/6/2025, indicated Patient 9 presented to the Emergency Department (Hospital C) on 1/6/25 at 6:51 p.m. with the chief complaint: generalized weakness. ...Pt states he woke up this morning feeling generally weak. Unable to ambulate secondary to weakness. Denies any abdominal pain nausea, vomiting, denies any fevers. Denies any numbness tingling. Pt presents jaundice ...Medical Decision Making: ...Patient is weak, had mechanical fall in the emergency department without any evidence of injury or trauma. Patient was reevaluated immediately after fall. ...Diagnosis 1. Cholelithiasis with choledocholithiasis (the condition of having a gallstone (or stones) in your common bile duct 2. Cholecystitis (inflammation of the gallbladder, a pear-shaped organ located beneath the liver that stores bile)., dated
During review of Patient 9's Physical Therapy (PT) Evaluation, dated 1/9/25 at 11:32 a.m., the PT evaluation indicated "Based on today's physical therapy, has pt met the mobility criteria for discharge? No Assessment: Weakness, Range of motion. Limitations, Impaired sensation/proprioception, Decreased balance, Decreased coordination, cardio, pulmonary deconditioning, and neglect. ... Subjective... Living environment comment: ...fell just prior to admission and required two persons assist to get up... Sensation: Patient reports numbness and or tingling in left hand was reason for coming to hospital.

During review of Patient 9's Occupational Therapy (OT) Evaluation, dated 1/9/25 at 12:40, the OT evaluation indicated "demonstrates left side weakness with left arm drift and impaired coordination. Patient noted to be leaning to left side. Patient also appears to have left neglect and slow to respond and required repeated clues for one step commands. RN and MD notified.

During a review of Patient 9's significant event document dated 1/9/25 at 5:39 p.m., the significant event document indicated, patient was noted to have left sided weakness. On further questioning, patients father states, that he fell at home and had left side at weakness on Monday. He again fell in the ER. He was noted to have generalized weakness with frequent vomiting and elevated blood pressure.... Post procedure, he remained weak on the left side with left pronator drift and some confusion. He was seen and evaluated this morning.... MRI showed acute right intraparenchymal hemorrhage with edema and leftward midline shift ....

During review of Patient 9's Plan of Care, dated 1/9/25 at 6:58 p.m., the plan of care indicated Patient transferred to ICU. Pt 9 was identified as a fall risk in the ICU.

During review of Patient 9's "Patient Care Timeline dated 1/6/25 -1/7/25, the Timeline indicated no evidence documented that Patient 9 had a fall.

During an interview on 1/29/25 at 9:56 a.m. with Emergency Department (ED) Assist Nurse Manager (EDANM), the EDANM stated, "pt 9 was standing when the lab tech went to draw blood, the lab tech requested patient to laydown, he went into the gurney and rolled off the other side of the bed. The day of the incident there was no report filed, there was no nursing documentation in the ED chart. Follow up documentation via email from nursing staff dated 1/16/25 from Registered Nurse (RN) J indicated, prior to the fall RN J had no interaction with the patient, he heard the lab tech asking for help. The NP was at the bedside, the patient was back in the bed. Another email from RN K dated 1/28/25 indicated, ...the lab tech yelled for assistance, stating that the Pt was lying in bed and slid off. ...Pt denied any pain or head injury after the fall."

During an interview on 1/29/25 at 10:22 a.m. with the EDANM, the EDANM stated Patient 9 did not have a primary nurse at the time of the fall, Patient 9 had a team of nurses. EDANM confirmed there was no nursing documentation about a fall, and there was no fall assessments completed.

During an interview on 1/29/25 at 10:25 with Hospital C's Quality Manager (QM) H, the QMH stated, Any of them, all of them could have reported a patient fall, during an investigation it was discovered the lab tech witnessed the fall.
During an interview on 1/29/25 at 11:19 a.m. with the Medical Doctor (MD) I , MDI stated PT informed him about the weakness and that prompted the evaluation, neurology consult and MRI. The MRI showed a massive bleed, and multiple strokes. The patients father told him about the fall in the ED, said the weakness has been going on since the beginning. Prior to 1/9/25 he was not aware of the fall, MDI stated if he was alerted of the fall, he would have evaluated the patient for the fall.

During an interview on 1/29/25 at 12:35 p.m. with Emergency Department Medical Director (ED MD), the EDMD stated on arrival Patient 9 had non focal weakness, not neurological.

