HospitalInspections.org

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13, PATIENT RIGHTS, was out of compliance.

A-0175 PATIENT RIGHTS: RESTRAINT OR SECLUSION. The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. Based on interviews and record review, the facility failed to ensure patients who required physical restraint were monitored according to facility policy in three of three medical records reviewed for patients who required restraint and were on the medical-surgical units. (Patient #1, Patient #8, and Patient #9).

Based on interviews and record review, the facility failed to ensure patients who required physical restraint were monitored according to facility policy in three of three medical records reviewed for patients who required restraint and were on the medical-surgical units. (Patient #1, Patient #8, and Patient #9).

Findings include:

Facility policy:

The Patient Restraints Seclusion policy read, Restraint and/or Seclusion may only be imposed to ensure the immediate physical safety of the patient, an associate, or others, may only be used for the time necessary to accomplish their purpose, and must be discontinued at the earliest possible time when criteria for release have been met. Restraint and/or Seclusion use within the hospital is limited to situations with adequate and appropriate clinical justification based on a current individual assessment and only after the least restrictive interventions and alternatives have been considered and are deemed
ineffective.

For patients to whom Mechanical Restraints have been applied, associates will loosen/remove the Restraints to provide relief, except when the patient is sleeping, for at least ten (10) minutes as often as every two (2) hours, as long as it is safe for the patient and others for the restraints to be loosened/removed. During such relief periods, associates will ensure proper positioning of the patient and provide movement of limbs, as necessary. The patient ' s dignity and safety shall be maintained during relief periods. Associates will document the relief periods in the patient ' s medical record.

Frequency of monitoring and documentation of that monitoring is determined by the type of Mechanical Restraint and setting. Monitoring is accomplished by observation, interaction with the patient, or direct examination of the patient by Qualified Staff. Patients Restrained with Non-Violent Behavior restraints should be assessed by a RN/LPN every 2 hours that includes: skin integrity, circulation, sensation and movement of restrained extremity; pressure points for skin impairment; and respiratory status/ airway not obstructed. Additionally, RNs, LPNs, or PCT/CNAs perform checks and addresses physical needs every 2 hours to include: safety and comfort; need for hygiene/elimination; need for ROM of restrained extremities; repositioning; and food/fluids offered.

1. The facility failed to ensure patients in non-violent behavior restraints were assessed every two hours according to facility policy.

A. Medical Record Review

i. On 7/27/24 Patient #1 was admitted for treatment after a motorcycle crash. While on the neuro-trauma unit, mechanical restraints were ordered. Upon review of Patient #1's flowsheets, gaps in restraint monitoring were identified. Examples include:

a. On 8/6/24 Patient #1's restraints were assessed at 5:00 p.m. The next assessment was completed at 7:51 p.m., two hours and 51 minutes after the previous assessment.

b. On 8/9/24 at 12:28 a.m. Patient #1's restraint status was assessed. The next assessment was completed at 4:00 a.m., three hours and 32 minutes after the previous assessment.

This was in contrast to the patient restraint and seclusion policy which read, patients restrained with Non-Violent Behavior restraints should be assessed by a RN/LPN every 2 hours that includes: skin integrity, circulation, sensation, and movement of restrained extremity; pressure points for skin impairment; and respiratory status/ airway not obstructed.

ii. On 10/14/24 Patient #8 was admitted to the facility for a potential GI bleed. During the admission, mechanical restraints were ordered. Upon the review of Patient #8's flowsheets, gaps in restraint monitoring were identified. Examples include:

a. On 10/19/24 at 4:00 p.m., Patient #8's restraint status was assessed. The next assessment was completed at 8:00 p.m., four hours after the previous assessment.

b. On 10/21/24 at 12:00 a.m., Patient #8's restraint status was assessed. The next assessment was completed at 4:00 a.m., four hours after the previous assessment.

