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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.11 Compliance with Federal, State and Local Laws was out of compliance.

A-0020 Based on document reviews and interviews, the facility failed to follow state laws. Specifically, the facility failed to ensure bedside nurses annually developed and oversaw a master nurse staffing plan for the facility in one of one staffing committee meeting minutes reviewed.

Findings include:

Facility policy:

The Staffing Plan read, committee establishment date: 12/8/22. The committee will receive input from staff nurses regarding the development, ongoing monitoring, and evaluation of the staffing plan. The nurse staffing advisory committee meets every quarter or more often if a need or staffing concern is identified. At least 60% of the members of the nurse staffing advisory committee are RNs who are involved in direct patient care at least 50% of their work time. The chief nursing officer and nurse manager are voting members of the committee.

References:

The Code of Colorado Regulations, 6 CCR 1011-1 Chapter 4 14.6(B)(2) and (3) read, the nurse staffing committee shall annually develop and oversee a master nurse staffing plan for the facility. The nurse staffing committee shall have at least 60% or greater participation by clinical staff nurses who routinely provide direct care to patients, in addition to auxiliary personnel and nurse management.

1. The facility failed to ensure bedside nurses annually developed and oversaw a master nurse staffing plan.

a. The Staffing Plan read that the facility established a nurse staffing committee on 12/8/22. A review of the facility's nursing staff committee meeting minutes revealed only one agenda dedicated to a nurse staffing committee; This document, titled Nurse Council Meeting Minutes, was dated October 2023. Further review of the agenda did not reveal evidence the staffing committee developed or had oversight of the master nurse staffing plan.

The Nurse Council Meeting Minutes identified 13 members as either registered nurses (RNs) or licensed practical nurses (LPNs). Two of the RNs were house supervisors, making it unclear if they provided direct patient care at least 50% of the time. The agenda and the Staffing Plan identified 26 members of the committee, which included the nurse manager and the facility's chief nursing officer (CNO). With the house supervisors included as bedside nurses and the nurse manager and CNO as members of the committee, 54% of the committee were bedside nurses.

The lack of evidence the bedside nurses had input into the development of the master staffing plan was in contrast to the Staffing Plan, which instructed the committee to receive input from staff nurses regarding the development, ongoing monitoring, and evaluation of the plan. Additionally, the Staffing Plan instructed the staffing committee to meet every quarter or more often if a staffing concern was identified.

The Staffing Plan also instructed at least 60% of the members of the nurse staffing advisory committee to have been nurses who were involved in direct patient care at least 50% of their work time.

Additionally, evidence showing bedside nurses had not had input into the facility's master staffing plan and less than 60% of committee membership was comprised of bedside nurses was in contrast to Code of Colorado Regulations, 6 CCR 1011-1 Chapter 4 14.6(B)(2) and (3). The regulation instructed the nurse staffing committee to annually develop and oversee a master nurse staffing plan for the hospital. The regulation instructed the nurse staffing committee to have at least 60% or greater participation by clinical staff nurses who routinely provided direct care to patients, in addition to auxiliary personnel and nurse management.

b. A review of the facility's nursing assignment sheets revealed the facility failed to provide an adequate number of certified nursing assistant (CNA) staff according to the staffing matrices provided by the facility. For example, on the day shift of 5/23/23, the facility census included 48 medical/surgical patients. The staffing matrix called for ten nursing and five CNA personnel to staff the medical/surgical floors. The nursing assignment sheet indicated only four CNAs worked that day.

An additional example occurred on the night shift of 11/7/23. The facility census indicated 48 medical/surgical patients. The staffing matrix called for ten nursing and five CNA personnel to staff the medical/surgical floors. The nursing assignment sheet indicated only four CNAs worked that night.

i. On 11/29/23 at 10:27 a.m., an interview was conducted with registered nurse (RN) #6. RN #6 explained two of the medical/surgical floors in the facility had 20 patient beds. RN #6 said if four nurses assigned to these floors each had five patients, the workload was manageable; however, if leadership assigned more patients, nurses did not have enough time to complete all necessary tasks.

