HospitalInspections.org

Based on interview and record review, the facility failed to implement their policy and procedure (P&P) for five patients (Patient 15, 16, 24, 29, and 30) when:

1. For Patient 15, daily weights were not taken per physician order and weight loss of 14.99 pounds was not reported to the physician;

2. For Patients 16, 24, and 30, pain levels were not assessed before and after administration of pain medications;

3. For Patient 29, a skin assessment and Braden scale (a tool used in healthcare to assess a patient's risk of developing pressure ulcers) was not completed on admission.

These failures had the potential to jeopardize the health and safety of the patients.

Findings:

1. On April 10, 2025, at 8:30 a.m., a review of Patient 15's medical record was conducted with the Risk Manager (RM) and the Director of Quality (DOQ).

On April 10, 2025, at 9 a.m., a review of the facility document titled, "History and Physical [H&P]," dated January 9, 2025, at 2:14 p.m., indicated, "...Inpatient, January 9, 2025 - February 19, 2025...COPD [Chronic obstructive pulmonary disease, a chronic lung disease], chronic hypotension [low blood pressure], malnutrition [a condition caused by an imbalance, deficiency, or excess of nutrients in the body, which can have an adverse effect on the tissue, body form, and function], right hip replacement with prolonged stay..."

On April 10, 2025, at 9:10 a.m., a review of the facility document titled, "Order information for Weight," dated January 8, 2025, at 10:42 p.m., indicated, "...Routine...q24H [every 24 hours]...Special instructions...Daily Weight..."

On April 10, 2025, at 9:17 a.m., a review of the facility document titled, "Nutrition Assessment/Plan - Text," dated January 11, 2025, at 10:56 a.m., indicated, "...Adult Nutrition Reason for Assessment: Consult...low BMI [body mass index, measures body fat based on your height and weight]...Tube Feeding...NPO [nothing by mouth] order...Weight Change, Unintentional...Yes...-4 kilograms [a unit of mass] x 2 months (since Nov [November 2024] '24) = -8%...Nutrition Status Compromised: Yes, S/S [signs and symptoms] of Severe Malnutrition...Last documented Height/Weight/BMI....Height/Length Dosing...167.64 cm [centimeters, unit of measurement] January 9, 2025...1:33 p.m...Weight Dosing...45.6 kg [kilograms] January 8, 2025...3:44 p.m...BMI Measured...16.23 kg/m2 [represent two different physical quantities...moment of inertia and surface density]...Monitor/Evaluation...Dietitian follow up/monitor, Monitor weight...High Nutritional Risk..."

On April 10, 2025, at 9:17 a.m., a review of the facility document titled, "Vital Sign flow sheet," was reviewed for the following dates:
-January 8, 2025, at 3:44 p.m., 45.6 kilograms - 100.53 pounds on admission;
-January 11, 2025, at 6:20 a.m., 43.4 kilograms - 95.68 pounds - a loss of 4.86 pounds;
-January 18, 2025, at 6:52 a.m., 40.4 kilograms - 89.07 pounds - a loss of 11.06 pounds;
-January 22, 2025, at 6:19 a.m., 41.4 kilograms - 91.27 pounds - a loss of 9.26 pounds;
-January 25, 2025, at 5:13 a.m., 42 kilograms - 92.59 pounds - a loss of 7.94 pounds; and
-January 26, 2025, at 4:55 a.m., 38.54 kilograms - 85.54 pounds - a loss of 14.99 pounds - this was the last documented weight.

There was no documented evidence weights were taken on the following dates:
-January 9, 2025, and January 10, 2025 (two days);
-January 12, 2025, through January 17, 2025 (six days);
-January 19, 2025, through January 21, 2025 (three days);
-January 23, 2025, and January 24, 2025 (two days); and
-January 27, 2025, through February 19, 2025 (24 days).

During the hospitalization, Patient 15 was not weighed per physician's order on 37 days.

There was no documented evidence the physician was notified by staff of Patient 15's weight loss during her hospitalization.

On April 10, 2025, at 9:50 a.m., a concurrent interview and record review were conducted with the RM. The RM stated the nurses did not follow the daily weight order; the last documented weight was on January 26, 2025. The RM further stated the policy was not followed. She stated there was no documentation in the EMR that the physician was notified by the nurses that Patient 15 had a significant weight loss.

On April 10, 2025, at 12:52 p.m., a concurrent interview and record review were conducted with the Clinical Nutrition Manager (CNM). The CNM stated it does not look like the weight loss was reported to the physician.

A review of the facility P&P titled, "Physician's Orders," dated June 17, 2024, indicated, "...Licensed personnel may carry out an order for which there is no established standard, or documented competency in which case the employee will timely notify the provider...Provider orders will be accurately processed and promptly followed..."