This was in contrast to the patient restraint and seclusion policy which read, patients restrained with Non-Violent Behavior restraints should be assessed by a RN/LPN every 2 hours that includes: skin integrity, circulation, sensation, and movement of restrained extremity; pressure points for skin impairment; and respiratory status/ airway not obstructed.

iii. On 8/1/24 Patient #9 was admitted for a subdural hemorrhage (a collection of blood between the brain and skull) after a fall. A review of Patient #9's flowsheets revealed gaps in restraint monitoring. Examples include:

a. On 8/1/24 at 10:00 p.m., Patient #9's restraint status was assessed. The next assessment was completed on 8/2/24 at 8:00 a.m., ten hours after the previous assessment.

b. On 8/6/24 at 2:00 p.m., Patient #9's restraint status was assessed. The next assessment was completed at 8:00 p.m., six hours after the previous assessment.

This was in contrast to the patient restraint and seclusion policy which read, patients restrained with Non-Violent Behavior restraints should be assessed by a RN/LPN every 2 hours that includes: skin integrity, circulation, sensation, and movement of restrained extremity; pressure points for skin impairment; and respiratory status/ airway not obstructed.

B. Interviews

i. On 11/12/24 at 10:01 a.m., an interview was conducted with registered nurse (RN) #8. RN #8 stated they primarily worked on the neuro-trauma unit. RN #8 stated if a patient was in non-violent mechanical restraints, the patient should have been assessed every two hours. RN #8 stated it was important for the patient to be assessed every two hours to ensure the patient had not injured themselves and was provided nourishment and other care as needed.

ii. On 11/12/24 at 12:00 p.m., an interview was conducted with chief nursing officer (CNO) #6. CNO #6 stated patients in non-violent restraints should have been assessed every two hours to check for circulation and status of the patient.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.21 QAPI, was out of compliance.

A-0286 PATIENT SAFETY (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events. (c) Program Activities. (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities. The hospital's governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: (3) That clear expectations for safety are established. Based on interviews and record reviews, the facility failed to thoroughly analyze the cause of a patient event and implement preventative actions to prevent recurrence. Specifically, upon review of a patient event record, the facility failed to identify CIWA scores were not completed in accordance with the Alcohol Withdrawal Assessment Scoring Guidelines which continued to occur in additional later patient admissions.

Based on interviews and record reviews, the facility failed to thoroughly analyze the cause of a patient event and implement preventative actions to prevent recurrence. Specifically, upon review of a patient event record, the facility failed to identify CIWA scores were not completed in accordance with the Alcohol Withdrawal Assessment Scoring Guidelines which continued to occur in additional later patient admissions. (Cross Reference Tag 0395)

Findings include:

Facility policy:

The patient safety event reporting/sentinel event management policy read, a Sentinel Event is a Patient Safety Event (not primarily related to the natural course of the [patient ' s] illness or underlying condition) that reaches a patient and results in death, Severe Harm (regardless of duration of Harm), or Permanent Harm (regardless of severity of Harm). A sentinel event is a Patient Safety Event that reaches a patient and results in any of the following: death; permanent harm; severe temporary harm and intervention required to sustain life.

Care sites that have experienced a Sentinel Event should focus attention on understanding the factors that contributed to the event (such as culture, systems, and processes), and on changing these factors to reduce the probability of such an event occurring in the future. Quality and Risk Management will be consulted when determining whether the event meets a Reviewable or not Reviewable Sentinel Event. A thorough and credible Root Cause Analysis and action plan will be prepared within 45 business days of the event or of becoming aware of the event. Clinical Risk Management will facilitate assembling the team to conduct the Root Cause Analysis. Team participation will include Operations from the area impacted, Quality and Risk Management representative(s), physicians, and individuals most closely involved in the event and processes or systems under review.

References:

The Alcohol Withdrawal Treatment Order Set (CIWA order set) read, CIWA Assessment - initiate assessments every six hours x 48 hours then per routine or if patient displays signs of withdrawal: If CIWA is 8 or greater - assess every one hour, then if CIWA is less than 8 x 3 consecutive assessments; assess every three hours x 3, then every six hours x 3, then per routine. If CIWA is 15 or greater for 3 consecutive assessments, contact the provider.