RN #6 stated the facility did not employ enough CNA staff to provide activities of daily living (essential and routine tasks that most healthy individuals can provide for themselves, such as bathing and toothbrushing). She said if nurses did not have enough CNAs to support patient's activities of daily living (ADLs), the nursing staff did not have enough time to give medications and perform other nursing duties. RN #6 said if the facility scheduled too few CNAs, nursing staff provided total patient care by acting as a CNA and a nurse.

c. On 11/30/2023 at 10:58 a.m., an interview was conducted with RN #1. RN #1 said he was a member of the staffing committee. He explained the first staffing committee meeting occurred in late October 2023. RN #1 stated during the meeting members discussed a generalized overview of committee responsibilities and held discussions regarding bedside staff concerns. RN #1 was unable to explain why a staffing committee meeting had not occurred before the October 2023 meeting. He stated other meetings before October 2023 were town hall meetings for all staff and not staffing committee meetings.

RN #1 said during the October 2023 nurse staffing committee leadership presented a staffing plan previously developed by the facility's corporate owner, but the matrix was not open for suggestions. RN #1 explained the bedside nurses discussed workflow on the floors and how to optimize nursing time for the patients, but this conversation was not taken into account when allocating nursing and associated personnel hours to patient care.

RN #1 stated bedside nurses provided the work of actual patient care and therefore had insight into workflow not available to a corporate owner. RN #1 also stated bedside nurses needed appropriately allocated time to assess patients, provide interventions, and give medications. RN #1 expressed concern that if staffing levels were not developed by bedside nurses, patients would not receive equitable amounts of nursing time and not get all needed interventions.

d. On 11/30/2023 at 3:25 p.m., an interview was conducted with RN #8. RN #8 said she was a member of the nurse staffing committee. She said during the October 2023 meeting leadership presented a staffing plan and matrix but did not allow bedside nurses to have input or make decisions concerning either document. RN #8 said the corporate owner developed the staffing matrix and that nurses felt prior staffing plans had been better suited to the nurses and their patients. RN #8 also said the corporate owner and local leadership had not set the nurse staffing committee up for success.

RN #8 explained the facility's corporate owner experienced culture shock after they had purchased the facilities in Colorado and explained the owner did not understand how nurses provided care in the state. She further explained the current corporate matrix worked well at high census numbers, but for lower census days nurses were assigned too many patients to provide all necessary care. RN #8 said this exhausted the bedside staff, and in turn, patients felt they had not received quality care.

RN #8 stated the facility had a nursing council under previous corporate owners, but these meetings stopped occurring due to frequent leadership changes. RN #8 said the meetings before October 2023 were open town hall, all-staff meetings and did not meet the Colorado requirements for a nurse staffing committee.

e. On 11/30/2023 at 1:49 p.m., an interview was conducted with CNO #5. CNO #5 said facility leadership had written the staffing plan, and that the corporate owner had developed the matrix. CNO #5 also said bedside nurses should have been given a voice in the staffing plan and the staffing matrix.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 Nursing Services was out of compliance.

A-0392 Based on document reviews, observations, and interviews, the facility failed to provide adequate numbers of licensed registered nurses, licensed practical nurses, and other personnel to provide nursing care to all patients as needed. Specifically, the facility failed to ensure staff provided bathing, assistance with activities of daily living (essential and routine tasks that most healthy individuals can provide for themselves), and assistance with turning in bed every two hours to meet patients' needs and in accordance with facility policy and national standards in four of four medical records reviewed (Patients #1, 2, 3, and 4).

A-0405 Based on document reviews and interviews, the facility failed to administer medications in accordance with the orders of the practitioner and acceptable standards of practice. Specifically, the facility failed to ensure staff administered patients' medications within the timeframe specified by facility policy and national guidelines in four of four medical records reviewed (Patients #1, 2, 3, and 4). Additionally, the facility failed to follow national guidelines by developing a policy regarding the administration of time-critical medications.

Based on document reviews, observations, and interviews, the facility failed to ensure nurses supervised and evaluated the nursing care for each patient. Specifically, the facility failed to ensure staff provided bathing, assistance with activities of daily living (essential and routine tasks that most healthy individuals can provide for themselves), and assistance with turning in bed every two hours to meet patients' needs and per facility policy and national standards in four of four medical records reviewed (Patients #1, 2, 3, and 4).

