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Based on interview and record review, the facility's Governing Body failed to ensure Nursing Services provided registered nurses (RN) oversight over licensed vocational nurses (LVNs) and conducting patient assessments for patients assigned to LVN. Four of 34 sampled patients (Patients 4, 18, 21, and 22) lacked assessments by a registered nurse, in accordance with policies and procedure and licensed vocational nurses' scope of practice.

This deficient practice had the potential to compromise patient care and safety due to lack of RN oversight on LVNs, to ensure that accurate patient assessments are conducted, and the plan of care/treatment are implemented to address patient care needs.

Findings:

1. During a concurrent interview and record review on 2/7/2024 at 11:50 a.m., with the Quality Assurance Registered Nurse (QARN), Patient 4's nursing assessment records were reviewed. The QARN stated the following: Patient 4 was admitted to the facility on 2/4/2024 for a gastrointestinal bleed (bleeding from the digestive tract). QARN reviewed Patient 4's "Daily Shift Assessment," dated 2/6/2024 at 8 a.m., and stated the assessment was documented by licensed vocational nurse (LVN) 6. The QARN verified that the assessment was not co-signed by a registered nurse (RN). In addition, the QARN verified that reassessments documented on 2/6/2024 at 12 p.m., and 4 p.m., were also documented by LVN 6 and not co-signed by a RN.

In the same interview on 2/7/2024 at 11:50 a.m., the QARN stated there were no other signatures, from RNs, associated with the assessments performed and documented by LVNs. The QARN stated that a RN should oversee and validate and agree with the LVNs assessment, and it should be documented in the medical record. The QARN stated a RN should assess patients to ensure LVN's documentation is accurate and fits the patient's plan of care.

During an interview on 2/6/2024 at 1:50 p.m. with the Director of Cardiac Services (DCS), the DCS stated the following: The RN oversees the LVN. RN performs the initial assessments and reassessments. RNs co-sign initial and shift assessments.

During an interview on 2/9/2024 at 11:38 a.m., with the Clinical Educator Nursing Administration (CENA), the CENA stated the following: LVNs can collect data related to the patient. However, the RN was responsible for conducting a total assessment of patients' conditions and to identify changes.

During a review of Patient 4's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/4/2024 at 4:46 p.m., the H&P indicated the following: Patient 4's chief complaint was gastrointestinal bleed (bleeding from the digestive tract). Patient 4 had a past medical history significant for hypertension (high blood pressure), congestive heart failure (heart does not pump blood as well as it should), diabetes mellitus (high blood sugar), deep vein thrombosis (DVT, a blood clot forms in a deep vein), GI bleed, and diverticulosis (bulging pouches that develop in the digestive tract). Patient 4 presented to the facility from home because of bloody bowel movements.

During a review of Patient 4's "Med/Surg/Tele Flowsheet - Shift," dated 2/6/2024, the flowsheet indicated it was documented by LVN 6.

During a review of Patient 4's "Reassessments," dated 2/6/2024 at 8 a.m., the reassessment was documented by LVN 6.

During a review of Patient 4's "Reassessments," dated 2/6/2024 at 12 p.m., the reassessment was documented by LVN 6.

During a review of Patient 4's "Reassessments," dated 2/6/2024 at 4 p.m., the reassessment was documented by LVN 6.

During an interview on 2/9/2024 at 2:16 p.m., with the Chief Nursing Officer (CNO), the CNO stated that the Governing Body had oversight to ensure staffing assignments were in compliance with mandated State and Federal regulations. The CNO stated 60 licensed vocational nurses (LVNs) worked at the facility, with the oversight of a registered nurse (RN). The CNO stated there was no oversight by the Governing Body, nor was the Governing Body conducting any audits to ensure that the registered nurses were performing patient assessments for patients assigned to LVNs.

During a review of the facility's "Governing Board Minutes," dated 1/11/2023, 4/12/2023, 7/12/2023, and 10/11/2023, the minutes did not reflect any actions or audits to ensure or evaluate the registered nurse's oversight over the licensed vocational nurses.

During a review of the facility's policy and procedure (P&P) titled, "Assessment and Reassessment of the Patient," dated 7/2023, the P&P indicated the following: All patients will have a baseline assessment of their problems and needs performed by a registered nurse ...An initial screening assessment, including consideration of the patient's health history prior to admission, as well as physical, psychological and social status, educational and discharge planning factors, is performed by a registered nurse ...All patients will have ongoing assessments and/or reassessment of their problems/needs/condition performed by a registered nurse. The registered nurse may delegate aspects of data collection to other health care personnel, who are trained, certified and authorized within their scope of practice. Based on the reassessment, the registered nurse may revise the patient's plan of care as appropriate. Reassessments are completed by an RN every shift in inpatients areas or more frequently as indicated by patient condition or unit-specific parameters.

During a review of the facility's policy and procedure titled, "Licensed Vocational Nurse, Scope of Practice," dated 1/2024, the P&P indicated the following: The LVN is authorized to perform services which require technical and manual skills acquired in an accredited vocational nursing school, and which are practiced under the direction of a licensed physician or registered nurse (RN). The responsible RN must delegate task within the LVN scope of practice and must oversee the performance to ensure high quality care for the patient ...Initial admission assessment and care plan formulation must be performed by the RN. The RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN.

2. During a review of Patient 18's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/3/2024, the H&P indicated, Patient 18 was admitted to the facility's Medical Surgical Unit (hospital ward service general patient population with variety of diseases and illnesses) with diagnoses of failure to thrive (a syndrome of global decline that occurs in older adults as a worsening of physical frailty) and hypertension (high blood pressure). The H&P also indicated Patient 18 had left knee arthritis (swelling and tenderness at joints), diabetes (high blood sugar) and cerebral vascular accident (CVA, stroke, brain attack affecting someone's ability to think, move and speak) with left-sided deficits (weakness).

During a concurrent interview and record review on 2/8/2024 at 11 a.m. with the Quality Assurance Registered Nurse (QARN), Patient 18's "Med/Surg/Tele Flowsheet Shift Assessment (nursing assessment, documentation of nursing assessment for patient)", dated from 2/2/2024 to 2/8/2024, was reviewed. The nursing assessment indicated LVNs 5, 10, 11, and 12 recorded the nursing assessment on the following days:

2/3/2024 at 8 a.m. by LVN 10
2/4/2024 at 8 a.m. by LVN 11
2/5/2024 at 8 a.m. by LVN 11
2/6/2024 at 8 a.m. by LVN 5
2/6/2024 at 8 p.m. by LVN 12
2/7/2024 at 8 p.m. by LVN 12

QARN verified that there was no RN sign off on the nursing assessment recorded by the LVNs listed. QARN stated RN was required to perform assessment on patient and validate the data the LVN had collected to make sure assessment was done accurately, and to address any problems identified in the assessment. QARN further stated without proper assessment, it could potentially compromise patient care due to lack of RN oversight.

During an interview on 2/9/2024 at 2:16 p.m. with the Chief Nursing Officer (CNO), the CNO stated that the Governing Body had oversight to ensure staffing assignments were in compliance with mandated State and Federal regulations. The CNO stated 60 licensed vocational nurses (LVNs) worked at the facility, with the oversight of a registered nurse (RN). The CNO stated there was no oversight by the Governing Body, nor was the Governing Body conducting any audits to ensure that the registered nurses were performing patient assessments for patients assigned to LVNs.

During a review of the facility's "Governing Board Minutes," dated 1/11/2023, 4/12/2023, 7/12/2023, and 10/11/2023, the minutes did not reflect any actions or audits to ensure or evaluate the registered nurse's oversight over the licensed vocational nurses.

During a review of the facility's policy and procedure (P&P) titled, "Assessment and Reassessment of the Patient," dated 7/2023, the P&P indicated the following: All patients will have a baseline assessment of their problems and needs performed by a registered nurse ...An initial screening assessment, including consideration of the patient's health history prior to admission, as well as physical, psychological and social status, educational and discharge planning factors, is performed by a registered nurse ...All patients will have ongoing assessments and/or reassessment of their problems/needs/condition performed by a registered nurse. The registered nurse may delegate aspects of data collection to other health care personnel, who are trained, certified and authorized within their scope of practice. Based on the reassessment, the registered nurse may revise the patient's plan of care as appropriate. Reassessments are completed by an RN every shift in inpatients areas or more frequently as indicated by patient condition or unit-specific parameters.

During a review of the facility's policy and procedure titled, "Licensed Vocational Nurse, Scope of Practice," dated 1/2024, the P&P indicated the following: The LVN is authorized to perform services which require technical and manual skills acquired in an accredited vocational nursing school, and which are practiced under the direction of a licensed physician or registered nurse (RN). The responsible RN must delegate task within the LVN scope of practice and must oversee the performance to ensure high quality care for the patient ...Initial admission assessment and care plan formulation must be performed by the RN. The RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN.

3. During a review of Patient 21's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 1/31/2024, the H&P indicated, Patient 21 was admitted to the facility's Definitive Observation Unit (DOU, hospital unit that provides the second-highest level of care) with diagnoses of acute respiratory failure (a condition in which the lungs cannot release enough oxygen into the blood) due to fluid overload (too much fluid in the body) requiring Bilevel positive airway pressure (BIPAP, a machine that helps someone to breath via noninvasive ventilation).

During a concurrent interview and record review on 2/8/2024 at 2:35 p.m. with the Quality Assurance Registered Nurse (QARN), Patient 21's "Critical care/Step down Shift Assessment (nursing assessment, documentation of nursing assessment for patient in DOU)," dated from 1/31/2024 to 2/8/2024, was reviewed. The nursing assessment indicated LVN 7 recorded the nursing assessment on 2/6/2024 at 8 p.m. QARN verified that there was no RN sign off on the nursing assessment recorded by LVN 7. QARN stated RN was required to perform head to toe assessment once per shift to identify any abnormality or changes from the previous shift and to report to physician if there were any changes. QARN further stated without RN assessment, something could be missed and could result in inadequate care.

During an interview on 2/9/2024 at 2:16 p.m. with the Chief Nursing Officer (CNO), the CNO stated that the Governing Body had oversight to ensure staffing assignments were in compliance with mandated State and Federal regulations. The CNO stated 60 licensed vocational nurses (LVNs) worked at the facility, with the oversight of a registered nurse (RN). The CNO stated there was no oversight by the Governing Body, nor was the Governing Body conducting any audits to ensure that the registered nurses were performing patient assessments for patients assigned to LVNs.

During a review of the facility's "Governing Board Minutes," dated 1/11/2023, 4/12/2023, 7/12/2023, and 10/11/2023, the minutes did not reflect any actions or audits to ensure or evaluate the registered nurse's oversight over the licensed vocational nurses.

During a review of the facility's policy and procedure (P&P) titled, "Assessment and Reassessment of the Patient," dated 7/2023, the P&P indicated the following: All patients will have a baseline assessment of their problems and needs performed by a registered nurse ...An initial screening assessment, including consideration of the patient's health history prior to admission, as well as physical, psychological and social status, educational and discharge planning factors, is performed by a registered nurse ...All patients will have ongoing assessments and / or reassessment of their problems/needs/condition performed by a registered nurse. The registered nurse may delegate aspects of data collection to other health care personnel, who are trained, certified and authorized within their scope of practice. Based on the reassessment, the registered nurse may revise the patient's plan of care as appropriate. Reassessments are completed by an RN every shift in inpatients areas or more frequently as indicated by patient condition or unit-specific parameters.

During a review of the facility's policy and procedure titled, "Licensed Vocational Nurse, Scope of Practice," dated 1/2024, the P&P indicated the following: The LVN is authorized to perform services which require technical and manual skills acquired in an accredited vocational nursing school, and which are practiced under the direction of a licensed physician or registered nurse (RN). The responsible RN must delegate task within the LVN scope of practice and must oversee the performance to ensure high quality care for the patient ...Initial admission assessment and care plan formulation must be performed by the RN. The RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN.

4. During a review of Patient 22's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 12/11/2023, the H&P indicated, Patient 22 was admitted to the facility's Telemetry (hospital unit where patients undergo continuous cardiac monitoring) with diagnoses of hypertension (high blood pressure), congestive heart failure (CHF, heart failure in which the heart cannot pump enough blood to meet the body's needs), and acute hypoxemic (lack of oxygen) respiratory distress.