During an interview on 1/29/24 at 2:44 p.m. with the Medical Lab Assistant (MLA), the MLA stated, she asked Patient 9 to laydown to draw blood, he tried to crawl into bed, fell off the other side hit the stuff on the side of the tent. He did not say anything. She called for help, the Nurse Practitioner (NP) came and asked if he hit his head, asked if he could get up. MLA told two nurses what happened when they arrived in the room. She did not do a report about the fall until she was notified by her supervisor.

During review of the facility's policy and procedure titled, "Fall Prevention Guidelines", dated 2/23/22 indicated, ...Patients who have been identified as a fall risk shall be monitored by nursing staff according to the care guidelines .... Reporting of patient falls.... is based on reports entered in the Occurrence Reporting System. ... Fall: any sudden unintentional change in position that causes an individual to land at a lower level, on an object, on the floor, or on the ground.

Post fall: Registered nurses shall comprehensively assess patient to ensure it is safe before moving a patient after a fall ... Observe for presence of injury such as fracture, bleeding, concussion, etc. Vital signs monitored vital signs every 15 minutes times one hour, presence of pain, level of consciousness and basic neurological assessment including pupil size, change of strength in extremity, comparison of left to right movement and strength, range of motion of extremities, and bruising. ... Registered nurses will document all pertinent information in the electronic health record. Date and time, how the patient fell, what the patient said about the fall.; What were they doing prior to the fall, presence of injury, location, and description, What preventative measures were in place at the time of the fall and update care plan with additional measures to prevent repeat fall, any witness, responding MD, family Medicare vacation and who notified the family, post fall assessment and condition, Any additional interventions necessary .... Procedure assisted/Intercept/ witness falls: A RN will assess the patient and interview the staff with the patient during the fall to determine the presence of risk for injury to the patient. If the RNC determines the patient is not injured and there is no suspicion that injury may have occurred, the RN will document the assessment, indicating the patient was not injured, and no further post fall assessments are required. If the RN's determined the patient was injured or suspected to be injured, post fall monitoring. And assessment documentation will commence per protocol. The RN will notify the provider and report the fall per policy.

3. During a review of Patient 13's medical record, the Inpatient Medicine Discharge Summary dated 1/28/25 indicated "Patient 13 Past Medical History (PMHx) CVA on Plavix was admitted after a ground level fall for pain control from rib fractures and epistaxis from nasal fracture .... Plan by issue: Epistaxis ...OK to restart Plavix AFTER 48 hours post injury -restarted. Medication list: continue talking these medications ... Plavix ..."

During a concurrent interview and record review on 1/30/25 at 11:15 with Nurse Coordinator (NC) E, Patient 13's After Visit Summary, dated 1/28/25 was reviewed, the AVS indicated, "Why you were hospitalized: Pain ... Medication list: ...Continue taking these medications: Plavix 75 mg tablet, take 1 tablet by mouth every evening ... last time given: 1/28/25 at 9:17 a.m. Doctor's comments: OK to resume taking in one week from 1/24/25." The Nurse Coordinator E (NC E) confirmed the instructions from the Doctors comment was not matching the discharge summary.

During an interview on 1/30/25 at 11:41 with Chief Quality Officer (CQO), CQO stated there was a "error in the AVS (After Visit Summary)."

During an interview on 1/30/25 at 1:13 with MD L, MD L reviewed the AVS, she agreed and stated "what was written and the date on Doctor's comment was confusing, medications to be taken were discussed at discharge."

During an interview on 2/3/25 at 9:57 a.m. with RN M, RN M stated she did not give the patient the information about the Doctors Comment, "I didn't see it ."

During a review of the Medical Staff Bylaws, dated 12/15/2020, indicated, "Prepare and complete, in a timely and accurate manner, the medical and other required records for all patients to whom the practitioner in any way provides services in the hospital., in the manner consistent with hospital policy and procedure."





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Findings:

A review of Patient 12's clinical record indicated that he was admitted to Hospital A on 12/24/2024. His skin assessment upon admission indicated that there was no skin issue on his buttocks.

A review of patient 12's wound flowsheet and Avatar documentation from 1/15/2025 to 2/4/2025 indicated Patient 12 had pressure injuries in the buttocks, right, left, and mid.

A review of patient 12's wound care follow-up note dated 1/15/2024 indicated buttocks wounds -superficial purple discoloration, not boggy, and blanching redness to a meaty portion of buttocks as seen in the photo-patient with tenderness to area. Petechiae was noted on the body, and platelets were recently low. The etiology was likely an abrasion with superficial bruising.

During an interview with the Wound Care Nurse (WCN) on 2/4/2025 at 1:46 p.m., the WCN confirmed that patient 12's buttocks wounds were not pressure injuries; they were abrasions with superficial bruising. He stated the documentation of buttocks preesure injuries on the flowsheet and Avatar were mistakes.