Findings include:

Facility policy:

The Guidelines for Nursing Care policy read, activity and mobility: The bedfast patient will be turned and documented every two hours and as needed. The patient's hair is combed or shaved every day and as needed. Oral care will be provided daily and as needed. If no contraindications, a bath or shower will be provided three times a week and as needed.

Reference:

The Lippincott Manual of Nursing Practice 11th Edition (2018), provided by the facility read, turning: Changing positions from back to side-lying (and vice-versa) stimulates circulation, encourages deeper breathing, and relieves pressure areas. 1. Help the patient to move onto his or her side if assistance is needed. 2. Place the uppermost leg in a more flexed position than that of the lower leg, and place a pillow comfortably between the legs. 3. Make sure that the patient is turned from one side to the back and onto the other side every 2 hours. Bathe the patient regularly.

1. The facility failed to ensure staff provided bathing, assistance with activities of daily living (ADLs) such as toothbrushing and assistance with turning in bed every two hours.

a. A review of Patient #1's medical record revealed the facility admitted her on 10/11/23 for treatment of a through-the-knee amputation of her right leg due to wound infections and lymphedema (body swelling caused by poor circulation in the immune system). An occupational (a type of therapy that encouraged rehabilitation through the performance of ADLs) therapist documented that Patient #1 required substantial or maximum assistance with toileting hygiene. Patient #1's medical record defined toileting hygiene as the ability to maintain perineal hygiene (washing the genital or rectal areas of the body) and adjusting clothes before and after voiding or having a bowel movement. The occupational therapist also documented that Patient #1 required partial or moderate assistance to bathe.

A review of the Shift ADL flowsheet for Patient #1 revealed multiple examples of days when she did not receive perineal care or a bath. For example, staff did not provide a bath for five days starting on 11/3/23 and ending on 11/7/23. During that time staff provided perineal hygiene for Patient #1 only once, on 11/5/23. Another example occurred on the three days starting on 11/23/23 and ending on 11/25/23, when staff did not provide either perineal care or bathing assistance to Patient #1.

This was in contrast to the Guidelines for Nursing Care policy, which instructed to provide a bath or shower three times a week and as needed.

i. On 11/27/23 at 9:59 a.m., an interview was conducted with Patient #1. Patient #1 said she needed help with toileting hygiene. Patient #1 stated when staff did not respond to the call light she activated for assistance with toileting, she had to sit in her urine or feces for up to 40 minutes. Patient #1 further explained staff rushed during certain busy times, which led to mistakes or missed care.

Patient #1 stated due to lymphedema increasing her skin's fragility she feared staff would have left her on a bedpan too long. Patient #1 explained the sharp edges of the pan could have easily cut her skin and caused wounds and further infections. She also stated the wounds from her amputation were close to the area affected by incontinence, which increased her fear of infection. Patient #1 said her concerns about lack of assistance with ADLs led her to experience poor sleep, anxiety, and stress because she had a prior experience with sepsis (blood infection) and could not live through the experience again.

ii. In an interview on 11/30/23 at 10:58 a.m., registered nurse (RN) #1 explained patients should have to wait less than five minutes for staff to respond to a call light. He said staff performed and documented perineal hygiene on the Shift ADL flowsheet each time they assisted a patient with incontinence care. RN #1 also said perineal hygiene was different from a bath. He stated a bath cleaned the entire body and perineal hygiene cleaned the perineum (rectum and genitals). RN #1 said both perineal hygiene and baths reduced the risk of patient infections.

iii. Upon request to the director of quality (Director) #9, the facility was unable to provide call bell response times for Patient #1. In an interview on 11/29/23 at 9:06 a.m., Director #9 stated the call bell system did not record the times when the patient activated the call bell and when staff turned it off after responding to it.

b. A review of Patient #2's medical record revealed the facility admitted her on 6/29/23 after she suffered two cerebral vascular accidents (strokes that occurred due to the loss of blood flow to the brain) which left her severely disabled on her right side. At the time of her admission, an occupational therapist documented that Patient #2 required maximal assistance for toileting and bathing, she communicated by gesturing with her left hand, and the patient's son provided most of the assistance with ADLs.

i. A review of the ADL flowsheet for Patient #2 revealed multiple days when she did not receive oral care or a bath. For example, there was no evidence that staff provided oral care between 7/25/23 and 7/30/23 or that Patient #2 received a bath between 9/30/23 and 10/6/23.