The Alcohol Withdrawal Assessment Scoring Guidelines (CIWA-ar) read, Procedure: 1. Assess and rate each of the 10 criteria of the CIWA scale. Each criterion is rated on a scale from 0 to 7, except for "Orientation and clouding of sensorium" which is rated on a scale of 0 to 4. Add up the scores for all ten criteria. This is the total CIWA-Ar score for the patient at that time. Prophylactic medication should be started for any patient with a total CIWA-Ar score of 8 or greater (i.e.. start on withdrawal medication). If started on scheduled medication, additional PRN medication should be given for a total CIWA-Ar score of 15 or greater. 2. Document vitals and CIWA-Ar assessment on the Withdrawal Assessment Sheet. Document administration of PRN medications on the assessment sheet as well. 3. The CIWA-Ar scale is the most sensitive tool for assessment of the patient experiencing alcohol withdrawal. Nursing assessment is vitally important. Early intervention for CIWA-Ar score of 8 or greater provides the best means to prevent the progression of withdrawal.

The assessment protocol from the Alcohol Withdrawal Assessment Scoring Guidelines read, the assessment includes an initial vitals and CIWA assessment. If the initial score is greater than or equal to 8, repeat every hour for 8 hours. Then, if stable, repeat every two hours for eight hours, then if stable, every four hours. If the initial score is less than 8, assess every four hours for 72 hours. If the score is less than 8 for 72 hours, discontinue the assessment. If the score is greater than or equal to 8 at any time, repeat every hour for eight hours. Then, if stable, repeat every two hours for eight hours, then if stable, every four hours. If indicated, administer prn medications as ordered and record on the medication administration record (MAR).

1. The facility failed to identify gaps in CIWA assessments for a patient who experienced an adverse event.

a. A review of medical records revealed gaps in Patient #2's CIWA assessments as well as gaps in additional CIWA assessments completed on alcohol withdrawal patients.

i. On 7/5/24 Patient #2 arrived at the emergency department (ED) for hematemesis (vomiting blood). On 7/6/24 Patient #2 was then admitted to the 8th Floor and CIWA protocol was ordered due to potential concerns of alcohol withdrawal. On 7/6/24 at 3:51 a.m., an admission assessment was documented by the registered nurse (RN). The RN documented under the neuro assessment they were unable to assess the patient's orientation status. Additionally, at that time, the patient status under orientation in the CIWA assessment was documented as oriented and able to do serial additions. The total CIWA score was 7.

At 7:25 a.m., a shift assessment and CIWA assessment were completed. The patient's orientation was documented as unable to assess. However, the patient's orientation under the CIWA assessment was documented as oriented and able to do serial additions. The total CIWA score was 8.

The CIWA assessments were in contrast to the neuro assessments which could have caused an inaccurately low CIWA score.

At 8:25 a.m. a CIWA assessment was completed with a score of 6. The next CIWA assessment was completed at 10:00 a.m., one hour and 35 minutes later.

This was in contrast to the CIWA order set which read if the score was greater or equal to 8, reassessments should occur every hour for three hours.

A review of Patient #2's medical record was in contrast to the record review in Patient #2's grievance report.

ii. On 10/18/24 Patient #6 was admitted to the facility and CIWA protocol was ordered. At 12:48 p.m., a CIWA assessment was completed and the patient's score was 18. The next CIWA assessment was done at 2:42 p.m., almost two hours later. At 9:27 p.m., a CIWA assessment was completed and the score was 11. The next documented CIWA assessment was on 10/19/24 at 12:00 a.m. which read a CIWA score of 0 and that the patient was sleeping.

On 10/19/24 at 8:55 p.m., a CIWA assessment was completed and the score was 20. The next CIWA assessment was on 10/20/24 at 12:00 a.m., over three hours later. The assessment read the score was 0 and the patient was asleep.

On 10/20/24 at 9:56 a.m., a CIWA assessment was completed with a score of 24. The next CIWA assessment was completed at 1:12 p.m., over three hours later. The score at that time was 29. The next CIWA assessment was completed at 3:44 p.m., over two hours later, and the score was 13. Another CIWA assessment was done at 7:50 p.m., almost four hours later, and the score was 18.

