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Based on record review and interview, the hospital failed to ensure the medical staff is accountable to the governing body for the quality of care provided to patients. This deficient practice if evidenced by medication reconciliation not being completed in a timely manner and the resumption of a home medication.
Findings:

A review of facility policy, Document Title: NSG 65, Subject: Medication Reconciliation, and approved 09/2018 revealed in part, Purpose: To accurately and completely reconcile medications across the continuum of care. Responsibility/Authority: Physicians, Allied Healthcare Professionals, Pharmacy and Nurses are responsible for this procedure as well as appropriate documentation of medication reconciliation. It is the responsibility of all licensed healthcare personnel to deliver clear, current medication communication at patient hand-off or with any transition in care. Policy/Procedure: 1. Nursing staff (ER (emergency room) staff for ER Admits and Floor Staff for Direct Admits) shall take all mediation history from patients that are admitted to the facility. 2. If the patient is admitted via the Emergency Room, the ER physician will write bridge orders. 3. Once the medication history is collected by the nurse, the physician will view and complete the medical record process.

An electronic medical record review of Patient #1 revealed an admission on 12/26/2024 through the Emergency Department (ED) with medication reconciliation by the ED nurse being performed on admission. The medication reconciliation reported by the ED nurse include the home medication of Eliquis (apixaban) 5mg, by mouth, twice daily. The medical history of Patient #1 included a history of atrial fibrillation and his current heart rhythm was atrial fibrillation. There was no bridge order by the emergency room provider for this medication to continue upon admissions to the hospital. A nursing note from 12/28/2023 at 6:57 p.m. revealed in part, S14MD being informed of the family's concern for the patient to resume his home medication - Eliquis. The patient received Eliquis 5mg by mouth on 12/29/2024 at 2:00 p.m. (3 days after admissions). A review of the Medication Reconciliation revealed this being performed by S15MD on 12/29/2023 at 3:46 p.m. (3 days after admission). This reconciliation included the resumption of Eliquis 5mg, by mouth, twice daily.

In an interview on 03/27/2024 at 11:55 a.m. S3RM and S13RN confirmed the above mentioned findings.

Based on record review, policy review and interview, the hospital failed to ensure the nursing care plan for each patient was kept current and reflected the patient's goals and the nursing care to be provided to meet the patient's needs. This deficient practice was evidenced by 1 (#1) of 3 (#1-#3) patient medical records reviewed not having a nursing care plan to reflect the patients current physiologic condition.
Findings:

A review of facility policy, Document ID: NSG3, Subject: Patient Assessment & Reassessment, and approved 09/2021 revealed in part, Purpose: To establish guidelines regarding the assessment and reassessment of patient's including scope and content of screening, assessment and reassessment information collected in order to formulate the plan of care. Policy: General: A. Patient will receive an initial assessment appropriate for the specific care setting and/or treatment the patient is seeking. Collecting information about the patient's health history as well as physical, functional and psychosocial status. Basic Admission Information includes: Height, Weight. B. The information gathered at the first patient contact may indicate that the patient needs a broader or more intensive assessment. Precisely what further assessment is needed will depend at least in part on: 1. The patient's diagnosis/presenting condition. E. Clinical data, to include presenting signs and symptoms, chief complaint and/or medical diagnosis is provided at the time of diagnostic order to ensure appropriate interpretation. F. An initial assessment is performed in a time frame that is appropriate for the patient's level of acuity and need. G. Reassessment is an ongoing process that is necessary to assure the care remains appropriate. Reassessment is based on the patient's diagnosis, condition, chief complaint, and/or physician's order. All patients may expect to be reassessed: 1. At regular specified times related to the patient's course of treatment; 2. To determine the patient's response to treatment; 3. When a significant change occurs in the patient's condition. Staff members are to integrate the information from various assessments to identify needs and prioritize care. H. The plan of care is based on identified needs and/or care deficits of the patient in conjunction with patient care standards according to treatment priorities which are consistent with the therapies of all health care disciplines. Nursing Unit: I. Assessment A. The nursing process will be used to assess, plan, implement and evaluate patient care. B. An initial assessment and data collection of the patient will be performed at the first point of entry in a time frame that is appropriate for the patient's care setting, age, level of acuity and need. C. The Registered Nurse is responsible for analyzing patient data and utilizes this information to formulate an assessment of identified needs and to determine the need for further assessment. The identified needs are prioritized and individualized to formulate the patient's plan of care. II. Reassessment: Each patient is reassessed as necessary based on his or her plan of care or changes in condition. On inpatient units, reassessments of patients are performed at least every shift. Reassessment and nursing interventions performed during the shift may include documentation of ... intake and outputs ... and any other pertinent information. Nursing documentation will reflect interventions and goals established in the patient's plan of care. III. Plan of Care: The Interdisciplinary Plan of Care is based on the data gathered during patient assessment/reassessment that identifies the patient's care needs, lists the strategy for providing services to meet those needs, documents treatment goals, outlines criteria for termination of specified interventions, and documents the individual's progress in meeting specified goals and objectives. 3. The Registered Nurse will review and update if indicated the Interdisciplinary Plan of Care every 24 hours. 4. The Interdisciplinary Plan of Care shall be used to document specific interventions identified for the patient in the Plan of Care for nursing and in the progress notes for other disciplines. 5. The Registered Nurse or the Licensed Practical Nurse assigned to provide care for the patient will utilize the Interdisciplinary Plan of Care as guide for providing care for the patient. In addition, the interventions and responses to interventions should be reflected in the daily documentation of patient care. 6. The Plan of Care is also utilized to identify and electronically notify other disciplines when needs are identified.