Additionally, on a Patient Rounding flowsheet which recorded recording every two-hour turns, multiple staff members documented the patient independently repositioned herself. For example, throughout the night shift on 11/26/23, staff documented Patient #2 repositioned herself.

On the same flowsheet, staff documented they turned the patient multiple times throughout a shift. However, each turn throughout the shift was entered in the medical record at the same date and time, indicating staff documented the turns before they occurred (forward documentation). For example, on 11/20/23, staff documented turning Patient #2 was turned every two hours throughout the night shift (from 7:00 p.m. until 7:00 a.m.), but all of the turns for the shift were documented at 1:55 a.m.

ii. On 11/30/23 at 12:57 p.m., observations were conducted of Patient #2 in her room in the presence of her son. Patient #2 appropriately answered yes or no questions by gesturing with her left hand. Upon request, Patient #2 was unable to independently turn herself from side to side. Patient #2 also required repeated cues to pay attention to questions and could not speak.

Also on 11/30/23 at 12:57 p.m., an interview was conducted with Patient #2 and her son. Patient #2 indicated she could not turn herself onto her right side when asked to do so. Patient #2's son explained she was mobile in bed but due to her strokes, could mainly only move up and down in the bed on her back. He also stated staff "breathed a sigh of relief" when he was present at the facility because they would not have to provide ADLs, baths, or turn her as he provided those services for his mother. He further stated he felt obligated to provide hygiene care and turns for his mother, as it would not otherwise have occurred.

Patient #2's son stated he was afraid to leave her alone at the facility because she was non-verbal, the staff felt rushed as they provided care, and he was concerned the lack of hygiene and turns could have led to long-term consequences such as depression, infection, or pressure injuries.

iii. On 11/27/23 at 9:05 a.m., an interview was conducted with certified nursing assistant (CNA) #2. CNA #2 stated the nursing assistant staff provided most of the assistance with ADLs if patients required support. She explained this included setting up the toothpaste and a toothbrush if a patient could brush for themselves, or brushing their teeth if they could not. CNA #2 said CNA and RN staff took turns rounding on (checking) patients every other hour and during these rounds, staff turned patients every two hours if they were unable to turn themselves. She stated staff provided bathing assistance for patients who required it every other day.

CNA #2 explained staff documented these activities on the ADL flowsheet, and if care was provided by a family member this should have been documented in the same place. She further explained if patients did not have their teeth brushed they could have developed sores in their mouths which could have led to infections. CNA #2 said if staff failed to turn or bathe patients who required assistance, patients could have developed pressure injuries (damage to the skin or underlying tissue), longer hospitalizations, and delayed discharges.

iv. In an interview on 11/30/23 at 10:58 a.m., RN #1 explained forward documentation was not acceptable because it documented something that had not yet happened. He stated this decreased the reliability of the medical record, recorded an action the staff member had not yet performed or could have been completely inaccurate if the patient experienced a change of condition.

c. A review of Patient #3's medical record revealed the facility admitted him on 12/30/22 for osteomyelitis (bone infection) in his left foot which led to a below-the-knee amputation. The occupational therapist documented Patient #3 required moderate assistance with ADLs, such as preparing the toothbrush and toothpaste, and assistance in the shower or set-up assistance for a bed bath. A review of Patient #3's ADL and Shift flowsheets revealed multiple days when Patient #3 had not received assistance to perform oral care or bathing. For example, staff did not assist Patient #3 with either oral care or bathing between 5/23/23 and 5/25/23.

d. A review of Patient #4's medical record revealed the facility admitted him on 6/13/23 due to quadriplegia (paralysis that affected all four limbs, starting at the neck) suffered after a fall. A review of Patient #3's ADL and Shift flowsheets revealed multiple days Patient #4 had not received oral care or a bath. For example, the staff did not provide oral care between 8/17/23 and 8/19/23 or bathe him between 6/26/23 and 7/12/23.