This was in contrast to the CIWA order set which read if the score was greater or equal to 8, reassessments should occur every hour for three hours.

On 10/21/24 at 8:30 a.m., a CIWA assessment was performed and the score was 15. The next CIWA assessment was completed at 12:12 p.m., over three hours later, with a result of 19. The next CIWA assessment was completed at 2:10 p.m., almost two hours later and the score was 16. There was no evidence the provider was notified of the CIWA scores during this time period.

This was in contrast to the CIWA order set which read, if CIWA was 15 or greater for 3 consecutive assessments, contact provider. Additionally, the CIWA assessments were not completed every hour for three hours as ordered by the provider.

Similar findings of the CIWA protocol not being followed were identified in Patient #4, Patient #5, and Patient #8's records.

b. An email correspondence conversation from 8/12/24 in the grievance report for Patient #2 was reviewed. The email read the CIWA was assessed and treated in accordance with the provider's order.

c. Interviews conducted with facility leadership revealed the CIWA assessments which were not completed according to the Alcohol Withdrawal Assessment Scoring Guidelines were not identified upon review of Patient #2's event.

i. On 11/6/24 at 1:25 p.m., an interview was conducted with RN #2. RN #2 stated a provider placed orders for CIWA protocols when they determined a patient needed these assessments. RN #2 stated they were unaware of a CIWA policy at the facility. Additionally, RN #2 stated they had not received any CIWA training at the facility. RN #2 explained it was important for patients with alcohol withdrawal to be assessed and treated since alcohol withdrawal can lead to additional concerns such as falls and seizures.

ii. On 11/6/24 at 2:30 p.m., an interview was conducted with the 8th floor medical surgical unit nurse manager (Manager) #4. Manager #4 explained they reviewed Patient #2's medical record since the patient had experienced a code blue event on 7/6/24. Manager #4 stated they had not identified inconsistencies in neuro assessments and CIWA assessments. Manager #4 further explained staff may have received CIWA education if it was presented during the facility's skills week or if the staff member was a newer nurse and was enrolled in the Specialty Nurse Advancement Program (SNAP). Manager #4 stated there was not a CIWA protocol policy at the facility, however, staff had access to Lippincott which held resources for clinical guidance.

iii. On 11/12/24 at 10:31 a.m., an interview was conducted with director of quality (Director) #5. Director #5 stated the event with Patient #2 was sent to physician peer review and nurse peer review and the record was reviewed by facility leadership. Director #5 stated they reviewed the patient's medical record however did not review the patient's CIWA scoring and neuro assessments for accuracy.

iv. On 11/5/24 at 1:20 p.m., an interview was conducted with the regional clinical risk and safety manager (Regional Manager) #7. Regional Manager #7 stated Patient #2's record went through peer review as well as an external review of the patient's course and care. Regional Manager #7 explained the review had identified potential inconsistencies with Patient #2's neuro exam in regards to the Glasgow Coma Scale (a scale used to measure a patient's level of consciousness). Regional Manager #7 stated it was determined that all nurses at the facility had the education and competency to perform CIWA assessments.

This interview was in contrast with previous interviews in which staff stated they had not received CIWA education at the facility.

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

A-0392 STAFFING AND DELIVERY OF CARE. The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. Based on record review and interviews, the facility failed to ensure nursing personnel provided nursing care to all patients as needed. Specifically, the facility failed to ensure patients were bathed and received oral care in three of three patient records reviewed who needed hygiene assistance on the medical surgical units (Patient #1, #8, and #9).

A-0395 RN SUPERVISION OF NURSING CARE. A registered nurse must supervise and evaluate the nursing care for each patient. Based on interviews and record review, the facility failed to ensure staff followed protocols and assessed patients for a change in condition. Specifically, the facility failed to ensure the Clinical Institute Withdrawal Assessment (CIWA) protocol (clinical assessment used to diagnose the severity of alcohol withdrawal) was followed according to provider orders for alcohol withdrawal patients. This failure was identified in five of six patients reviewed with CIWA orders (Patients #2, #4, #5, #6, and #8).