An electronic medical record review of Patient #1 revealed an admission from 12/26/2024 till 01/24/2024. The initial Emergency Department (ED) triage note on 12/26/2023 at 3:22 p.m. had a chief complaint of shortness of breath and swelling to right leg with weeping occurring, a documented weight of 223.8kg (493lbs), respiratory rate of 28 breaths/minute (normal 12 - 20 breaths/min) and SpO2 (blood oyxgen saturation) of 80% (normal 95% - 100 %) on room air.
The ED provider note revealed in part, the patient having increasing difficulty ambulating due to increased swelling and pain to his lower extremities. Also, the patient had wheezing with shortness of breath over the prior few days. The past medical history revealed lymphedema, hypertension, past cellulitis to lower extremities, chronic kidney disease (CKD), morbid obesity, and congested heart failure (CHF). Initial exam revealed bilateral wheezing to chest, morbid obesity with large abdomen, and lymphedema to lower extremities. Labs revealed a BUN (blood urea nitrogen) of 67 mg/dl (normal range 6 - 20 mg/dl) and Creatinine (Cr) of 1.67 mg/dl (normal range 0.7 - 1.3 mg/dl). Chest X-ray revealed CHF, volume overload with pulmonary edema. The assessment included 1. Cellulitis of the lower extremities, 2. Tines pedis, 3. Lymphedema, 4. Congestive Heart Failure, 5. Chronic obstructive pulmonary disease exacerbation, 6. Acute kidney injury (AKI) in the setting of chronic kidney disease As the admission progressed, the patient had increasing difficulty breathing with any attempt to sit at beside. With this progression, the patient was placed in a brief because he was unable to use a urinal or be up to bedside for bowel elimination.

A nephrology consult was initiated on 12/27/2023 at 1:41 p.m. for acute kidney injury. Recommendation was to place a Foley catheter.

A urology consult was initiated on 12/28/2023 at 3:47 p.m. because multiple nurse attempts to place a Foley catheter were unsuccessful. It was documented on the consult there was significant edema throughout the scrotum and inguinal regions. The urologist note revealed in part, will be unable to insert a Foley given the patient's anatomy, unable to adequately feel the flans penis because of the swelling.

Inability to adequately measure urine output resulted in the documentation of daily urine counts (the number of times the patient voided) and diaper counts. However, there was no documentation of any output on 5 (12/26-27/2023, 01/11/2024, 01/14/2024, 01/20/2024) of 30 (12/26/2023 - 01/24/2024) days of the patient's admissions.

Provider progress notes revealed in part: 12/27/2023 at 8:08 a.m. plan to discontinue IV fluids related to possibly contributing to his congestive heart failure; Progress note on 12/28/2024 at 10:40 a.m. Assessment/Plan 1. AKI, ongoing. BUN, Cr still elevated. Unclear urine output. Progress note on 12/30/3034 at 11:23 a.m. Assessment/Plan 1. AKI, ongoing. BUN rising, but Cr decreasing. Unclear urine output. There was no other documentation by the providers in regards to urine output during the course of the patient's admission. There was no documentation from a provider as to the patient's weight status during the course of the patient's admission besides the diagnosis of morbid obesity.

The review of the electronic medical record revealed an initial admission weight on the patient, but did not reveal another patient weight during the course of his 30 day admission.

In an interview on 03/27/2024 at 11:55 a.m. S3RM and S13RN confirmed the above mentioned findings.

Based on observations and interviews, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being of patients are assured. This deficient practice was evidenced by failing to maintain the physical plant in good repair.
Findings:

Observations during a tour on 03/26/2024 from 9:45 a.m. till 11:00 a.m. with S2CNO, S3RM, S6RNM and S7RNCC present, revealed exposed wood surfaces on wall-mounted wood bench seats in Shower Rooms #a - #c. These exposed wood surfaces prevent the areas from being properly cleaned and sanitized.

In an interview on 03/26/2024 during the tour, S2CNO confirmed the above mentioned findings.

Based on observation and interview, the hospital failed to ensure supplies and equipment were maintained to ensure an acceptable level of safety and/or quality. This deficient practice is evidenced by failing to ensure expired supplies were not available for patient use.
Findings:

Observations during a tour 03/26/2024 from 9:45 a.m. till 11:00 a.m. with S2CNO, S3RM, S6RNM and S7RNCC present, revealed, eSwab Collection and Preservation sets (consisting of 1 swab with a collection tube), quantity 12, with an expiration of 05/31/2023 and being available for patient use.

In an interview on 03/26/2024 during the tour, S6RNM and S7RNCC confirmed the above mentioned findings.