i. A review of Patient #4's Patient Rounding flowsheet revealed staff documented Patient #4 turned himself. The Patient Rounding flowsheet also included evidence of forward documentation for his every two-hour turns. Throughout the flowsheet, there were multiple days when staff documented the same date and time for each turn. For example, on 11/21/23 staff documented Patient #4 repositioned himself throughout the day shift. On 10/1/23, staff documented Patient #4 refused turns throughout the shift but each refusal was timed at 12:56 a.m.

ii. On 11/27/23 at 9:40 a.m., observations were conducted of Patient #4 in his room. Patient #4 was able to move his head in a limited range from side to side and up and down but was otherwise immobile. Patient #4 could not reposition himself in bed when requested to do so.

Also on 11/27/23 at 9:40 a.m., an interview was conducted with Patinet #4. Patient #4 said he was dependent on others for all care, including assistance with ADLs, bathing, and turning in bed. He further said he was concerned staff did not brush his teeth frequently, as he had caps and feared the lack of care would lead to an oral infection. Patient #4 explained he received ADL assistance, turns, and bathing depending on which staff member cared for him during the shift. He stated if the facility hired agency (temporary) staff he would not receive assistance with ADLs or a bath.

The findings in the medical records of Patients #1, 2, 3, and 4 were in contrast to the Guidelines for Nursing Care policy which instructed to turn and document bedfast patients every two hours and as needed. The policy also instructed to provide oral care daily and as needed. Additionally, the policy instructed to provide a bath or shower three times a week and as needed.

The findings were also in contrast to the Lippincott Manual of Nursing Practice which read changing positions from back to side-lying (and vice-versa) stimulated circulation, encouraged deeper breathing, and relieved pressure areas. The guideline instructed to help the patient to move onto his or her side if assistance was needed and to make sure that the patient turned from one side to the back and onto the other side every two hours. The guideline also instructed to bathe patients regularly.

e. On 11/27/23 at 10:45 a.m., an interview was conducted with RN #3. RN #3 stated staff bathed patients who required assistance every other day. RN #3 explained incontinent patients required more frequent bathing and perineal hygiene. She said she was not familiar with the Guidelines for Nursing Care policy but understood the expectations from the facility's leadership. RN #3 also said nursing care extended beyond providing medications and all nursing staff should have provided hands-on care. RN #3 explained failure to provide hygiene could have caused infections. She also explained if a patient refused ADLs staff should have documented the refusal in the medical record. RN #3 said if an action was not documented in the medical record, it was not done.

f. On 11/29/23 at 7:47 a.m., an interview was conducted with RN #4. RN #4 explained she was a certified wound care nurse and had practiced wound care at the facility for the past four years. RN #4 said if patients were not turned every two hours they developed pressure injuries. She further said if this occurred the patients became less interactive with staff and their hospitalizations became harder.

RN #4 said failure to provide oral care and bathing impacted patients because moisture caused skin breakdown. She also explained many patients remained hospitalized in the facility for months at a time, and staff assisting patients with ADLs and providing baths gave isolated patients a chance to receive human interactions. RN #4 stated hands-on care allowed nursing staff to see their patients' skin and identify pressure injuries as soon as they developed.

g. On 11/30/23 at 1:49 a.m., an interview was conducted with chief nursing officer (CNO) #5. CNO #5 reviewed the Patient Rounding flowsheets used to document every two-hour turns and agreed it was not possible to determine if and when staff had turned patients. CNO #5 stated forward documentation should not have occurred as it caused the medical record to be inaccurate.

Based on document reviews and interviews, the facility failed to administer medications in accordance with the orders of the practitioner and standards of practice. Specifically, the facility failed to ensure staff administered patients' medications within the timeframe specified by facility policy and national guidelines in four of four medical records reviewed (Patients #1, 2, 3, and 4). Additionally, the facility failed to follow national guidelines by developing a policy regarding the administration of time-critical medications.