Based on record review and interviews, the facility failed to ensure nursing personnel provided nursing care to all patients as needed. Specifically, the facility failed to ensure patients were bathed and received oral care in three of three patient records reviewed who needed hygiene assistance on the medical surgical units (Patient #1, #8, and #9).

Findings include:

References:

The Lippincott Bathing Procedure read, Performing a bed bath not only cleans a patient's skin but also stimulates circulation, provides mild exercise, and promotes comfort. It also enables assessment of the condition of the patient's skin, as well as joint mobility and muscle strength. Documentation associated with bed bath includes: the date and time of the bed bath, self-care abilities, and any unusual findings.

The Lippincott Oral Care Procedure read, Oral care promotes patient comfort, nutritional intake, and oral health, and reduces dental plaque, oral colonization, and mucosal inflammation. Research shows that changes in oral bacterial colonization can occur within 48 hours of hospital admission. Aspiration of small droplets of secretions while sleeping can occur even in healthy adults from such causes as supine positioning and medications that suppress the central nervous system. Aspiration of small droplets does not usually cause pneumonia; however, in combination with decreased mobility and changes in oral colonization, patients are at an increased risk for infection due to organism growth in the respiratory tract. Without effective oral care, a patient can develop hospital-acquired pneumonia and other infections as well as reduced nutritional intake, which can increase mortality and hospital length of stay. Documentation associated with oral care includes the date and time of oral care.

1. The facility failed to ensure bathing and oral care were provided to patients needing assistance.

A. Medical Record Review

i. On 7/27/24 Patient #1 was admitted to the facility after a motorcycle crash. A review of the speech therapy notes revealed on 8/2/24, the speech therapist recommended oral care to be completed twice a day. On 8/3/24, Patient #1 was transferred from the ICU to the Neuro-Trauma unit.

A review of Patient #1's flowsheets revealed the patient had not received a bed bath or shower until 8/14/24, 11 days after admission to the Neuro-trauma unit. Additionally, Oral care was not documented until 8/14/24. On 8/16/24, Patient #1 received a shower and oral care. The next shower/bath the patient received was on 8/27/24, 11 days after the previous shower.

ii. On 8/1/24 Patient #9 was admitted for a subdural hemorrhage (a collection of blood between the brain and skull) after a fall. A review of Patient #9's flowsheets revealed on 8/5/24 the patient received a bed bath and oral care. On 8/14/24, Patient #9 received a shower, ten days after the previous bath/shower.

iii. On 10/14/24 Patient #8 was admitted to the facility for a potential GI bleed. A review of Patient #8's flowsheets revealed on 10/23/24 Patient #8 received a bed bath and oral care. On 10/28/24, Patient #8 received oral care and a shower, five days after the previous bath/shower.

B. Interviews

i. On 11/6/24 at 2:02 p.m., an interview was conducted with patient care technician (PCT) #10. PCT #10 stated a few of their assigned job duties were to assist patients with oral care and bathing. PCT #10 explained they tried to ensure patients received a shower or bed bath every other day. PCT #10 stated at times, PCTs may have 16 patients to care for, and in those situations, it was difficult to provide showers and baths to patients. PCT #10 explained it was important for patients to receive bathing and oral care to prevent skin and mouth issues.

ii. On 11/6/24 at 1:49 p.m., an interview was conducted with PCT #11. PCT #11 stated some of their job duties were to assist patients with activities of daily living (ADLs), bathing, and taking vital signs, and bathing patients. PCT #11 explained there were typically two PCTs on the day shift on the 8th floor medical surgical unit, which was where they typically worked. PCT #11 further stated it was difficult to complete some tasks such as bathing when only two PCTs were staffed. PCT #11 explained that the expectation was for patients to receive a bed bath or shower every couple of days. They further explained this was important in order to provide dignity to patients and prevent skin issues.