During a concurrent interview and record review on 2/8/2024 at 3:16 p.m. with the Quality Assurance Registered Nurse (QARN), Patient 22's "Critical care/Step down Shift Assessment (nursing assessment)," dated from 1/6/2024 to 1/7/2024, was reviewed. The nursing assessment indicated LVN 6 and LVN 13 recorded the nursing assessment on 1/6/2024 at 8 a.m. and 1/6/2024 at 8 p.m. QARN verified that there was no RN sign off on the nursing assessment recorded by LVN 6 and LVN 13.

During a concurrent interview and record review on 2/8/2024 at 3:30 p.m. with QARN, Patient 22's nurse notes (narrative notes documented by nursing staff to reflect care given during the shift), dated 1/7/2024, was reviewed. The nurse notes indicated, at 3:30 a.m., Patient 22 bit bottom of his (Patient 22) tongue and resulted in tongue bleeding. QARN verified that there was no documentation that LVN 13 reported it to a RN or Patient 22's physician. QARN stated that it was a change of condition and LVN 13 should have reported it to the RN who oversaw Patient 22 so the RN could perform assessment and address the problem. QARN stated there was no RN oversight over LVN 13.
During a concurrent interview and record review on 2/9/2024 at 12:03 p.m. with the Director of Nursing (DON), Patient 22's nursing assignment, dated 1/6/2024, was reviewed. The nursing assignment indicated LVN 13 was assigned to Patient 22 on 1/6/2024 night shift. DON verified that there was no documentation indicating a RN was assigned to oversee LVN 13's patients including Patient 22.

During an interview on 2/9/2024 at 2:16 p.m., with the Chief Nursing Officer (CNO), the CNO stated that the Governing Body had oversight to ensure staffing assignments were in compliance with mandated State and Federal regulations. The CNO stated 60 licensed vocational nurses (LVNs) worked at the facility, with the oversight of a registered nurse (RN). The CNO stated there was no oversight by the Governing Body, nor was the Governing Body conducting any audits to ensure that the registered nurses were performing patient assessments for patients assigned to LVNs.

During a review of the facility's "Governing Board Minutes," dated 1/11/2023, 4/12/2023, 7/12/2023, and 10/11/2023, the minutes did not reflect any actions or audits to ensure or evaluate the registered nurse's oversight over the licensed vocational nurses.

During a review of the facility's policy and procedure (P&P) titled, "Assessment and Reassessment of the Patient," dated 7/2023, the P&P indicated the following: All patients will have a baseline assessment of their problems and needs performed by a registered nurse ...An initial screening assessment, including consideration of the patient's health history prior to admission, as well as physical, psychological and social status, educational and discharge planning factors, is performed by a registered nurse ...All patients will have ongoing assessments and/or reassessment of their problems/needs/condition performed by a registered nurse. The registered nurse may delegate aspects of data collection to other health care personnel, who are trained, certified and authorized within their scope of practice. Based on the reassessment, the registered nurse may revise the patient's plan of care as appropriate. Reassessments are completed by an RN every shift in inpatients areas or more frequently as indicated by patient condition or unit-specific parameters.

During a review of the facility's policy and procedure titled, "Licensed Vocational Nurse, Scope of Practice," dated 1/2024, the P&P indicated the following: The LVN is authorized to perform services which require technical and manual skills acquired in an accredited vocational nursing school, and which are practiced under the direction of a licensed physician or registered nurse (RN). The responsible RN must delegate task within the LVN scope of practice and must oversee the performance to ensure high quality care for the patient ...Initial admission assessment and care plan formulation must be performed by the RN. The RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN.

Based on interview and record review, the facility's Governing Body failed to ensure Nursing Services provided registered nurses (RN) oversight over licensed vocational nurses (LVNs) and conducting patient assessments for patients assigned to LVN. Four of 34 sampled patients (Patients 4, 18, 21, and 22) lacked assessments by a registered nurse, in accordance with policies and procedure and licensed vocational nurses' scope of practice.

This deficient practice had the potential to compromise patient care and safety due to lack of RN oversight on LVNs, to ensure that accurate patient assessments are conducted, and the plan of care/treatment are implemented to address patient care needs.

Findings:

1. During a concurrent interview and record review on 2/7/2024 at 11:50 a.m., with the Quality Assurance Registered Nurse (QARN), Patient 4's nursing assessment records were reviewed. The QARN stated the following: Patient 4 was admitted to the facility on 2/4/2024 for a gastrointestinal bleed (bleeding from the digestive tract). QARN reviewed Patient 4's "Daily Shift Assessment," dated 2/6/2024 at 8 a.m., and stated the assessment was documented by licensed vocational nurse (LVN) 6. The QARN verified that the assessment was not co-signed by a registered nurse (RN). In addition, the QARN verified that reassessments documented on 2/6/2024 at 12 p.m., and 4 p.m., were also documented by LVN 6 and not co-signed by a RN.

The QARN stated there were no other signatures, from RNs, associated with the assessments performed and documented by LVNs. The QARN stated that a RN should oversee and validate and agree with the LVNs assessment, and it should be documented in the medical record. The QARN stated a RN should assess patients to ensure LVN's documentation is accurate and fits the patient's plan of care.

During an interview on 2/6/2024 at 1:50 p.m. with the Director of Cardiac Services (DCS), the DCS stated the following: The RN oversees the LVN. RN performs the initial assessments and reassessments. RNs co-sign initial and shift assessments.

During an interview on 2/9/2024 at 11:38 a.m., with the Clinical Educator Nursing Administration (CENA), the CENA stated the following: LVNs can collect data related to the patient. However, the RN was responsible for conducting a total assessment of patients' conditions and to identify changes.

During a review of Patient 4's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/4/2024 at 4:46 p.m., the H&P indicated the following: Patient 4's chief complaint was gastrointestinal bleed (bleeding from the digestive tract). Patient 4 had a past medical history significant for hypertension (high blood pressure), congestive heart failure (heart does not pump blood as well as it should), diabetes mellitus (high blood sugar), deep vein thrombosis (DVT, a blood clot forms in a deep vein), GI bleed, and diverticulosis (bulging pouches that develop in the digestive tract). Patient 4 presented to the facility from home because of bloody bowel movements.

During a review of Patient 4's "Med/Surg/Tele Flowsheet - Shift," dated 2/6/2024, the flowsheet indicated it was documented by LVN 6.

During a review of Patient 4's "Reassessments," dated 2/6/2024 at 8 a.m., the reassessment was documented by LVN 6.

During a review of Patient 4's "Reassessments," dated 2/6/2024 at 12 p.m., the reassessment was documented by LVN 6.

During a review of Patient 4's "Reassessments," dated 2/6/2024 at 4 p.m., the reassessment was documented by LVN 6.

During an interview on 2/9/2024 at 2:16 p.m., with the Chief Nursing Officer (CNO), the CNO stated that the Governing Body had oversight to ensure staffing assignments were in compliance with mandated State and Federal regulations. The CNO stated 60 licensed vocational nurses (LVNs) worked at the facility, with the oversight of a registered nurse (RN). The CNO stated there was no oversight by the Governing Body, nor was the Governing Body conducting any audits to ensure that the registered nurses were performing patient assessments for patients assigned to LVNs.

During a review of the facility's "Governing Board Minutes," dated 1/11/2023, 4/12/2023, 7/12/2023, and 10/11/2023, the minutes did not reflect any actions or audits to ensure or evaluate the registered nurse's oversight over the licensed vocational nurses.

During a review of the facility's policy and procedure (P&P) titled, "Assessment and Reassessment of the Patient," dated 7/2023, the P&P indicated the following: All patients will have a baseline assessment of their problems and needs performed by a registered nurse ...An initial screening assessment, including consideration of the patient's health history prior to admission, as well as physical, psychological and social status, educational and discharge planning factors, is performed by a registered nurse ...All patients will have ongoing assessments and/or reassessment of their problems/needs/condition performed by a registered nurse. The registered nurse may delegate aspects of data collection to other health care personnel, who are trained, certified and authorized within their scope of practice. Based on the reassessment, the registered nurse may revise the patient's plan of care as appropriate. Reassessments are completed by an RN every shift in inpatients areas or more frequently as indicated by patient condition or unit-specific parameters.

During the review of the facility's policy and procedure titled, "Licensed Vocational Nurse, Scope of Practice," dated 1/2024, the P&P indicated the following: The LVN is authorized to perform services which require technical and manual skills acquired in an accredited vocational nursing school, and which are practiced under the direction of a licensed physician or registered nurse (RN). The responsible RN must delegate task within the LVN scope of practice and must oversee the performance to ensure high quality care for the patient ...Initial admission assessment and care plan formulation must be performed by the RN. The RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN.

2. During a review of Patient 18's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/3/2024, the H&P indicated, Patient 18 was admitted to the facility's Medical Surgical Unit (hospital ward service general patient population with variety of diseases and illnesses) with diagnoses of failure to thrive (a syndrome of global decline that occurs in older adults as a worsening of physical frailty) and hypertension (high blood pressure). The H&P also indicated Patient 18 had left knee arthritis (swelling and tenderness at joints), diabetes (high blood sugar) and cerebral vascular accident (CVA, stroke, brain attack affecting someone's ability to think, move and speak) with left-sided deficits (weakness).

During a concurrent interview and record review on 2/8/2024 at 11 a.m. with the Quality Assurance Registered Nurse (QARN), Patient 18's "Med/Surg/Tele Flowsheet Shift Assessment (nursing assessment, documentation of nursing assessment for patient)", dated from 2/2/2024 to 2/8/2024, was reviewed. The nursing assessment indicated LVNs 5, 10, 11, and 12 recorded the nursing assessment on the following days:

2/3/2024 at 8 a.m. by LVN 10
2/4/2024 at 8 a.m. by LVN 11
2/5/2024 at 8 a.m. by LVN 11
2/6/2024 at 8 a.m. by LVN 5
2/6/2024 at 8 p.m. by LVN 12
2/7/2024 at 8 p.m. by LVN 12

QARN verified that there was no RN sign off on the nursing assessment recorded by the LVNs listed. QARN stated RN was required to perform assessment on patient and validate the data the LVN had collected to make sure assessment was done accurately, and to address any problems identified in the assessment. QARN further stated without proper assessment, it could potentially compromise patient care due to lack of RN oversight.

During an interview on 2/9/2024 at 2:16 p.m. with the Chief Nursing Officer (CNO), the CNO stated that the Governing Body had oversight to ensure staffing assignments were in compliance with mandated State and Federal regulations. The CNO stated 60 licensed vocational nurses (LVNs) worked at the facility, with the oversight of a registered nurse (RN). The CNO stated there was no oversight by the Governing Body, nor was the Governing Body conducting any audits to ensure that the registered nurses were performing patient assessments for patients assigned to LVNs.

During a review of the facility's "Governing Board Minutes," dated 1/11/2023, 4/12/2023, 7/12/2023, and 10/11/2023, the minutes did not reflect any actions or audits to ensure or evaluate the registered nurse's oversight over the licensed vocational nurses.

During a review of the facility's policy and procedure (P&P) titled, "Assessment and Reassessment of the Patient," dated 7/2023, the P&P indicated the following: All patients will have a baseline assessment of their problems and needs performed by a registered nurse ...An initial screening assessment, including consideration of the patient's health history prior to admission, as well as physical, psychological and social status, educational and discharge planning factors, is performed by a registered nurse ...All patients will have ongoing assessments and/or reassessment of their problems/needs/condition performed by a registered nurse. The registered nurse may delegate aspects of data collection to other health care personnel, who are trained, certified and authorized within their scope of practice. Based on the reassessment, the registered nurse may revise the patient's plan of care as appropriate. Reassessments are completed by an RN every shift in inpatients areas or more frequently as indicated by patient condition or unit-specific parameters.

During a review of the facility's policy and procedure titled, "Licensed Vocational Nurse, Scope of Practice," dated 1/2024, the P&P indicated the following: The LVN is authorized to perform services which require technical and manual skills acquired in an accredited vocational nursing school, and which are practiced under the direction of a licensed physician or registered nurse (RN). The responsible RN must delegate task within the LVN scope of practice and must oversee the performance to ensure high quality care for the patient ...Initial admission assessment and care plan formulation must be performed by the RN. The RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN.

3. During a review of Patient 21's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 1/31/2024, the H&P indicated, Patient 21 was admitted to the facility's Definitive Observation Unit (DOU, hospital unit that provides the second-highest level of care) with diagnoses of acute respiratory failure (a condition in which the lungs cannot release enough oxygen into the blood) due to fluid overload (too much fluid in the body) requiring Bilevel positive airway pressure (BIPAP, a machine that helps someone to breath via noninvasive ventilation).