Findings include:

Facility policies:

The Medication Administration Record and Medication Administration policy read, all medication will be administered within one hour before or after the scheduled time. Recording of medication administration will occur immediately after the medication is given and prior to proceeding to the next patient. Prior to administering the medication, the nurse will verify against the medication administration record (MAR) the time of administration. If the medication is given at a time greater than one hour before or one hour after the scheduled time, document in the medication administration record why the medication was not given at the scheduled time.

The Medication Administration - Pharmacy policy read, time-critical scheduled medications are those where early or delayed administration of maintenance doses of greater than 30 minutes before or after the scheduled dose may cause harm or result in substantial sub-optimal therapy or pharmacological effect. Medications shall be administered by or under the supervision of appropriately licensed personnel designated by the medical staff in its approved rules and regulations.

References:

The Lippincott Procedure - Safe Medication Administration Practices, General guideline provided by the facility read, for medications that require administration more frequently than daily but less frequently than every for hours (for example, twice daily, three times per day), administration should occur no more than one hour before or after the scheduled time.

Identify a time-critical list of common scheduled medications specific to the patient population of the unit.

1. The facility failed to ensure staff administered patients' medications within the timeframe specified by facility policy and national guidelines.

a. The facility's Medication Administration Record (MAR) and Medication Administration policy instructed to administer all medication within one hour before or after the scheduled time. The policy also instructed to record medication administration immediately after the medication was given and before proceeding to the next patient.

i. A review of Patient #1's medical record revealed the facility admitted her on 10/11/23 for treatment of a through-the-knee amputation of her right leg due to wound infections. A review of Patient #1's MAR revealed multiple instances of late medication administration. For example, physicians had ordered the nurses to administer methocarbamol (a muscle relaxer) and gabapentin (an anti-seizure medication also used for nerve pain) four times a day. On 10/12/23 these medications were due at noon. The nurse administered the medications to Patient #1 at 1:24 p.m., 24 minutes past the time frame specified in the facility's policy. Another example of late administration in Patient #1's medical administration record occurred on 11/26/23. The medications given once a day included venlafaxine (an antidepressant also used for pain) and rivaroxaban (a blood thinner, used to prevent blood clots) were due at 9:00 a.m. Patient #1 did not receive her daily medications until 10:19 a.m., 19 minutes outside of the expected time frame.

ii. A review of Patient #2's medical record revealed the facility admitted her on 6/29/23 after she suffered two cerebral vascular accidents (strokes that occurred due to the loss of blood flow to the brain) which left her severely disabled on her right side. A review of Patient #2's MAR revealed multiple instances of late medication administration. For example, physicians ordered ondansetron (to treat nausea and vomiting) four times a day. On 10/17/23 a dose was due at 4:00 p.m. Nurses did not give Patient #2 the medication until 6:24 p.m., 1 hour and 24 minutes outside of the expected time frame. Another example of late medication administration occurred on 11/11/23. Patient #2's daily medications, which included oxcarbazepine (an anti-seizure medication), were due at 9:00 a.m. Patient #2 received her medication at 10:24 a.m., 24 minutes outside of the expected time frame.

A review of the medical records of Patients #3 and 4 revealed similar findings. The medical records did not include documentation of why the medications were not administered at the scheduled time.

The late medication administrations in the medical records of patients #1, 2, 3, and 4 were in contrast to the Medication Administration Record and Medication Administration policy which instructed nurses to verify against the MAR the time of administration before the medication was administered. If the medication was given at a time greater than one hour before or one hour after the scheduled time, the policy instructed to document in the MAR why the medication was not given at the scheduled time.

b. On 11/29/23 at 10:27 a.m., an interview was conducted with registered nurse (RN) #6. RN #6 stated nursing staff had one hour before and one hour after a medication's scheduled time to administer it. She explained nurses administered medication late if a patient needed to be cleaned or have linen changed, required transportation for medical imaging in the middle of medication administration times, or too many nurses were waiting for access to the Pyxis (an automated medication dispensing system) to retrieve the medications.

RN #6 stated nursing staff also administered medications late due to the assigned number of patients. She explained two of the medical/surgical floors in the facility had 20 patient beds. RN #6 said if four nurses assigned to these floors each had five patients, the workload was manageable. However, if leadership assigned more than five patients, nurses did not have enough time to complete all necessary tasks.