iii. On 11/6/24 at 2:11 p.m., an interview was conducted with registered nurse (RN) #3. RN #3 stated the expectation was for patients to receive a shower or bed bath every other day. RN #3 explained bathing and hygiene assisted in preventing skin breakdown.

iv. On 11/6/24 at 1:25 p.m., an interview was conducted with RN #2. RN #2 stated patients were expected to receive a bed bath or shower once a day. RN #2 stated it was important for patients to receive bathing in order to ensure the patient did not have any skin breakdown.

v. On 11/12/24 at 12:00 p.m., an interview was conducted with chief nursing officer (CNO) #6. CNO #6 stated bathing was to be offered to patients daily. They further explained if a patient refused a bed bath or shower, staff were to document the refusal in the patient's record.

Based on interviews and record review, the facility failed to ensure staff followed protocols and assessed patients for a change in condition. Specifically, the facility failed to ensure the Clinical Institute Withdrawal Assessment (CIWA) protocol (clinical assessment used to diagnose the severity of alcohol withdrawal) was followed according to provider orders for alcohol withdrawal patients. This failure was identified in five of six patients reviewed with CIWA orders (Patients #2, #4, #5, #6, and #8).

Findings include:

References:

The Lippincott Alcohol Withdrawal Management resources read, signs and symptoms of alcohol withdrawal can begin within six hours after the patient stops drinking and usually resolve in 24 to 48 hours. The patient initially experiences minor withdrawal signs and symptoms, including anorexia, nausea, anxiety, headache, insomnia, diaphoresis, tremulousness, and palpitations. Major motor seizures (alcohol withdrawal seizures) can also occur in the first 12 to 48 hours but rarely occur after that. Alcoholic hallucinations can develop 12 to 24 hours after the patient stops drinking and usually resolve in 24 to 48 hours. Delirium tremens (also called alcohol withdrawal delirium) - including hallucinations, disorientation, tachycardia, hypertension, hyperthermia, agitation, and diaphoresis - usually begins 48 to 96 hours after the patient stops drinking and lasts one to five days.

Healthcare professionals should be skilled in assessing and monitoring patients at risk for withdrawal signs and symptoms. If you know that the patient has a history of chronic alcohol use, using the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) assessment tool may help predict the severity of withdrawal symptoms. In addition to indicating withdrawal, a high score can predict whether seizures and delirium are likely to develop. The CIWA-Ar measures 10 signs and symptoms. The maximum score is 67. A patient who scores less than 10 usually does not require additional medication for withdrawal. The CIWA-Ar requires only about 5 minutes to administer.

Orientation and clouding of sensorium - Ask "What day is this? Where are you? Who am I?" Score based on the observation as follows: 0 Oriented and can do serial additions; 1 Can't do serial additions or is uncertain about the date; 2 Disoriented for date by no more than 2 calendar days; 3 Disoriented for date by more than 2 calendar days; Disoriented for place or person.

Reassess the patient's vital signs and condition frequently, as indicated by the withdrawal process. Patients with severe symptoms may require reassessment every 10 to 15 minutes. Use a facility-approved assessment tool to guide and evaluate the effectiveness of treatment.

The facility's Alcohol Withdrawal Treatment Order set (CIWA order set) read, CIWA Assessment - initiate assessments every six hours x 48 hours then per routine or if patient displays signs of withdrawal: If CIWA is 8 or greater - assess every one hour, then if CIWA is less than 8 x 3 consecutive assessments; assess every three hours x 3, then every six hours x 3, then per routine. If CIWA is 15 or greater for 3 consecutive assessments, contact the provider.