During a concurrent interview and record review on 2/8/2024 at 2:35 p.m. with the Quality Assurance Registered Nurse (QARN), Patient 21's "Critical care/Step down Shift Assessment (nursing assessment, documentation of nursing assessment for patient in DOU)," dated from 1/31/2024 to 2/8/2024, was reviewed. The nursing assessment indicated LVN 7 recorded the nursing assessment on 2/6/2024 at 8 p.m. QARN verified that there was no RN sign off on the nursing assessment recorded by LVN 7. QARN stated RN was required to perform head to toe assessment once per shift to identify any abnormality or changes from the previous shift and to report to physician if there were any changes. QARN further stated without RN assessment, something could be missed and could result in inadequate care.

During an interview on 2/9/2024 at 2:16 p.m. with the Chief Nursing Officer (CNO), the CNO stated that the Governing Body had oversight to ensure staffing assignments were in compliance with mandated State and Federal regulations. The CNO stated 60 licensed vocational nurses (LVNs) worked at the facility, with the oversight of a registered nurse (RN). The CNO stated there was no oversight by the Governing Body, nor was the Governing Body conducting any audits to ensure that the registered nurses were performing patient assessments for patients assigned to LVNs.

During a review of the facility's "Governing Board Minutes," dated 1/11/2023, 4/12/2023, 7/12/2023, and 10/11/2023, the minutes did not reflect any actions or audits to ensure or evaluate the registered nurse's oversight over the licensed vocational nurses.

During a review of the facility's policy and procedure (P&P) titled, "Assessment and Reassessment of the Patient," dated 7/2023, the P&P indicated the following: All patients will have a baseline assessment of their problems and needs performed by a registered nurse ...An initial screening assessment, including consideration of the patient's health history prior to admission, as well as physical, psychological and social status, educational and discharge planning factors, is performed by a registered nurse ...All patients will have ongoing assessments and / or reassessment of their problems/needs/condition performed by a registered nurse. The registered nurse may delegate aspects of data collection to other health care personnel, who are trained, certified and authorized within their scope of practice. Based on the reassessment, the registered nurse may revise the patient's plan of care as appropriate. Reassessments are completed by an RN every shift in inpatients areas or more frequently as indicated by patient condition or unit-specific parameters.

During a review of the facility's policy and procedure (P&P) titled, "Licensed Vocational Nurse, Scope of Practice," dated 1/2024, the P&P indicated the following: The LVN is authorized to perform services which require technical and manual skills acquired in an accredited vocational nursing school, and which are practiced under the direction of a licensed physician or registered nurse (RN). The responsible RN must delegate task within the LVN scope of practice and must oversee the performance to ensure high quality care for the patient ...Initial admission assessment and care plan formulation must be performed by the RN. The RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN.

4. During a review of Patient 22's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 12/11/2023, the H&P indicated, Patient 22 was admitted to the facility's Telemetry (hospital unit where patients undergo continuous cardiac monitoring) with diagnoses of hypertension (high blood pressure), congestive heart failure (CHF, heart failure in which the heart cannot pump enough blood to meet the body's needs), and acute hypoxemic (lack of oxygen) respiratory distress.

During a concurrent interview and record review on 2/8/2024 at 3:16 p.m. with the Quality Assurance Registered Nurse (QARN), Patient 22's "Critical care/Step down Shift Assessment (nursing assessment)," dated from 1/6/2024 to 1/7/2024, was reviewed. The nursing assessment indicated LVN 6 and LVN 13 recorded the nursing assessment on 1/6/2024 at 8 a.m. and 1/6/2024 at 8 p.m. QARN verified that there was no RN sign off on the nursing assessment recorded by LVN 6 and LVN 13.

During a concurrent interview and record review on 2/8/2024 at 3:30 p.m. with QARN, Patient 22's nurse notes (narrative notes documented by nursing staff to reflect care given during the shift), dated 1/7/2024, was reviewed. The nurse notes indicated, at 3:30 a.m., Patient 22 bit bottom of his (Patient 22) tongue and resulted in tongue bleeding. QARN verified that there was no documentation that LVN 13 reported it to a RN or Patient 22's physician. QARN stated that it was a change of condition and LVN 13 should have reported it to the RN who oversaw Patient 22 so the RN could perform assessment and address the problem. QARN stated there was no RN oversight over LVN 13.

During a concurrent interview and record review on 2/9/2024 at 12:03 p.m. with the Director of Nursing (DON), Patient 22's nursing assignment, dated 1/6/2024, was reviewed. The nursing assignment indicated LVN 13 was assigned to Patient 22 on 1/6/2024 night shift. DON verified that there was no documentation indicating a RN was assigned to oversee LVN 13's patients including Patient 22.

During an interview on 2/9/2024 at 2:16 p.m., with the Chief Nursing Officer (CNO), the CNO stated that the Governing Body had oversight to ensure staffing assignments were in compliance with mandated State and Federal regulations. The CNO stated 60 licensed vocational nurses (LVNs) worked at the facility, with the oversight of a registered nurse (RN). The CNO stated there was no oversight by the Governing Body, nor was the Governing Body conducting any audits to ensure that the registered nurses were performing patient assessments for patients assigned to LVNs.

During a review of the facility's "Governing Board Minutes," dated 1/11/2023, 4/12/2023, 7/12/2023, and 10/11/2023, the minutes did not reflect any actions or audits to ensure or evaluate the registered nurse's oversight over the licensed vocational nurses.

During a review of the facility's policy and procedure (P&P) titled, "Assessment and Reassessment of the Patient," dated 7/2023, the P&P indicated the following: All patients will have a baseline assessment of their problems and needs performed by a registered nurse ...An initial screening assessment, including consideration of the patient's health history prior to admission, as well as physical, psychological and social status, educational and discharge planning factors, is performed by a registered nurse ...All patients will have ongoing assessments and/or reassessment of their problems/needs/condition performed by a registered nurse. The registered nurse may delegate aspects of data collection to other health care personnel, who are trained, certified and authorized within their scope of practice. Based on the reassessment, the registered nurse may revise the patient's plan of care as appropriate. Reassessments are completed by an RN every shift in inpatients areas or more frequently as indicated by patient condition or unit-specific parameters.

During a review of the facility's policy and procedure titled, "Licensed Vocational Nurse, Scope of Practice," dated 1/2024, the P&P indicated the following: The LVN is authorized to perform services which require technical and manual skills acquired in an accredited vocational nursing school, and which are practiced under the direction of a licensed physician or registered nurse (RN). The responsible RN must delegate task within the LVN scope of practice and must oversee the performance to ensure high quality care for the patient ...Initial admission assessment and care plan formulation must be performed by the RN. The RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN.

Based on observation, interview, and record review, the facility failed to ensure two of five sampled crash carts (crash cart, a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency) in the Telemetry Units (a unit in a hospital where patients undergo continuous heart monitoring) were stocked completely with all necessary equipment, and readily available, to be used in the event of a medical emergency according to the crash cart checklist.

This deficient practice had the potential for emergency medical equipment to not be readily available in case of an emergency and had the potential to result in a delayed provision of emergency care needed by a patient, which may lead to patient harm and/or death.

Findings:

During an observation on 2/6/2024 at 10:15 a.m., in the West Telemetry Unit on the 8th floor, the crash cart # 129, was missing a backboard (a rigid plastic backboard that is placed under a person's back to perform chest compressions during CPR [cardiopulmonary resuscitation, an emergency life-saving procedure performed when the heart stops beating]). There was only one crash cart on the unit.

Concurrently, on 2/6/2024, at 10:15 a.m., during an interview with Charge Nurse (CN) 4, CN 4 verified the backboard was missing and should be located in front of the crash cart. CN 4 stated the back board was located in the dirty utility room because the backboard had been used earlier in the day and needed to be disinfected. CN 4 stated there was only one crash cart on the unit. CN 4 stated emergency equipment, including back boards, should be readily available on crash carts to be used in case of an emergency.

Concurrently, on 2/6/2024, at 10: 15 a.m., during an interview with the Director of Telemetry (DOT), the DOT stated that back boards were used in an event of an emergency and were placed under a person's back during CPR, to create a hard surface during chest compressions. The DOT verified the backboard was missing.

During an observation on 2/6/2024 at 10:43 a.m., in the West Telemetry Unit on the 7th floor, two crash carts were observed, crash carts # 118 and 119. Crash cart #118 was missing the suction machine (a pump used for removing obstructions, such as saliva, mucus, and blood) and canister (a container used to collect body fluids, such as mucus or blood).

Concurrently, on 2/6/2024 at 10:43 a.m., during an interview with Charge Nurse (CN) 5, CN 5 stated the suction machine and canister were not present on the crash cart because the items had been used and were taken to Central Supply Department (an area of a hospital responsible for receiving, storing, and distributing medical equipment) to be cleaned on 2/3/2024. CN 5 stated she (CN 5) ordered a suction machine however, none were available. CN 5 stated the suction machine and canister should be available on the crash cart to be used to clear a person's airway in the event of an emergency.

A review of a document titled, "Crash Cart Checklist," dated 2/2024, for West Telemetry Unit on the 8th floor, indicated the high suction machine was not present from 2/3/2024 to 2/6/2024. On 2/4/2024, day shift, the Crash Cart Checklist indicated the suction machine was ordered, however, "none available."

During a review of the facility's policy and procedure (P&P) titled, "Crash Cart Checks," dated 10/2023, the P&P indicated the following: Purpose Statement, to ensure that all crash carts are complete, equipment functions properly and supplies are current ...A licensed staff member will use the crash cart checklist daily to verify that the cart is locked and all unsecured equipment is present and ready for use. After a Code Blue (a patient with unexpected cardiac or respiratory arrest, requiring resuscitation) or emergency situation requiring use of crash cart, the licensed staff will: ...Close cart drawers and bins, replace cardiac board in its housing on front of the cart ... Check high suction machine located on the side of the crash cart: The electric outlet is plugged, verify proper functioning, and check for the present of canister/lining.

Based on interview and record review of Medical Staff ongoing evaluations of approved privileges (authorizes medical practitioners for a specific practice of patient care in a specified healthcare facility) for two of nine sampled physicians' credential files (MD 6 and MD 7), Credential file did not have current ongoing evaluation and monitoring of approved privileges per the facility Policy and procedure.

This deficient practice had the potential to result in the delivery of unsafe patient care from unevaluated for credentialing physicians.

Findings:

During a concurrent interview and record review on 2/8/2024 at 2 p.m. with the Director of Medical Staff (MSD) and the Director of Data Quality (DDQ), the Medical Staff Credential files for physicians MD 6 and MD 7 provided ongoing evaluation and monitoring of approved privileges were evaluated from 4/2021 to 11/2021. The MSD stated the Ongoing Physician Performance Evaluation (OPPE) is ongoing and completed yearly over an 8-month period. However, the reviewed credential files for MD 6 and MD 7 did not have current ongoing performance evaluation included for review.

During a review of the facility's policy and procedure (P&) titled" Bylaws of the Medical Staff." dated 9/2/2020, under the Section for Reappointment, the P&P indicated, "Current Competency: objective evidence of the individual's clinical performance" and "included such evidence includes evaluation of applicants ongoing practice review including data comparison to peers during the prior period of appointment."

During a review of the facility's undated policy and procedure (P&P) titled "Department of Surgery Rules and Regulations", the P&P indicated "There will be an evaluation of practitioner performance when privileges are initially granted and on an ongoing basis thereafter. The ongoing process will allow for identification of any potential problems with a practitioner's performance along with an efficient evidence-based privilege renewal process."

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

1a. The facility failed to follow State and Federal regulatory standards regarding safe patient care assignments. Over 50 % of the patient care assignment in one of 3 sampled units (Unit 1) consisted of licensed vocational nurses (LVNs). One registered nurse (RN 5) and two LVNs (LVN 7 and 8) were assigned to perform direct patient care in the Medical Surgical unit (a unit that serves the general population hospitalized for various cases such as surgery, etc.) on 2/6/2024 from 7 a.m., to 7 p.m. This deficient practice had the potential to result in patient needs not being met. (Refer to A - 0392)

1b. The facility failed to ensure Charge Nurse 3 (CN 3) remained free of job duties that prevented CN 3 from fulfilling the functions of the Charge Nurse role for one of one telemetry nursing units (Unit 1, a floor in the hospital where patients receive continuous cardiac [heart] monitoring), when CN 3 was assigned as the Charge Nurse (CN, oversee the operations of their specific nursing unit during a set period while working alongside the team) and at the same time functioned as Monitor Technician (MT, a skilled professional who supports doctors and nurses in interpreting and diagnosing conditions related to the heart by using non-invasive monitor) on Unit 1. This deficient practice resulted in CN 3 being unable to fulfill assigned Charge Nurse duties, including the supervision of patient care, and operations of the assigned hospital unit.