RN #6 stated the facility did not employ enough certified nurse assistants (CNAs). RN #6 explained CNAs primarily assisted patients with activities of daily living (essential and routine tasks that most healthy individuals can provide for themselves) and baths. She further explained if nurses provided this care due to a lack of CNA staff, the nursing staff was unable to give medications on time.

c. On 11/30/23 at 10:58 a.m., an interview was conducted with RN #1. RN #1 stated if physicians scheduled medications several times a day and one of these was given late, it affected the patient's blood levels of the medication. He said physicians scheduled many daily medications at 9:00 a.m., which was a time when many patients required assistance with ADLs. RN #1 explained if the patients needed assistance with ADLS, the medication for the fourth and fifth patients were late because he was behind the schedule.

d. On 11/30/23 at 10:22 a.m., an interview was conducted with pharmacy manager (Pharmacist) #7. Pharmacist #7 said the facility gave the hour before and hour after the medication's due time for the medication to be administered because it allowed nurses flexibility in their schedules. She explained it took nurses 15 to 20 minutes to retrieve medications for one patient, and that nurses completed medication administration before returning to the Pyxis to retrieve the next patient's medication.

Pharmacist #7 stated the timing of administration for scheduled medications used to decrease spasticity or pain, such as baclofen and gabapentin, was important because patients were less likely to participate in therapy if they experienced increased pain or muscle tightness. Pharmacist #7 explained nurses should have administered antidepressant medication, such as venlafaxine, at the same time daily because it took weeks for antidepressant blood levels to increase to the point where patients experienced relief from depression or pain symptoms.

2. Based on national guidelines, the facility failed to identify a time-critical list of common scheduled medications.

a. The facility failed to identify a list of time-critical medications specific to their patient population.

i. A review of the facility policy Medication Administration Record and Medication Administration failed to reveal evidence the facility identified a list of time-critical medications. The Medication Administration - Pharmacy policy defined time-critical scheduled medications as those where early or delayed administration of maintenance doses of greater than 30 minutes before or after the scheduled dose caused harm or resulted in substantial sub-optimal therapy or pharmacological effect.

ii. On 11/29/23 at 10:27 a.m., an interview was conducted with RN #6. RN #6 stated she was not familiar with time-critical medications. She was unable to give examples of time-critical medications. RN #6 was unable to identify why nurses should have administered time-critical medications within 30 minutes of the scheduled time.

This interview was in contrast to the Lippincott Procedure - Safe Medication Administration Practices, General guideline that instructed to identify a time-critical list of common scheduled medications specific to the patient population of the unit.

iii. On 11/30/23 at 10:22 a.m., an interview was conducted with Pharmacist #7. Pharmacist #7 explained certain classes of medications, such as scheduled pain medications, antibiotics, and anti-seizure medications were time-critical. Pharmacist #7 said without time-critical administration patients experienced increased pain, a decrease in the antibiotic's ability to fight infection, lab work timing would have been wrong which led to over- or underdosing of antibiotics such as Vancomycin, or a patient seizure as blood levels of the medication decreased.

Further, Pharmacist #6 said the pharmacy kept a list of time-critical medications that nurses should have administered within a 30-minute window before or after the scheduled due time. Upon request to CNO #5, the facility was unable to provide this list.

iv. During an interview on 11/30/23 at 1:49 p.m., chief nursing officer (CNO) #5 reviewed the Medication Administration Record and Medication Administration policy used by nurses to guide medication administration. CNO #5 was unable to identify any time-critical guidelines within the policy or in any other policies or procedures used by the facility. He stated antibiotics that required lab testing to guide dosing such as Vancomycin and anti-seizure medications were time-critical, due to the harm that could have come to patients via suboptimal antibiotic blood levels or the increased possibility of seizures. CNO #5 was unable to identify other, specific time-critical medications and stated he deferred the question to the pharmacy.
The interviews with RN #6 and CNO #5 were in contrast to the Lippincott Procedure - Safe Medication Administration Practices, General guideline that instructed to identify a time-critical list of common, scheduled medications specific to the patient population of the unit.