The Alcohol Withdrawal Assessment Scoring Guidelines (CIWA-ar) read, Procedure: 1. Assess and rate each of the 10 criteria of the CIWA scale. Each criterion is rated on a scale from 0 to 7, except for "Orientation and clouding of sensorium" which is rated on a scale of 0 to 4. Add up the scores for all ten criteria. This is the total CIWA-Ar score for the patient at that time. Prophylactic medication should be started for any patient with a total CIWA-Ar score of 8 or greater (i.e.. start on withdrawal medication). If started on scheduled medication, additional PRN medication should be given for a total CIWA-Ar score of 15 or greater. 2. Document vitals and CIWA-Ar assessment on the Withdrawal Assessment Sheet. Document administration of PRN medications on the assessment sheet as well. 3. The CIWA-Ar scale is the most sensitive tool for assessment of the patient experiencing alcohol withdrawal. Nursing assessment is vitally important. Early intervention for CIWA-Ar score of 8 or greater provides the best means to prevent the progression of withdrawal.

The assessment protocol from the Alcohol Withdrawal Assessment Scoring Guidelines read, the assessment includes an initial vitals and CIWA assessment. If the initial score is greater than or equal to 8, repeat every hour for 8 hours. Then, if stable, repeat every two hours for eight hours, then if stable, every four hours. If the initial score is less than 8, assess every four hours for 72 hours. If the score is less than 8 for 72 hours, discontinue the assessment. If the score is greater than or equal to 8 at any time, repeat every hour for eight hours. Then, if stable, repeat every two hours for eight hours, then if stable, every four hours. If indicated, administer prn medications as ordered and record on the medication administration record (MAR).

A PowerPoint presentation used at the facility to educate newer nurses read, alcohol withdrawal symptoms (AWS) can escalate during sleep, assessments should not be deferred or omitted. Vital signs should be taken in conjunction with CIWA assessments.

1. The facility failed to ensure CIWA protocols were followed according to provider orders and guidelines.

A. A review of medical records revealed gaps in the CIWA protocol being followed as ordered by the provider.

i. On 7/5/24 Patient #2 arrived at the emergency department (ED) for hematemesis (vomiting blood). On 7/6/24 Patient #2 was then admitted to the 8th Floor medical surgical unit and CIWA protocol was ordered due to potential concerns of alcohol withdrawal. On 7/6/24 at 3:51 a.m., an admission assessment was documented by the registered nurse (RN). The RN documented under the neuro assessment they were unable to assess the patient's orientation status. However, at that same time, the patient status under orientation in the CIWA assessment was documented as oriented and able to do serial additions. The total CIWA score was 7.

At 7:25 a.m., a shift assessment and CIWA assessment were completed. The patient's orientation was documented as unable to be assessed. However, the patient's orientation under the CIWA assessment was noted as oriented and able to do serial additions. The total CIWA score was 8.

The CIWA assessments were in contrast to the neuro assessments which could have caused an inaccurately low CIWA score.

At 8:25 a.m. a CIWA assessment was completed with a score of 6. The next CIWA assessment was completed at 10:00 a.m., 1 hour and 35 minutes later.

This was in contrast to the CIWA order set which read if the score was greater or equal to 8, reassessments should occur every hour for three hours. Since Patient #2's CIWA score was 8 at 7:25 a.m., this required a reassessment a CIWA assessment at 9:25 a.m.

ii. On 10/18/24 Patient #6 was admitted to the facility and CIWA protocol was ordered. At 12:48 p.m., a CIWA assessment was completed and the patient's score was 18. The next CIWA assessment was done at 2:42 p.m. (almost two hours later). At 9:27 p.m., a CIWA assessment was completed and the score was 11. The next documented CIWA assessment was on 10/19/24 at 12:00 a.m. which read a CIWA score of 0 and that the patient was sleeping.

On 10/19/24 at 8:55 p.m., a CIWA assessment was completed and the score was 20. The next CIWA assessment was on 10/20/24 at 12:00 a.m., three hours later. The assessment read the score was 0 and the patient was asleep.

This was in contrast to the facility's staff education which read, alcohol withdrawal symptoms (AWS) can escalate during sleep, and assessment should not be deferred or omitted.

On 10/20/24 at 9:56 a.m., a CIWA assessment was completed with a score of 24. The next CIWA assessment was completed at 1:12 p.m., over three hours later. The score at that time was 29. The next CIWA assessment was completed at 3:44 p.m., over two hours later, and the score was 13. Another CIWA assessment was done at 7:50 p.m., almost four hours later, and the score was 18.