This deficient practice also had the potential to compromise the quality of medical care delivered to patients when the Charge Nurse is not readily available to assist the other nursing staff in case of medical emergencies on the unit. (Refer to A - 0392)

2. The facility failed to provide registered nurse's oversight over licensed vocational nurses' assessments for four of 34 sampled patients (Patients 4, 18, 21, 22), in accordance with the facility's policy and procedure regarding assessment (in depth evaluation conducted by a registered nurse that evaluates a patient's current physical, mental and emotional state) and reassessment and professional standards of practice.

This deficient practice resulted in assessments documented by LVNs without RN oversight and had the potential to result in an inaccurate assessment of patients' condition and inappropriate provision and plan of care to patients. (Refer to A - 0395)

3a. The facility failed to ensure the call light (a means of communication for patients to their care providers that are outside the patients' rooms was within reach for one of 34 sampled patients (Patient 3), in accordance with the Patient's plan of care (provides a framework for evaluating and providing patient care needs related to the nursing process) and the facility's policies and procedures regarding care plans.

This deficient practice had the potential to result in a fall and immediate needs unattended for Patient 3. (Refer to A - 0396)

3b. The facility failed to develop the nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for seizure (sudden, uncontrolled burst of electrical activity in the brain) and cardiopulmonary arrest (the cessation of effective breathing and blood flow) specific to patient's needs for one of 35 sampled patients (Patient 15).

This deficient practice had the potential to result in Patient 15 not receiving the right level of care and not meeting the needs for the identified patient's concerns. (Refer to A - 0396)

3c. The facility failed to Initiate a care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) upon admission for one of 34 sampled patients (Patient 18).

This deficient practice had the potential to result in the delay of treatment by not identifying Patient 18's needs and risks, which may result in worsening of Patient 18's condition and prolonged hospitalization. (Refer to A - 0396)

4a. The facility failed to ensure two of six sampled nursing staff (Registered Nurse [RN] 9 and Licensed Vocational Nurse [LVN] 3) had annual skill competency evaluations (assessment of a clinician's skills, abilities and knowledge to ensure provision of safe and effective care to patients) done.

This deficient practice had the potential to result in patients receiving inadequate care and treatment from nursing staff whose competencies were not checked annually. (Refer to A - 0397)

4b. The facility failed to ensure three of three sampled staff (Registered Nurse (RN) 6, RN 7, and Charge Nurse (CN) 4) followed the facility Policy and Procedure regarding emergency termination procedure for hemodialysis machine and were competent in the hemodialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) emergency termination procedure (safe process of disconnecting a patient from the dialysis machine in case of an emergency) for one (1) out of 34 sampled patients (Patient 6).

This deficient practice had the potential to result in inadequate return of blood from the machine to Patient 6 causing harm or even death during hemodialysis treatment. (Refer to A - 0397)

5a. The facility failed to ensure one of one sampled registered nurse (Registered Nurse (RN) 5) followed the facility's policy and procedure for putting on (donning) PPE (personal protective equipment, equipment worn to minimize exposure to illness, includes gown, gloves, mask etc.) and removing (doffing) personal protective equipment in taking care of one of 34 sampled patients (Patient 10), who was on contact precaution (interventions taken to prevent transmission of infectious agents).

This deficient practice had the potential to spread infection to other Patients on the Unit due to improper donning and doffing of PPEs. (Refer to A - 0398)

5b. The facility failed to ensure one of one sampled staff (Licensed Vocational Nurse [LVN] 13) adhered to the facility's policy and procedure on the LVN Scope of Practice when LVN 13 administered Methylprednisolone (Solu-Medrol, steroid injection provides relief of inflamed area of the body, lungs and breathing problem such as asthma) intravenously (given into the vein) for one of 34 sampled patients (Patient 22).

This deficient practice had the potential for Patient 22 to develop a respiratory problem and reaction from an untrained staff's improper administration of medication. (Refer to A - 0398)

5c. The facility failed to change enteral (a method of feeding that uses the gastrointestinal [GI, the digestive system consisting of the mouth, throat, stomach, small intestines, etc.] tract to deliver nutrition and calories) feeding container and feeding tube set (feeding tube inserted through an abdominal wall to deliver nutrients directly into the patient's stomach) after 24 hours of use for one of 34 patients (Patient 15) in accordance with the facility's policy and procedure regarding enteral feeding and feeding tube set replacement.

This deficient practice had the potential for risk of contamination (growing microorganisms, such as bacteria or parasites, or toxic substances making feeding unfit for consumption), which may result in gastrointestinal problems for Patient 15 such as diarrhea (loose stools), abdominal pain, vomiting, etc. (Refer to A - 0398)

5d. The facility failed to renew an order for restraints (a physical restraint is any manual method, material or equipment that is attached to patient's body that cannot be easily removed and restricts freedom of movement) use for one of 34 patients (Patient 16) after 24 hours that the restraint was initially ordered.

This deficient practice had the potential to violate Patient 16's rights regarding restraint use, as nursing staff continued documenting the prolonged use of restraints without a physician's renewal order for restraints. This deficient practice also had the potential to result in patient harm such as skin injury from prolonged and inappropriate use of restraints. (Refer to A - 0398)

5e. The facility failed to label a feeding tube container after initiating tube feeding (a way to provide nutrition for patients who are unable to eat or drink by mouth) to indicate the need for replacement after 24 hours of use and also did not indicate the date, time, and patient's name when tube feeding container was hanged or initiated for one of 34 sampled patients (Patient 16) in accordance with the facility's policy and procedure regarding labeling and replacing tube feeding containers after 24 hours from the time the feeding tube container was used.

This deficient practice had the potential for risk of contamination (growing microorganisms, such as bacteria or parasites, or toxic substances making feeding unfit for consumption), which may result in gastrointestinal problems for Patient 16 such as diarrhea, abdominal pain, vomiting, etc. (Refer to A - 0398)

5f. The facility failed to use translator services (facilitates communication between healthcare providers and non-English speaking patients to provide the best possible quality of care) when obtaining informed consent (the process in which a healthcare provider educates a patient about the risks, benefits and alternatives, of a given procedure or intervention) for one of 34 sampled patients (Patient 14).

This deficient practice had the potential for Patient 14 not receiving accurate and current information in the language Patient 14 could understand, which may result in Patient 14 not understanding information regarding her (Patient 14) health status and treatment and may delay recovery from illness. (Refer to A - 0398)

6. The facility failed to ensure its nursing staff documented properly and follow medication administration procedure on the electronic Medication Administration Record (eMAR, a record of medications given to patient) after a narcotic (opioids medication for pain relief) was given to one of 34 sampled patients (Patient 21) per facility Policy and Procedure.

This deficient practice had the potential to put Patient 21 at risk for overdose on narcotics as it was not recorded on the electronic Medication Administration Record properly. (Refer to A - 0405)

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

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

1. Follow State and Federal regulatory standards regarding safe patient care assignments. Over 50% of the patient care assignment in one of 3 sampled units (Unit 1) consisted of licensed vocational nurses (LVNs). One registered nurse (RN 5) and two LVNs (LVN 7 and 8) were assigned to perform direct patient care in the Medical Surgical unit (a unit that serves the general population hospitalized for various cases such as surgery, etc.), for 13 of 13 sampled patients, on 2/6/2024 from 7 a.m., to 7 p.m. This deficient practice had the potential to result in patient needs not being met.

2. Ensure Charge Nurse 3 (CN 3) remained free of job duties that prevented CN 3 from fulfilling the functions of the Charge Nurse role for one of one telemetry nursing units (Unit 1, a floor in the hospital where patients receive continuous cardiac [heart] monitoring), when CN 3 was assigned as the Charge Nurse (CN, oversee the operations of their specific nursing unit during a set period while working alongside the team) and at the same time functioned as Monitor Technician (MT, a skilled professional who supports doctors and nurses in interpreting and diagnosing conditions related to the heart by using non-invasive monitor) on Unit 1.

This deficient practice resulted in CN 3 being unable to fulfill assigned Charge Nurse duties, including the supervision of patient care, and operations of the assigned hospital unit. This deficient practice also had the potential to compromise the quality of medical care delivered to patients when the Charge Nurse is not readily available to assist the other nursing staff in case of medical emergencies on the unit.

Findings:

1. During an observation on 2/6/2024 at 11:29 a.m., in the Medical Surgical Unit, CN 2, RN 5, LVN 8 and LVN 9 were observed on the unit. There were 13 patients on the unit.

During a concurrent interview on 2/6/2024 at 11:29 a.m. with CN 2, CN 2 stated the following: There were 2 RNs (CN 2 and RN 5) and two LVNs (LVN 8 and 9) on the unit. She (CN 2) was the Charge Nurse, and not assigned patient care duties. RN 5, LVN 8 and LVN 9 were assigned to perform patient care. CN 2 stated since there were two RNs (including herself as the CN) and two LVNs on the unit, she (CN 2) interpreted that assignment as meeting mandatory State and Federal staffing ratios. CN 2 verified that over 50% of the licensed nurses assigned to patient care were licensed vocational nurses (LVNs). In this case, there was only 1 RN with her own patients and there were 2 LVNs who had 5 patients each. The CN 2 had oversight over both LVNs who had 5 patients each. CN 2, in addition to her charge nurse tasks, had to perform all patient care tasks such as IV medication administration, assessment and reassessment, etc., which were not within the LVNs ' scope of practice.

During an interview, on 2/6/2024 at 1:50 p.m., with the Director of Cardiac Services (DCS), the DCS stated the following: Nursing ratios should be 50% or less of LVNs to RNs assigned to patient care. Charge nurses were not included in the LVN to RN ratio of the patient care assignment.

During an interview on 2/7/2024 at 9:24 a.m., with the Director of the Medical Surgical (DMS) Unit and the Director of Nursing (DON), the DMS and the DON verified that the patient care assignment on the Medical Surgical Unit on 2/6/2024 consisted of one RN (RN 5) and two LVNs (8 & 9), which was over 50 % of LVNs to RNs. The DMS and DON stated the assignment might impact patient care.

During an interview on 2/9/2024 at 12 p.m., with the DON, the DON verified that the facility's policy and procedure indicated that only nurses (RN and LVNs) assigned to perform direct patient care should be included in the staffing ratio excluding the charge nurse.

During a review of a patient care assignment titled, "6-West Med/Surg Daily Assignment Sheet," dated 2/6/2024, day shift 7 a.m. - 7 p.m., the assignment indicated the following: Charge Nurse (CN) 2 was assigned to be the Charge Nurse. Registered Nurse (RN) 5, LVN 8, and LVN 9 were assigned to perform patient care. Census 13.

During a review of the facility's policy and procedure (P&P) titled, "Staffing Plan," dated 10/2023, the P&P indicated the following: The facility shall provide staffing by licensed nurses, within the scope of their licensure in accordance with the nurse-to-patient ratios by Title XXII (a set of rules and regulations established by the California Department of Social Services that governs community care facilities, from licensing requirements to staffing ratios to safety standards, and resident rights), California Licensing and Certification of Health Facilities in the General Acute Hospitals ...In no case shall the staffing level for licensed nurses fall below the requirements ...Only licensed nurses providing direct patient care shall be included in the ratios.

2. During a concurrent observation and interview on 2/26/2024 at 11:25 a.m. with Charge Nurse 3 (CN 3), CN 3 was observed on the unit at the telemetry monitoring screen (shows real-time monitoring of a patient's heart rhythm). Furthermore, CN 3's name was observed on the daily assignment board assigned as the Charge Nurse (CN, oversees the operations of their specific nursing unit and patient care during a set period of time while working alongside the team) and Monitor Technician (MT, a skilled professional who supports doctors and nurses in interpreting and diagnosing conditions related to the heart by using non-invasive monitor). CN 3 said that the MT called in sick for the day. CN 3 verified that CN 3 was assigned and working both roles (CN and MT roles) concurrently. CN 3 stated that due to staffing, CN 3 was the only available staff to work as a MT, in addition to the role as a CN.