A review of facility P&P titled, "Nutrition Assessment: Standard Of Care," dated March 23, 2023, indicated, "...Nutrition Reassessment...A reassessment provides further recommendations and nutritional interventions as needed based on each individual plan of care...Change in weight status...HIGH NUTRITIONAL RISK...Attachment A...feeding modality...tube feeding...Parenteral Nutrition...Weight Status...BMI...18.5 or less [adult 64 yrs (years) and younger]...Difficult Swallowing...Malnutrition...Pressure injury/wounds...Stage 2 or greater..."

A review of facility P&P titled, "WWeight [sic] Obtaining Inpatient - Adult and Pediatric," dated April 28, 2022, indicated, "...To provide clear guidelines to clinical staff on when it is appropriate and necessary to obtain an actual patient weight to ensure optimal clinical patient information to guide patient care, nutrition and medication dosing...It is recommended that patients with the following conditions be considered for frequent or daily weights...Conditions where fluid retention and fluid shift are a concern...Nutritionally compromised patients, including those with tube feedings, high protein needs...Patient experiencing sudden weight loss, or gain in a short period of time...Patients npo for 24 hours or longer...Intensive Care patients should be weighed daily..."

2a. On April 9, 2025, at 10 a.m., a review of Patient 16's record was conducted with the Clinical Systems Analyst (CSA) and the Senior Clinical Effectiveness Coordinator (SCEC).

On April 9, 2025, at 10:05 a.m., a review of the facility document titled, "ED [Emergency Department] Physician Record," dated March 29, 2025, at 11 p.m., indicated Patient 16 was admitted to the ED for suicidal ideation's. The document indicated Patient 16 had a medical history of Bipolar disorder (a mental health condition that causes extreme mood swings), Congestive Heart Failure (a condition where the heart cannot pump enough blood to meet the body's needs, leading to fluid buildup in the lungs and other tissues), Cerebral Vascular Accident (CVA - a medical condition where blood flow to the brain is interrupted) and Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves, often causing individuals to experience hallucinations, delusions, and disorganized thinking).

On April 9, 2025, at 10:10 a.m., a review of the facility document titled, "Orders," dated April 8, 2025, at 8:14 a.m., indicated an order for "...Acetaminophen...1000 mg [milligrams - unit of measurement]...2...Tabs (tablets)...Oral [by mouth]...Once..."

On April 9, 2025, at 10:15 a.m., a review of the facility document titled, "MAR [Medication Administration Record] Summary," dated April 8, 2025, at 8:34 a.m., indicated, Patient 16 received a dose of "...Acetaminophen...1,000 mg...2 Tabs...Oral...Once..."

On April 9, 2025, at 10:17 a.m., a review of the facility document titled, "Nursing note," dated April 8, 2025, at 8 a.m., indicated, "...pt [patient] c/o [complained of] allk [sic-all] over body aches. Dr. [doctor - name of physician] notified and orders rec'd [received]. pt [patient] calm and cooperative with staff..."

There was no documented evidence of a pain level prior to or after pain medication was administered to Patient 16.

On April 9, 2025, at 10:30 a.m., an interview was conducted with the CSA and SCEC. They stated pain should have been assessed prior to and after pain medication was administered to check for a baseline pain level and after to check if treatment was effective.

On April 10, 2025, at 1:30 p.m., an interview with the DOQ was conducted. The DOQ stated, an initial pain level should be assessed prior to receiving pain medication and within one hour after pain medication is administered.

2b. On April 9, 2025, at 10:50 a.m., a review of Patient 24's record was conducted with the CSA and the SCEC.

On April 9, 2025, at 11 a.m., a review of facility document titled, "H&P," dated April 5, 2025, at 10:51 p.m., indicated Patient 24 had a history of Systemic Lupus Erythematosus (a chronic inflammatory, autoimmune disease that can affect many parts of the body), End-stage Renal disease (a severe condition where the kidneys have lost their ability to effectively filter waste and excess fluid from the blood), Hypertension (high blood pressure), and Depression.

On April 9, 2025, at 11:05 a.m., a review of the facility document titled, "Order," dated April 5, 2025, at 10:13 p.m., indicated, an order for "...Hydromorphone (Dilaudid)...1 mg, 1 mL [milliliter- unit of measurement]...Injection...IV [intravenous] Push...q4H Interval...PRN...pain 4-6 (Moderate)..."

On April 9, 2025, at 11:10 a.m., a review of the facility document titled, "MAR," dated April 6, 2025, at 8:40 a.m., indicated "...Site...Left Arm...Hydromorphone 0.5 mg 0.5 mL...Route...IV Push...Given on...April 6, 2025, at 8:40 a.m...Reason for Medication...Pain 4-6 Moderate..."