This was in contrast to the CIWA order set which read, if the score was greater or equal to 8, reassessments should occur every hour for three hours.

On 10/21/24 at 8:30 a.m., a CIWA assessment was performed and the score was 15. The next CIWA assessment was completed at 12:12 p.m., over three hours later, with a result of 19. The next CIWA assessment was completed at 2:10 p.m., almost two hours later, and the score was 16. There was no evidence the provider was notified of the CIWA scores during this time period.

This was in contrast to the CIWA order set which read if CIWA was 15 or greater for 3 consecutive assessments, contact provider. Additionally, the CIWA assessments were to be completed every hour for three hours as ordered by the provider.

iii. On 10/29/24 Patient #5 was admitted to the facility and CIWA protocol was ordered by the provider. On 10/29/24 at 3:21 p.m., a CIWA assessment was completed and the score was 10. The next CIWA assessment was not completed until 6:58 p.m., over three hours later.

On 10/30/24 at 9:57 a.m., a CIWA assessment was completed and the score was 20. The next CIWA assessment was not completed until 3:40 p.m., over five and a half hours later.

This was in contrast to the CIWA order set which read, if the score was greater or equal to 8, reassessments should occur every hour for three hours.

Similar findings of the CIWA protocol not being followed were identified in Patient #4 and Patient #8's records.

B. A review of the facility's alcohol withdrawal order set and the alcohol withdrawal assessment scoring guidelines revealed contradictions.

i. The Alcohol Withdrawal Assessment Scoring Guidelines read, the assessment included an initial vitals and CIWA assessment. If the initial score was greater than or equal to 8, repeat every hour for eight hours. Then, if stable, repeat every two hours for eight hours then if stable, every four hours. If the initial score was less than 8, assess every four hours for 72 hours. If the score was less than 8 for 72 hours, discontinue the assessment. If the score was greater than or equal to 8 at any time, repeat every hour for eight hours. Then, if stable, repeat every two hours for eight hours, then if stable, every four hours.

ii. The facility's Alcohol Withdrawal Treatment Order set (CIWA order set) read, CIWA Assessment - initiate assessments every six hours x 48 hours then per routine or if patient displays signs of withdrawal: If CIWA was 8 or greater - assess every one hour, then If CIWA was less than 8 x 3 consecutive assessments; assess every three hours x 3, then every six hours x 3, then per routine. If CIWA was 15 or greater for 3 consecutive assessments, contact the provider.

The facility's order set was inconsistent and less stringent with the time frames and frequencies required from the CIWA Scoring Guidelines for when a patient should have been reassessed.

C. Interviews

i. On 11/4/24 at 2:30 p.m. an interview was conducted with registered nurse (RN) #1. RN #1 stated if a patient had orders for CIWA, a CIWA assessment was to be completed at the beginning of the shift and then every one to two hours. RN #1 further explained if the patient's CIWA score was 0-2 for some assessments, the CIWA scoring only needed to be done once a shift. RN #1 explained when a patient was on CIWA assessments, the provider would place an order for this assessment.

ii. On 11/6/24 at 1:25 p.m., an interview was conducted with RN #2. RN #2 stated a provider placed orders for CIWA protocols when they determined a patient needed these assessments. RN #2 stated they were unaware of a CIWA policy at the facility. Additionally, RN #2 stated they had not received any CIWA training at the facility. RN #2 explained it was important for patients with alcohol withdrawal to be assessed and treated since alcohol withdrawal could lead to additional concerns such as falls and seizures.

iii. On 11/6/24 at 2:11 p.m., an interview was conducted with RN #3. RN #3 stated they had worked on the neuro-trauma unit at the facility for about one year. RN #3 stated they had received training on CIWA when they were orienting with a preceptor. RN #3 stated when a patient was on CIWA, the protocol was ordered by the provider. RN #3 stated it was important for the CIWA protocol to be followed in order to track if a patient was exhibiting worsening withdrawal and potentially administer medications as ordered.