During an interview on 2/26/2024 at 1:50 p.m. with the Director of Cardiac Services (DCS), the DCS stated that the assigned Charge Nurse should be relieved of their job duties if they were assigned as the Monitor Technician. DCS stated that it was the responsibility of the DCS to cover the Charge Nurse when the Charge Nurse was doing the Monitor Technician role.

During an interview on 2/7/2024 at 9:25 a.m. with Director of Nursing (DON), DON stated that if there was no MT, the CN can work as a MT per facility policy. However, DON said that if CN 3 was assigned the MT role, CN 3 should be relieved of the CN duties. DON stated that when CN 3 was working concurrently as the CN and MT, DCS should have taken over the CN role.

During an interview on 2/8/2024 at 11:32 a.m. with the Clinical Supervisor of Telemetry (CST), CST stated that the MT role required to maintain line of sight on the telemetry monitoring screen always and that the MT should not take eyes off the telemetry monitoring screen. CST further stated that the CN cannot perform the MT role and the CN role at the same time.

During a review of a patient care assignment titled, "3-West Cardiac Telemetry Report Sheet," dated 2/6/2024, day shift 7 a.m. - 7 p.m., the assignment indicated the following: CN 3 was assigned as the Charge Nurse and Monitor Technician.
During a review of a document titled "Job Description," dated 1/2023, the document indicated: "Position Title: Charge Nurse, Department: Med/Surg ... Job Summary: The Med/Surg Charge Nurse is responsible and accountable for the quality of staff and functions during their shift. Assists the Department Director in the daily operations of the unit, directing, supervising, and evaluating personnel, ensuring the proper use of time, equipment and resources. Ensures the efficient functions of the department. Performs direct patient care, only as needed, within the scope of practice. Continually assesses patient care and directs staff to make necessary changes in the plan of care. Effectively communicates with physician and staff to ensure positive patient outcomes ... B. Duties and Responsibilities 1. When in charge: ... b) Serves as a resource to staff in area of expertise ..."

During a review of the facility's policy and procedure (P&P) dated 9/2023 titled "Telemetry Monitoring (Central Monitoring Unit)," the P&P indicated: "Section 1. Purpose: To establish guidelines for hospital personnel to ensure safe and consistent care of the patients requiring continuous telemetry monitoring and SP02 monitoring, Section 2. Policy: Continuous telemetry monitoring will be provided by trained hospital staff that have demonstrated competency in basic arrythmia monitoring and can safely utilize monitor alarm setting and protocols set by the hospital as described in this policy, Section 3. Applicability & Scope: This policy applies to: Monitor Technicians and Licensed Nurses (LN's) who have demonstrated competency in basic arrythmia monitoring. Patients in the telemetry units who require telemetry monitoring shall be provided accurate, safe, and competent telemetry monitoring and nursing care, Section 4. Procedure: General Management of Telemetry Patients'. Remote Telemetry Monitoring: Remote telemetry monitoring stations are located on the 3rd floor (Central Monitoring Unit- CMU) and provide electrocardiographic (ECG, records the electrical signal from the heart to check for different heart conditions) monitoring for patients admitted to telemetry beds on telemetry floors. Telemetry monitoring stations are manned continuously ..."

Based on interview and record review, the registered nurses failed to:

1. Provide registered nurses' oversight over licensed vocational nurses' assessments for four of 34 sampled patients (Patients 4, 18, 21, 22), in accordance with the facility's policy and procedure regarding assessment (in depth evaluation conducted by a registered nurse that evaluates a patient's current physical, mental and emotional state) and reassessment and professional standards of practice.

This deficient practice resulted in assessments documented by LVNs without RN oversight and had the potential to result in an inaccurate assessment of patients' condition and inappropriate provision and plan of care to patients.

Findings:

1. During a concurrent interview and record review on 2/7/2024 at 11:50 a.m., with the Quality Assurance Registered Nurse (QARN), Patient 4's nursing assessments record, was reviewed. The QARN stated the following: Patient 4 was admitted to the facility on 2/4/2024 for a gastrointestinal bleed (bleeding from the digestive tract). QARN reviewed Patient 4's "Daily Shift Assessment," dated 2/6/2024 at 8 a.m., and stated the assessment was documented by licensed vocational nurse (LVN) 6. The QARN verified that the assessment was not co-signed by a registered nurse (RN). In addition, the QARN verified that reassessments documented on 2/6/2024 at 12 p.m., and 4 p.m., were also documented by LVN 6 and not co-signed by a RN. The QARN stated there were no other signatures, from RNs, associated with the assessments. The QARN stated that a RN should oversee and validate and agree with the LVNs assessment, and it should be documented in the medical record. The QARN stated a RN should assess patients to ensure LVN's documentation was accurate and fits the patient's plan of care.

During an interview on 2/6/2024 at 1:50 p.m. with the Director of Cardiac Services (DCS), the DCS stated the following: The RN oversees the LVN. RN performs the initial assessments and reassessments. RNs co-sign initial and shift assessments.

During an interview on 2/9/2024 at 11:38 a.m. with the Clinical Educator Nursing Administration (CENA), the CENA stated the following: LVNs can collect data related to the patient. The RN was responsible for conducting a total assessment of patients' conditions and to identify changes.

During a review of Patient 4's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/4/2024 at 4:46 p.m., the H&P indicated the following: Patient 4's chief complaint was gastrointestinal bleed (bleeding from the digestive tract). Patient 4 had a past medical history significant for hypertension (high blood pressure), congestive heart failure (heart does not pump blood as well as it should), diabetes mellitus (high blood sugar), deep vein thrombosis (DVT, a blood clot forms in a deep vein), GI bleed, and diverticulosis (bulging pouches that develop in the digestive tract). Patient 4 presented to the facility from home because of bloody bowel movements.

During a review of Patient 4's "Med/Surg/Tele Flowsheet - Shift," dated 2/6/2024, the flowsheet indicated it was documented by LVN 6.

During a review of Patient 4's "Reassessments," dated 2/6/2024 at 8 a.m., the reassessment was documented by LVN 6.

During a review of Patient 4's "Reassessments," dated 2/6/2024 at 12 p.m., the reassessment was documented by LVN 6.

During a review of Patient 4's "Reassessments," dated 2/6/2024 at 4 p.m., the reassessment was documented by LVN 6.

During a review of the facility's policy and procedure (P&P) titled, "Assessment and Reassessment of the Patient," dated 7/2023, the P&P indicated the following: All patients will have a baseline assessment of their problems and needs performed by a registered nurse ...An initial screening assessment, including consideration of the patient's health history prior to admission, as well as physical, psychological and social status, educational and discharge planning factors, is performed by a registered nurse ...All patients will have ongoing assessments and / or reassessment of their problems/needs/condition performed by a registered nurse. The registered nurse may delegate aspects of data collection to other health care personnel, who are trained, certified and authorized within their scope of practice. Based on the reassessment, the registered nurse may revise the patient's plan of care as appropriate. Reassessments are completed by an RN every shift in inpatients areas or more frequently as indicated by patient condition or unit-specific parameters.

During the review of the facility's policy and procedure titled, "Licensed Vocational Nurse, Scope of Practice," dated 1/2024, the P&P indicated the following: The LVN is authorized to perform services which require technical and manual skills acquired in an accredited vocational nursing school, and which are practiced under the direction of a licensed physician or registered nurse (RN). The responsible RN must delegate task within the LVN scope of practice and must oversee the performance to ensure high quality care for the patient ...Initial admission assessment and care plan formulation must be performed by the RN. The RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN.

2. During a review of Patient 18's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/3/2024, the H&P indicated, Patient 18 was admitted to the facility's Medical Surgical Unit (hospital ward service general patient population with variety of diseases and illnesses) with diagnoses of failure to thrive (a syndrome of global decline that occurs in older adults as a worsening of physical frailty) and hypertension (high blood pressure). The H&P also indicated Patient 18 had left knee arthritis (swelling and tenderness at joints), diabetes (high blood sugar) and cerebral vascular accident (CVA, stroke, brain attack affecting someone's ability to think, move and speak) with left-sided deficits (weakness).

During a concurrent interview and record review on 2/8/2024 at 11 a.m. with the Quality Assurance Registered Nurse (QARN), Patient 18's "Med/Surg/Tele Flowsheet Shift Assessment (nursing assessment, documentation of nursing assessment for patient)," dated from 2/2/2024 to 2/8/2024, was reviewed. The nursing assessment indicated LVNs 5, 10, 11, and 12 recorded the nursing assessment on the following days:

2/3/2024 at 8 a.m. by LVN 10
2/4/2024 at 8 a.m. by LVN 11
2/5/2024 at 8 a.m. by LVN 11
2/6/2024 at 8 a.m. by LVN 5
2/6/2024 at 8 p.m. by LVN 12
2/7/2024 at 8 p.m. by LVN 12
QARN verified that there was no RN sign off on the nursing assessment recorded by the LVNs listed. QARN stated RN was required to perform assessment on patient and validate the data the LVN had collected to make sure assessment was done accurately, and to address any problems identified in the assessment. QARN further stated without proper assessment, it could potentially compromise patient care due to lack of RN oversight.

During a review of the facility's policy and procedure (P&P) titled, "Assessment and Reassessment of the Patient," dated 7/2023, the P&P indicated the following: All patients will have a baseline assessment of their problems and needs performed by a registered nurse ...An initial screening assessment, including consideration of the patient's health history prior to admission, as well as physical, psychological and social status, educational and discharge planning factors, is performed by a registered nurse ...All patients will have ongoing assessments and/or reassessment of their problems/needs/condition performed by a registered nurse. The registered nurse may delegate aspects of data collection to other health care personnel, who are trained, certified and authorized within their scope of practice. Based on the reassessment, the registered nurse may revise the patient's plan of care as appropriate. Reassessments are completed by an RN every shift in inpatients areas or more frequently as indicated by patient condition or unit-specific parameters.

During a review of the facility's policy and procedure (P&P) titled, "Licensed Vocational Nurse, Scope of Practice," dated 1/2024, the P&P indicated the following: The LVN is authorized to perform services which require technical and manual skills acquired in an accredited vocational nursing school, and which are practiced under the direction of a licensed physician or registered nurse (RN). The responsible RN must delegate task within the LVN scope of practice and must oversee the performance to ensure high quality care for the patient ...Initial admission assessment and care plan formulation must be performed by the RN. The RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN.

3. During a review of Patient 21's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 1/31/2024, the H&P indicated, Patient 21 was admitted to the facility's Definitive Observation Unit (DOU, hospital unit that provides the second-highest level of care) with diagnoses of acute respiratory failure (a condition in which the lungs cannot release enough oxygen into the blood) due to fluid overload (too much fluid in the body) requiring Bilevel positive airway pressure (BIPAP, a machine that helps someone to breath via noninvasive ventilation).

During a concurrent interview and record review on 2/8/2024 at 2:35 p.m. with the Quality Assurance Registered Nurse (QARN), Patient 21's "Critical care/Step down Shift Assessment (nursing assessment, documentation of nursing assessment for patient in DOU)," dated from 1/31/2024 to 2/8/2024, was reviewed. The nursing assessment indicated LVN 7 recorded the nursing assessment on 2/6/2024 at 8 p.m. QARN verified that there was no RN sign off on the nursing assessment recorded by LVN 7. QARN stated RN was required to perform head to toe assessment once per shift to identify any abnormality or changes from the previous shift and to report to physician if there were any changes. QARN further stated without RN assessment, something could be missed and could result in inadequate care.

During a review of the facility's policy and procedure (P&P) titled, "Assessment and Reassessment of the Patient," dated 7/2023, the P&P indicated the following: All patients will have a baseline assessment of their problems and needs performed by a registered nurse ...An initial screening assessment, including consideration of the patient's health history prior to admission, as well as physical, psychological and social status, educational and discharge planning factors, is performed by a registered nurse ...All patients will have ongoing assessments and/or reassessment of their problems/needs/condition performed by a registered nurse. The registered nurse may delegate aspects of data collection to other health care personnel, who are trained, certified and authorized within their scope of practice. Based on the reassessment, the registered nurse may revise the patient's plan of care as appropriate. Reassessments are completed by an RN every shift in inpatients areas or more frequently as indicated by patient condition or unit-specific parameters.

During a review of the facility's policy and procedure (P&P) titled, "Licensed Vocational Nurse, Scope of Practice," dated 1/2024, the P&P indicated the following: The LVN is authorized to perform services which require technical and manual skills acquired in an accredited vocational nursing school, and which are practiced under the direction of a licensed physician or registered nurse (RN). The responsible RN must delegate task within the LVN scope of practice and must oversee the performance to ensure high quality care for the patient ...Initial admission assessment and care plan formulation must be performed by the RN. The RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN.