On April 9, 2025, at 11:15 a.m., a review of the facility document titled, "Vital Signs Flowsheet," dated April 6, 2025, at 8:40 a.m., indicated no initial assessment of pain level prior to pain medication administration. The document further indicated on April 6, 2025, at 8:55 a.m., a numeric pain scale rating of 3 out of 10 after pain medication administration.

On April 9, 2025, at 11:30 a.m., an interview was conducted with the CSA and SCEC. They stated pain should have been assessed prior to and after pain medication was given to check for a baseline pain level and after to check if treatment was effective.

On April 10, 2025, at 1:30 p.m., an interview with the DOQ was conducted. The DOQ stated, an initial pain level should be assessed prior to receiving pain medication and within one hour after pain medication is administered.

2c. On April 9, 2025, at 11:50 a.m., a review of Patient 30's record was conducted with the CSA and the SCEC.

On April 9, 2025, at 12:30 p.m., a review of the facility document titled, "H&P," dated March 19, 2025, at 11:11 p.m., indicated Patient 30 had a history of Diabetes (a metabolic disorder characterized by persistently high blood sugar levels) and Hypertension.

On April 9, 2025, at 12:35 p.m., a review of the facility document titled, "Order," dated March 31, 2025, at 10:29 p.m., indicated an order for "...hydrocodone-acetaminophen (Norco 10mg-325 mg oral tablet)...1 Tab...route of administration...PEG-Tube [tube in the stomach]...Frequency...q6H [every 6 hours]...PRN...Yes...PRN Reason...Pain 7-10 (Severe)..."

On April 9, 2025, at 12:38 p.m., a review of the facility document titled, "MAR," dated April 6, 2025, at 8:49 p.m., indicated, "...hydrocodone-acetaminophen (Norco 10 mg...1 Tabs, Tab, Peg-Tube, q6H PRN Pain 7-10 (Severe)..." was administered to Patient 30.

On April 9, 2025, at 12:40 p.m., a review of the facility document titled, "Vital Sign Flowsheet," dated April 6, 2025, at 8:48 p.m., indicated, "...Pain assessment tool...Faces...FACES Pain Scale Score...6...Pain Assessment Detail...Location...Foot...Laterality...Bilateral..."

There was no documented evidence of pain being reassessed after pain medication was administered to Patient 30.

On April 9, 2025, at 12:45 p.m., an interview was conducted with the CSA and SCEC. They stated pain should have been assessed prior to and after pain medication was given to check for a baseline pain level and after to check if treatment was effective.

On April 10, 2025, at 1:30 p.m., an interview with the DOQ was conducted. The DOQ stated, an initial pain level should be assessed prior to receiving pain medication and within one hour after pain medication is administered.

A review of the facility P&P titled, "Medication Ordering and Administration," dated December 16, 2022, indicated, "...Administered PRN [as needed] medications must be documented in the medical record along with the indication for administration and patient response. Assessment of patient response to the medication must occur within one hour following the administration..."

A review of the facility P&P titled, "Pain Management," dated August 26, 2021, indicated, "...[Name of facility] reassesses and responds to the patient's pain...Evaluates and documents responses to pain interventions...Progresses toward pain management goals including functional ability...Evaluates any side effects of treatment...Evaluates risk factors for adverse events cause by the treatment..."

3. On April 9, 2025, a review of Patient 29's record was conducted with the CSA and the SCEC.

On April 9, 2025, at 1 p.m., a review of the facility document titled, "H&P," dated March 7, 2025, at 6:54 p.m., indicated, Patient 29 had a history of Chronic Kidney Disease (a condition where the kidneys are damaged and can't filter blood properly). Patient 29 was admitted on March 7, 2025, at 10:37 a.m., to the Medical/Surgical/Telemetry Unit (a specialized nursing area where nurses provide care to patients requiring continuous cardiac monitoring) for Leukocytosis (elevated white blood cell count).

On April 9, 2025, at 1:15 p.m., a review of the facility document titled, "Integumentary [skin system] Flowsheet," dated March 7, 2025, indicated, no documentation of a skin assessment or Braden scale on admission.

On April 9, 2025, at 1:20 p.m., an interview with the Director of Emergency Department (DED) was conducted. The DED indicated, when a patient is admitted and stays in the emergency department, the nurse caring for the patient should be doing a Braden scale and skin assessment. The DED indicated, "I do not see a Braden scale and skin assessment for this patient[Patient 29]...It should have been done per policy..."

A review of the facility P&P titled, "Pressure Injuries: Assessment, Documentation and Treatment Guidelines," dated September 26, 2024, indicated, "...Skin assessment and Braden scale documented on admission and daily..."

A review of the facility P&P titled, "Assessment/Reassessment of Patient," dated June 17, 2024, indicated, "...A Head-to-Toe Assessment is completed and documented on all inpatients upon admission (Body Systems Assessment...Braden Scale...)...within eight (8) hours of admission..."