4. During a review of Patient 22's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 12/11/2023, the H&P indicated, Patient 22 was admitted to the facility's Telemetry (hospital unit where patients undergo continuous cardiac monitoring) unit with diagnoses of hypertension (high blood pressure), congestive heart failure (CHF, heart failure in which the heart cannot pump enough blood to meet the body's needs), and acute hypoxemic (lack of oxygen) respiratory distress.

During a concurrent interview and record review on 2/8/2024 at 3:16 p.m. with the Quality Assurance Registered Nurse (QARN), Patient 22's "Critical care/Step down Shift Assessment (nursing assessment)," dated from 1/6/2024 to 1/7/2024, was reviewed. The nursing assessment indicated LVN 6 and LVN 13 recorded the nursing assessment on 1/6/2024 at 8 a.m. and 1/6/2024 at 8 p.m. QARN verified that there was no RN sign off on the nursing assessment recorded by LVN 6 and LVN 13.

During a concurrent interview and record review on 2/8/2024 at 3:30 p.m. with QARN, Patient 22's nurse notes (narrative notes documented by nursing staff to reflect care given during the shift), dated 1/7/2024, was reviewed, the nurse notes indicated, at 3:30 a.m., Patient 22 bit bottom of tongue and resulted in tongue bleeding. QARN verified that there was no documentation that LVN 13 reported it to a RN or Patient 22's physician. QARN stated that it was a change of condition and LVN 13 should have reported it to the RN who oversaw Patient 22 so the RN could perform assessment and address the problem. QARN stated there was no RN oversight over LVN 13.

During a concurrent interview and record review on 2/9/2024 at 12:03 p.m. with the Director of Nursing (DON), Patient 22's nursing assignment record, dated 1/6/2024, was reviewed, the nursing assignment indicated LVN 13 was assigned to Patient 22 on 1/6/2024 night shift. DON verified that there was no documentation indicating a RN was assigned to oversee LVN 13's patients including Patient 22.

During a review of the facility's policy and procedure (P&P) titled, "Assessment and Reassessment of the Patient," dated 7/2023, the P&P indicated the following: All patients will have a baseline assessment of their problems and needs performed by a registered nurse ...An initial screening assessment, including consideration of the patient's health history prior to admission, as well as physical, psychological and social status, educational and discharge planning factors, is performed by a registered nurse ...All patients will have ongoing assessments and/or reassessment of their problems/needs/condition performed by a registered nurse. The registered nurse may delegate aspects of data collection to other health care personnel, who are trained, certified and authorized within their scope of practice. Based on the reassessment, the registered nurse may revise the patient's plan of care as appropriate. Reassessments are completed by an RN every shift in inpatients areas or more frequently as indicated by patient condition or unit-specific parameters.

During a review of the facility's policy and procedure (P&P) titled, "Licensed Vocational Nurse, Scope of Practice," dated 1/2024, the P&P indicated the following: The LVN is authorized to perform services which require technical and manual skills acquired in an accredited vocational nursing school, and which are practiced under the direction of a licensed physician or registered nurse (RN). The responsible RN must delegate task within the LVN scope of practice and must oversee the performance to ensure high quality care for the patient ...Initial admission assessment and care plan formulation must be performed by the RN. The RN must document on each patient at least once per shift or per unit policy, whichever is greater. The assessment may include data, which is collected by the LVN, which the RN has reviewed and discussed with the LVN.

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

1. Ensure the call light (a means of communication for patients to their care providers that are outside the patients' rooms) was within reach for one of 34 sampled patients (Patient 3), in accordance with the Patient's plan of care (provides a framework for evaluating and providing patient care needs related to the nursing process) and the facility's policies and procedures regarding care plans. This deficient practice had the potential to result in a fall and immediate needs unattended for Patient 3.

2. Develop the nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for seizure (sudden, uncontrolled burst of electrical activity in the brain) and cardiopulmonary arrest (the cessation of effective breathing and blood flow) specific to patient's needs for one of 35 sampled patients (Patient 15).

This deficient practice had the potential to result in Patient 15 not receiving the right level of care and not meeting the needs for the identified patient's concerns.

3. Initiate a care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) upon admission for one of 34 sampled patients (Patient 18). This deficient practice had the potential to result in the delay of treatment by not identifying Patient 18's needs and risks, which may result in worsening of Patient 18's condition and prolonged hospitalization.

Findings:

1. During a concurrent observation and interview on 2/6/2024 at 10:20 a.m., in the Telemetry Unit (a unit in a hospital where patients undergo continuous heart monitoring), Patient 3 was awake and alert in bed, and sitting up on the bed. Bed rails on each side of the bed were up. Patient 3 was leaning towards the left side of the bed against the bed rail. The call light was placed on top of the nightstand against the back wall. The call light was not within Patient 3's reach. Patient 3 stated (Patient 3) she did not know where the call light was. Patient 3 was asked how she (Patient 3) calls for help. Patient 3 stated "I just tell them," when the staff passes by.

Concurrently during an interview, on 2/6/2024 at 10:20 a.m., with the Discharge Planner (DCP), the DCP verified that the call light was not within Patient 3's reach and should be within reach to prevent falls (an unplanned descent to the floor with or without injury to the patient).

Concurrently during an interview, on 2/6/2024 at 10:20 a.m., with the Director of Telemetry (DOT), the DOT stated that the call light should be with Patient 3's reach. DOT stated Patient 3 may fall if Patient 3 tried reaching for the call light on the nightstand.

During a review of Patient 3's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/5/2024 at 1:47 p.m., the H&P indicated the following: Patient 3 had a past medical history of Chronic Obstructive Pulmonary Disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), on nasal cannula (a device that delivers supplemental oxygen) 2 Liters (L, a unit of measurement) of oxygen, presented to the emergency department for shortness of breath.

During a review of Patient 3's "Admission Initial Assessment," dated 2/5/2024 at 1:01 p.m., the assessment indicated the following: Patient 3's Fall Risk Score was 60 (over 45 indicates high risk for fall). Patient is a high risk for fall: Yes ...Call light within reach: Yes, Patient instructed to call for assistance: Yes.

During a review of Patient 3's care plan titled, "Risk Injury/Fall," initiated on 2/5/2024 at 12:13 p.m., the care plan indicated interventions, including having the call light within Patient 3's reach.

During a review of the facility's policy and procedure (P&P) titled, "Fall Reduction," dated 7/2023, the P&P indicated the following: All patients identified as high risk for falls will have the following measures initiated ...The patient and family will be educated. Educational interventions may include ...using brochures, pictures and signage as reminders about using the call bell system ...General strategies for patients at moderate or high risk for falls may include ...Call light within patient reach ...

During a review of the facility's policy and procedure (P&P) titled, "Plan of Care: Patient, Interdisciplinary," dated 7/2023, the P&P indicated the following: The plan of care shall consist of problems, measurable expected outcomes and interventions that reflect acceptable standards of care ...Formulation the Plan of Care: Identify the problem ... Establish an expected outcome for the problem ...Choose the interventions. Interventions reflect the course of actions that will be taken to move the patient towards the expected outcomes that have been established.

2. During a review of Patient 15's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 2/6/2024, the H&P indicated, Patient 15 was admitted on 1/31/2024 due to pneumonia (PNA, lung inflammation caused by bacterial or viral infection), acute (sudden) on chronic (long-lasting) respiratory failure (the inability of the respiratory system to meet the oxygenation, ventilation, or body requirements of the patient), and sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death).

The H&P further indicated, Patient 15 had past medical history (PMH, a record of information about a patient's health) of recent (1/19/2024) anoxic brain injury (a complete lack of oxygen to the brain, which results in the death of brain cells) due to prolonged seizure (sudden, uncontrolled burst of electrical activity in the brain) and cardiopulmonary arrest ( the cessation of effective breathing and blood flow) resulting in chronic ventilator dependence (long term mechanical support for breathing) with tracheostomy (surgical opening created to insert a tube through the neck into the windpipe to allow air to fill the lungs and remove secretions) and percutaneous endoscopic gastrostomy feeding tube (PEG, a tube inserted through the wall of the abdomen directly into the stomach) placement.

During a review of Patient 15's medical record (MR) titled, "Nutrition Assessment," dated 2/1/2024, the MR indicated, Patient 15 required enteral (any method of feeding that uses the gastrointestinal [GI, includes the mouth, the throat, the stomach, etc.] tract to deliver nutrition and calories) nutrition infusion via PEG feeding tube with a recommendation to monitor for signs and symptoms of tube feeding (TF) intolerance (indicated by symptoms of vomiting, abdominal pain, etc. that diminishes the nutrient being delivered via tube feeding) and for aspiration (accidental breathing in of food or fluid into the lungs).

During a review of Patient 15's medical record (MR) titled, "Pulmonary Progress Note," dated 2/6/2024, the MR indicated, Patient 15's treatment plan consisted of, but not limited to, monitoring and treatment for seizures.

During a review of Patient 15's medical record (MR) titled, "Care Activity-Plan of Care," dated 2/7/2024, the MR indicated, Patient 15 did not have a nursing care plan developed for seizures and aspiration precautions.

During a concurrent interview and record review on 2/8/2024 at 2:45 p.m. with house supervisor (HS), Patient 15's medical record (MR) titled, "Care Activity-Plan of Care," dated 2/7/2024, was reviewed. The MR indicated, no Plan of Care was developed and kept for Patient 15's potential risk for seizures and risk for aspiration related to TF was done. The HS stated, nursing must develop a care plan for all actual or potential patient's needs to plan patient care and interventions toward meeting those needs, but the primary nurse did not.

During a review of the facility's policy and procedure (P&P) titled, "Plan of Care: Patient Interdisciplinary," last reviewed 4/2023, the P&P indicated, "A plan of care is developed to ensure each patients received individualized plan of care meeting the patients' needs. The plan of Care shall consist of problems, measurable expected outcomes, and interventions that reflect acceptable standards of care and are consistent with the medical care being provided. The plan of care shall be developed within 24 hours of admission and shall be developed based on identified through assessment data actual or potential problems and should reflect the course of action that will be taken to move the patient toward the expected outcomes that have been established. The Plan of Care is a permanent part of the Medical Record."

3. During a review of Patient 18's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/3/2024, the H&P indicated, Patient 18 was admitted to the facility's Medical Surgical Unit (hospital ward service general patient population with variety of diseases and illnesses) on 2/2/2024 with diagnoses of failure to thrive (a syndrome of global decline that occurs in older adults as a worsening of physical frailty) and hypertension (high blood pressure). The H&P also indicated Patient 18 had left knee arthritis (swelling and tenderness at joints), diabetes (high blood sugar) and cerebral vascular accident (CVA, stroke, brain attack affecting someone's ability to think, move and speak) with left-sided deficits (weakness).

During a concurrent interview and record review on 2/8/2024 at 11 a.m. with the Quality Assurance Registered Nurse (QARN), Patient 18's care plan was reviewed. QARN verified that there was no nursing care plan initiated for Patient 18 regarding Patient 18's diagnosis of failure to thrive and hypertension. QARN further stated care plan should have been initiated upon admission by a Registered Nurse (RN) to set plan and goals for the patient and to determine what interventions were needed in order to achieve the goals to reach the optimal level.

During a concurrent interview and record review on 2/8/2024 at 11:05 a.m. with QARN, the facility's policy and procedure (P&P) titled, "Plan of Care: Patient, Interdisciplinary," dated 4/2023, was reviewed. The P&P indicated, "a Plan of Care is developed for each patient that is individualized to meet the patient's unique needs ...within 24 hours of admission, an RN will initiate the care plan, document and review age related and other factors ... all disciplines involved in patient care will document on the Interdisciplinary Plan of Care. The LVN can implement care that is planned by the RN." QARN verified that the RN did not develop care plan for Patient 18 at all. QARN further stated LVN needed to follow the care plan to provide intervention outlined by RN, without the care plan, Patient 18 could not receive optimal care needed, and the LVN would not have directions of what nursing care to provide for Patient 18.

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

1. Two of six sampled nursing staff (Registered Nurse [RN] 9 and Licensed Vocational Nurse [LVN] 3) had annual skill competency evaluations (assessment of a clinician's skills, abilities and knowledge to ensure provision of safe and effective care to patients) done.

This deficient practice had the potential to result in patients receiving inadequate care and treatment from nursing staff whose competencies were not checked annually.

2. Three of three sampled staff (Registered Nurse (RN) 6, RN 7, and Charge Nurse (CN) 4) followed the facility Policy and Procedure regarding emergency termination procedure for hemodialysis machine and were competent in the hemodialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) emergency termination procedure (safe process of disconnecting a patient from the dialysis machine in case of an emergency) for one (1) of 34 sampled patients (Patient 6).

This deficient practice had the potential to result in inadequate return of blood from the machine to Patient 6 causing harm or even death during hemodialysis treatment.

Findings:

1. During a concurrent interview and record review of Registered Nurse (RN) 9 and Licensed Vocational Nurse (LVN) 3's personnel file, on 2/8/2024 at 3 p.m., with the Director of Human Resources (DHR) and the Manager of Human Resources (MHR), the DHR and the MHR stated the following: RN 9 was hired on 10/15/2012. RN 9's last annual skills competency evaluation was conducted on 6/21/2022. In addition, the DHR and MHR stated LVN 3 was hired on 1/20/2023. LVN 3 did not have an annual skills competency evaluation in the personnel file from the date LVN 3 was hired until present. The DHR and MHR stated the skills competency evaluation should be performed annually and upon hire and was overdue for RN 9 and LVN 3. The DHR stated the that the skills competency evaluations should be performed upon hire and annually to validate that the staff was capable of doing what they (staff) were supposed to do.

During a review of the facility's policy and procedure (P&P) titled, "Competency Assessment," dated 1/2024, the P&P indicated the following: Competency assessment begins upon employment and continues with ongoing evaluation of competency-based performance ...Competencies will be assessed on a continuum throughout the employment of an individual. This continuum will include assessment during the hire process, initial competencies during the orientation period and ongoing annual competency assessment.

2. During a review of Patient 6's, History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 2/6/2024, the H&P indicated Patient 6 was admitted to the facility to restart Hemodialysis (a treatment to filter wastes and water from your blood).

During a concurrent observation and interview on 2/6/2024 at 10:15 a.m. with the House Supervisor (HS) and the Director of Data Quality (DDQ), observed a sign posted in the dialysis machine regarding how to shut off the Hemodialysis machine safely in case of an emergency. The DDQ stated hemodialysis services at the facility was a contracted service and was provided hospital wide. Likewise, Dialysis RN (RN10) confirmed there was a sign posted in the dialysis machine regarding instructions on how to shut off the Hemodialysis machine safely in case of an emergency.

Concurrently, during an interview on 2/6/2024 at 10:15 a.m., Registered Nurse (RN) 6 (who was taking care of Patient 6 being dialyzed) was asked if she (RN 6) was trained on how to turn off the dialysis machine in case of an emergency. RN 6 stated she (RN6) was not trained. RN 7 was asked if she (RN7) was trained on how to turn off the dialysis machine in case of emergency, she stated she (RN7) did not know how to turn off the dialysis machine in case of an emergency. In addition, Charge Nurse (CN) 4 stated that an in-service on how to turn off the dialysis in case of emergency was provided but she (CN 4) was not sure of the procedure.

During an interview and record review on 2/9/2024 at 11:30 a.m., with the Clinical Educator Nursing Administration (CENA) and the Clinical Educator (CED), the CENA and CED stated RN 6 and RN 7 did not have yearly competency on how to turn off the dialysis machine in case of emergency. CENA and CED stated hospital wide Inservice on how to turn off the dialysis machine in case of emergency was provided in 2023.

During a review of the Facility's policy and procedure (P&P) titled" Care for the Patient needing STAT (immediately) Hemodialysis," dated 4/20/2023, indicated under Section 2, "If the Hemodialysis Nurse (HD) nurse becomes incapacitated during a treatment, hospital nursing staff must immediately attend to the patient safety." Instructions on how to safely discontinue hemodialysis and temporary disconnection procedure was also included.

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

1. Ensure one of one sampled registered nurse (Registered Nurse (RN) 5) followed the facility's policy and procedure for putting on (donning) PPE (personal protective equipment, equipment worn to minimize exposure to illness, includes gown, gloves, mask etc. ) and removing (doffing) personal protective equipment while taking care of one of 34 sampled patients (Patient 10), who was on contact precaution (interventions taken to prevent transmission of infectious agents). This deficient practice had the potential to spread infection to other Patients on the Unit due to improper donning and doffing of PPEs.

2. Ensure one of one sampled staff (Licensed Vocational Nurse [LVN] 13) adhered to the facility's policy and procedure on the LVN Scope of Practice when LVN 13 administered Methylprednisolone (Solu-Medrol, steroid injection provides relief of inflamed area of the body, lungs and breathing problem such as asthma) intravenously (given into the vein) for one of 34 sampled patients (Patient 22). This deficient practice had the potential for Patient 22 to develop respiratory problem and reaction from an untrained staff's improper administration of medication.

3a. Change enteral (a method of feeding that uses the gastrointestinal [GI] tract to deliver nutrition and calories) feeding container and feeding tube set (feeding tube inserted through an abdominal wall to deliver nutrients directly into the patient's stomach) after 24 hours of use for one of 34 patients (Patient 15) in accordance with the facility's policy and procedure regarding enteral feeding and feeding tube set replacement. This deficient practice had the potential for risk of contamination (growing microorganisms, such as bacteria or parasites, or toxic substances making feeding unfit for consumption), which may result in gastrointestinal problems such as diarrhea, abdominal pain, vomiting, etc. for Patient 15.

3b. Renew an order for restraints (a physical restraint is any manual method, material or equipment that is attached to patient's body that cannot be easily removed and restricts freedom of movement) use for one of 34 patients (Patient 16) after 24 hours that the restraint was initially ordered. This deficient practice had the potential to violate Patient 16's rights regarding restraint use, as nursing staff continued documenting the prolonged use of restraints without a physician's renewal order for restraints. This deficient practice also had the potential to result in patient harm such as skin injury from prolonged and inappropriate use of restraints.

3c. Label a feeding tube container after initiating tube feeding (a way to provide nutrition for patients who are unable to eat or drink by mouth) to indicate the need for replacement after 24 hours of use and did not indicate the date, time, and patient's name when initiated for one of 34 sampled patients (Patient 16) in accordance with the facility's policy and procedure regarding labeling and replacing tube feeding containers after 24 hours from the time the feeding tube container was used.

This deficient practice had the potential for risk of contamination (growing microorganisms, such as bacteria or parasites, or toxic substances making feeding unfit for consumption), which may result in gastrointestinal problems such as diarrhea, abdominal pain, vomiting, etc. for Patient 16.

3d. Use translator services (facilitates communication between healthcare providers and non-English speaking patients to provide the best possible quality of care) when obtaining informed consent (the process in which a healthcare provider educates a patient about the risks, benefits and alternatives, of a given procedure or intervention) for one of 34 sampled patients (Patient 14).

This deficient practice had the potential for Patient 14 not receiving accurate and current information in the language Patient 14 could understand which may result in Patient 14 not understanding information regarding her (Patient 14) health status and treatment and may delay recovery from illness.

Findings:

1. During a concurrent observation and interview on 2/6/2024 at 11:40 a.m. on 6 West (Medical Unit) with the Infection Preventionist (IP) and the Director of Data Quality (DDQ), RN5 was observed exiting a contact precaution room (used for patients with infections, diseases, or germs that are spread by touching the patients or items in the room) with shoe covers, a hair cover, N95 mask (a respiratory protective device that is designed to provide very efficient filtration of airborne particles) and underneath the N95 mask was a surgical mask. RN 5 stated her assignment included two contact precautions Patients. RN 5 said she does not change her hair-cover, shoe covers and her N95 mask when leaving the Contact precaution rooms. The IP stated daily rounds are done hospital wide to conduct surveillance for compliance with Infection prevention practices.

During an interview on 2/7/2024 at 10 a.m. with IP, the IP stated all PPE must be removed when leaving a contact precaution room. Shoe cover and hair cover should not be worn on the unit and should be removed when leaving a Contact Precaution room. IP stated there were daily rounds to conduct surveillance for compliance with policy and procedure including for Contact precautions and donning (putting on) and doffing (removing) of personal protective equipment (PPE, equipment worn to minimize exposure to illness, includes gown, gloves, mask etc.)

During a concurrent interview and record review on 2/9/2024 at 11 a.m. with the Clinical Educator Nursing Administration (CENA) and the Clinical Educator (CED), CENA and CED stated all registered nurses have yearly competency for Infection prevention including contact precaution and donning and doffing of PPE.

During a review of the facility's policy and procedure (P&P) titled, "Standard and Isolation Precautions," dated 7/20/23, the P&P indicated, "standard precautions prevent the spread of infectious organisms and include the use of barriers including gloves gowns masks and protective eyewear precautions" and the P&P also indicated to remove all PPE prior to leaving the contact precautions patient room.

2. During a review of Patient 22's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 12/11/2023, the H&P indicated, Patient 22 was admitted to the facility with diagnoses of hypertension (high blood pressure), congestive heart failure (CHF, heart failure in which the heart cannot pump enough blood to meet the body's needs), and acute hypoxemic (lack of oxygen) respiratory distress.

During a concurrent interview and record review on 2/9/2024 at 10:59 a.m. with the Quality Assurance Registered Nurse (QARN), Patient 22's "electronic Medication Administration Record (eMAR, a record of medications given to patient)," dated from 1/5/2024 to 1/7/2024, was reviewed. The MAR indicated IV (intravenous, into the vein) Solu-Medrol (steroid injection provides relief of inflamed area of the body, lungs and breathing problem such as asthma) 20 mg (milligram, unit of measurement) was given by LVN 13 on the following days:
1/5/2024 at 11:16 p.m.
1/6/2024 at 5:44 a.m.
1/6/2024 at 10 p.m.
1/7/2024 at 6 a.m.
QARN stated that LVN 13 was not allowed to give any IV medications because it was out of her (LVN 13) scope of practice.

During an interview on 2/9/2024 at 11:38 a.m. with the Clinical Educator Nursing Administration (CENA), CENA stated per facility's policy, LVN was not allowed to give any medication administration intravenously. CENA further stated LVN 13 should not have given the Solu-Medrol to Patient 22 because it was not under her (LVN 13) scope of practice, she (LVN 13) was not trained to give IV medication and could not perform assessment and assess the possible side effects after the IV medication was given. CENA stated Patient 22 might develop respiratory problem if Solu-Medrol was given too fast or too slow.

During a review of the facility's policy and procedure (P&P) titled, "Licensed Vocational Nurse, Scope of Practice," dated 10/2023, the P&P indicated, "LVN's may not: mix or administer IV medications (this includes IVP [intravenous push, medication is administered into the bloodstream very quickly], IVPB [Intravenous Piggy Back, a small bag of solution attached to a primary infusion line or intermittent venous access device to deliver medication over a specified period of time. Example: antibiotic solutions] and IV drips) ... may not implement any actions or activities not in their scope of practice ... it is the LVN's responsibility to always perform within their Scope of Practice and the must comply with current Standards of Care."

During a review of the facility's policy and procedure (P&P) titled, "Administration of Medications," dated 08/2023, the P&P indicated, "All medications shall be administered only by individuals licensed by local state and are authorized to administer medication. These routinely include Licensed Vocational Nurse, Administration by the parental route is limited to non-intravenous dosage forms and intravenous solutions without added medications."

3a. During a review of Patient 15's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 2/6/2024, the H&P indicated, Patient 15 was admitted on 1/31/2024 due to pneumonia (PNA, lung inflammation caused by bacterial or viral infection), acute (sudden) on chronic (long-lasting) respiratory failure (the inability of the respiratory system to meet the oxygenation, ventilation, or body requirements of the patient), and sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death).
The H&P further indicated, Patient 15 had a past medical history (PMH, a record of information about a patient's health) of recent (1/19/2024) anoxic brain injury (a complete lack of oxygen to the brain, which results in the death of brain cells) due to prolonged seizure (sudden, uncontrolled burst of electrical activity in the brain) and cardiopulmonary arrest ( the cessation of effective breathing and blood flow) resulting in chronic ventilator dependence (long term mechanical support for breathing) with tracheostomy (surgical opening created to insert a tube through the neck into the windpipe to allow air to fill the lungs and remove secretions) and percutaneous endoscopic gastrostomy feeding tube (PEG, a tube inserted through the wall of the abdomen directly into the stomach) placement.

During a review of Patient 15's medical record ( MR) titled, "Nutrition Assessment," dated 2/1/2024, the MR indicated, Patient 15 required enteral (any method of feeding that uses the gastrointestinal [GI] tract to deliver nutrition and calories) nutrition infusion via PEG feeding tube with a recommendation to provide continuous enteral feeding at a rate of 45 milliliters an hour (ml, a unit of measurement) to meet Patient 15's necessary body caloric (the number of calories your body needs to support your body's basic functions, such as breathing, digestion, circulation, and regulating your body temperature) requirements.

During an observation on 2/7/2024, at 11:23 a.m., in Patient 15's room in a Direct Observation Unit (DOU), Patient 15 was observed in bed, receiving an enteral feeding nutrition via feeding pump, running at 45 milliliters an hour (ml/h, a unit of measurement). The tube feeding container label indicated, the feeding was initiated on 2/6/2024, at 6:30 a.m.

During an interview on 2/7/2024, at 11:23 a.m., with Director of Nursing (DON) and Patient 15's primary nurse (RN 12), the DON stated, the feeding bottle and the infusion set must be changed every 24 hours or as soon as the feeding runs out because of the risk of contamination (growing microorganisms, such as bacteria or parasites, or toxic substances making feeding unfit for consumption). The RN 10 stated, the feeding container and feeding set had to be changed on 2/7/2024 at/or before 6:30 a.m. as per the facility's policy, but the primary nurses forgot to change it.

During a review of the facility's policy and procedure (P&P) titled, "Enteral Feeding Protocol," last reviewed on 6/2023, the P&P indicated, "Enteral feeding is used to provide nutrients directly into the stomach, duodenum (the first part of the small intestine), and jejunum (one of the three sections that make up the small intestine) by tube for those patients with a minimally functioning gastrointestinal (GI) tract who cannot take adequate nutrition by mouth. Enteral feeding container and spike set are to be changed every 24 hours or sooner as the formula runs out. Each container must be labeled with the date and time when initiated and the patient's name and initialed."

3b. During a review of Patient 16's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 01/27/2024, the H&P indicated, Patient 16 was admitted on 1/27/2024 due to abdominal pain, nausea (feeling the urge to vomit) and weight loss. The H&P further indicated, Patient 16's past medical history (PMH) included hypertension (a condition in which the blood vessels have persistently raised pressure).

During a review of Patient 16's medical record (MR) titled, "Nutrition Notes," dated 2/1/2024, the MR indicated, Patient 16 required nasogastric tube (NGT) feeding (a narrow feeding tube is placed through your nose down into your stomach) due to being too lethargic (a state of fatigue and low energy) to eat. The MR further indicated; Patient 16 was started on continuous NG tube feeding.

During an interview and concurrent record review on 2/8/2024, at 2:04 p.m., with house supervisor (HS), Patient 16's medical record (MR) titled, "Care Activity-Assessments: Acute Medical Restraint Flowsheet," dated 2/5/2024- 2/6/2024, was reviewed. The MR indicated, nursing documented that Patient 16 required bilateral (applied to both sides) soft wrist restraints (a physical restraint is any manual method, material or equipment that is attached to patient's body that cannot be easily removed and restricts freedom of movement) due to behavior (pulling on lines [attempts to remove necessary medical equipment such as NGT or intravenous (IV) lines and was confused) interfering with patient care. The HS stated, the MR documentation indicated, Patient 16 was in restraints on 2/5/2024 and 2/6/2024. The HS further stated, nursing documentation in Patient 16's MR indicated, on 2/6/2024, Patient 16 was restrained from 12:00 a.m. to 6:00 p.m. The HS stated, per the facility's policies and procedures and federal regulation, nursing must have a physician's order to use restraints when a clinical justification for use of restraints is present.

During a concurrent interview and record review on 2/8/2024, at 2:04 p.m., with house supervisor (HS), Patient 16's medical record (MR) titled "Physician's Orders," dated 2/5/2024-2/6/2024, was reviewed. The MR indicated, an order for soft bilateral wrist restraints was placed by the physician on 2/5/2024 to prevent Patient 16 from pulling on lines and interfering with care. The HS stated, the MR contained no order for soft bilateral wrist restraints on 2/6/2024.The HS further stated, nursing can initiate restraints, but the order for restraints must be renewed/rewritten every 24 hours if there was a clinical justification for its use.

During a review of the facility's policy and procedure (P&P) titled, "Restraints," last reviewed on 12/2023, the P&P indicated, "All patients have the right to be free from restraint of any form. Restraints are only used in an emergency, when less restrictive interventions are ineffective, only when it can be clinically justified or warranted by patient behavior. Initiation of restrain by a qualified, competent RN in the absence of a licensed independent practitioner is permitted, but the order must be obtained as soon as possible, but no longer than one hour after initiation. All restraint orders must be renewed/rewritten based on the direction of the physician if there is clinical justification, for up to 24 hours. The attending physician must be consulted as soon as possible if the restrain is not ordered by the patient's attending physician."

3c. During a review of Patient 16's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 01/27/2024, the H&P indicated, Patient 16 was admitted on 1/27/2024 due to abdominal pain, nausea and weight loss. The H&P further indicated, Patient 16's past medical history (PMH) included hypertension (a condition in which the blood vessels have persistently raised pressure).

During a review of Patient 16's medical record (MR) titled, "Nutrition Notes," dated 2/1/2024, the MR indicated, Patient 16 required nasogastric tube (NGT, a nasogastric (NG) tube is a thin, soft tube that goes in through the nose, down the throat, and into the stomach and is used to feed formula when a person is unable to get nutrition by mouth) feeding due to being too lethargic (A person experiencing lethargy may not have the energy or motivation to do the tasks they need to each day) to eat. The MR further indicated Patient 16 was started on continuous NGT tube feeding (TF).

During a review of Patient 16's medical record (MR) titled, "Nutrition Notes," dated 2/7/2024, the MR indicated, Patient 16 had severe malnutrition (lack of proper nutrition caused by not having enough to eat) related, difficulty swallowing related to mentation, and required administration of continuous NGT feeding formula.

During an observation on 2/7/2024, at 11:34 a.m., Patient 16 was observed in bed, in Patient 16's room. Patient 16 had NG Tube attached to an enteral feeding pump (Enteral feeding pumps use feeding tubes to deliver nutrition to patients who cannot obtain such by swallowing) with a spiked enteral feeding container (a sterile feeding container is spiked with a feeding set) attached to the tubing set. The enteral feeding container was not labeled with the date and time initiated and the patient's name.

During an interview on 2/7/2024 at 11:36 a.m. with director of nursing (DON), the DON stated, nursing must label newly spiked feeding container with the date and time initiated, the patient's name and initialed by the administering nurse. The DON further stated enteral feeding bottle and spike set are to be changed every 24 hours or sooner to prevent bacterial contamination as per the facility's policy.

During a review of the facility's policy and procedure (P&P) titled, "Enteral Feeding Protocol," last reviewed on 6/2023, the P&P indicated, "Enteral feeding is used to provide nutrients directly into the stomach or small intestine by tube for those patients with a minimally functioning gastrointestinal (GI) tract (digestive tract) who cannot take adequate nutrition by mouth. Enteral feeding container and spike set are to be changed every 24 hours or sooner as the formula runs out. Each container must be labeled with the date and time when initiated and the patient's name and initialed."

3d. During a review of Patient 14's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 1/23/2024, the H&P indicated, Patient 14 had a past medical history (PMH) of epidural abscess (an infection that forms in the space between your skull bones and your brain lining), diabetes (a disease in which the body's ability to produce or respond to the hormone insulin resulting in elevated levels of glucose [sugar] in the blood) and laminectomy (surgery that creates space by removing bone spurs and tissues associated with arthritis of the spine) and was admitted with a chief complaint of bilateral (relating to two sides) flank pain (the area on either side of the lower back, between the pelvis and the ribs).

During a review of Patient 14's medical record (MR) titled, "Admission Initial Assessment," dated 1/23/2024, the MR indicated, Patient 14's preferred spoken and written language was Spanish.

During a review of Patient 14's medical record (MR) titled, "Blood Transfusion Consent," dated 1/24/2024, the MR indicated, Patient 14 signed the informed consent (the process in which a healthcare provider educates a patient about the risks, benefits and alternatives, of a given procedure or intervention) for blood transfusion (a process in which blood or blood components are administered to the patient through an intravenous [into the vein] line) on 1/24/2024, but nursing did not document using translator services (facilitates communication between healthcare providers and non-English speaking patients to provide the best possible quality of care) when obtaining the informed consent.

During a review of Patient 14's medical record (MR) titled, "Consent for Peripherally Inserted Central Catheter (a type of long catheter that is inserted through a peripheral vein, often in the arm, into a larger vein in the body, used when intravenous treatment is required over a long period)," dated, 2/1/2024, the MR indicated, Patient 14 signed the Informed Consent on 2/1/2024, but nursing did not document using the translator services that was supposed to be used when obtaining the informed consent for a patient whose preferred language was not English.

During a concurrent interview and record review on 2/8/2024 at 1:57 p.m. with house supervisor (HS), Patient 14's medical records (MR) titled, "Blood Transfusion Consent," dated 1/24/2024 and "Consent for Peripherally Inserted Central Catheter," dated 2/1/2024, were reviewed. The MR indicated, nursing did not document using translator services on both Informed Consents. The HS stated nursing should provide a qualified translator for non-English speaking patients and document in the patient's medical record the name or the interpreter identification (ID) number of the person who acted as a translator, but nursing did not.

During a review of the facility's policy and procedure (P&P) titled, "Translation/Interpretation Services for Patients," last reviewed, 7/2022, the P&P indicated, "non-English speaking patients must be provided with translators/interpreters to provide quality health care services and allowed patients to feel comfortable in the healthcare environment. Hospital staff shall make appropriate arrangements if the patient is identified as needing interpreter services/ Once a translator was provided to a patient, documentation should be placed in the patient's medical record indicating the name or the Interpreter ID # of the person who acted as the interpreter."

During a review of the facility's policy and procedure (P&P) titled, Patient Rights and Responsibilities, "last revised 6/2022, the P&P indicated, "The patient's rights include being informed of his/her health status, being involved in care planning and treatment. The patient has the right to receive accurate and current information regarding the health status in terms they can understand and have the interpreter to assist language needs."

Based on interview and record review, the facility failed to ensure its nursing staff documented properly and follow medication administration procedure on the electronic Medication Administration Record (eMAR, a record of medications given to patient) after a narcotic (opioids medication for pain relief) was given to one of 34 sampled patients (Patient 21) per facility Policy and Procedure.

This deficient practice had the potential to put Patient 21 at risk for overdose on narcotics as it was not recorded on the electronic Medication Administration Record properly.

Findings:

During a review of Patient 21's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 1/31/2024, the H&P indicated, Patient 21 was admitted to the facility's Definitive Observation Unit (DOU, hospital unit that provides the second-highest level of care) with diagnoses of acute respiratory failure (a condition in which the lungs cannot release enough oxygen into the blood) due to fluid overload (too much fluid in the body) requiring Bilevel positive airway pressure (BIPAP, a machine that helps someone to breath via noninvasive ventilation). The H&P also indicated Patient 21 was awake and alert.

During a concurrent interview and record view on 2/8/2024 at 2:40 p.m. with QARN, Patient 21's nurse notes (narrative notes documented by nursing staff to reflect care given during the shift), dated 2/7/2024 at 7:28 a.m., was reviewed. The Nurse notes indicated Patient 21 complained of 9/10 (pain scale of 0 - 10 utilized to rate the severity of pain with 10 being the most severe) foot pain and Norco (narcotics, type of opioid medication for pain relief) was given by LVN 7. QARN verified that LVN 7 did not record Norco administration on Patient 21's electronic Medication Administration Record.

During an interview on 2/9/2024 at 2:05 p.m. with the Charge Nurse (CN 6) of DOU, CN 6 stated narcotics should be scanned and recorded on the eMAR upon medication administration. CN 6 stated if it was not recorded on the MAR, there would be risk for overdosing the patient as the nurse might not know the narcotics was given previously.

During a review of the facility's policy and procedure (P&P) titled, "Administration of Medications," dated 08/2023, the P&P indicated, "the administration of each dose of medication shall be accurately recorded in the patient's electronic medication administration record (eMAR) via barcode scanning (verifies patient identity as well as insuring that the patient receives the right medication, in the right dose, via the right route, at the right time) during administration ... the electronic medication administration record shall include the name and dose of the medication, the route of administration, the date and time of administration, and the initial of the person administering the dose."