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Based on interview and record review, the facility failed to document a post-fall evaluation (physical assessment) performed by a physician after one of thirty sampled patients (Patient 30) fell following a colonoscopy (a procedure to look inside the colon and rectum using a flexible tube) in the Gastroenterology Department (deals with patients with digestive issues such as changes to bowel habits, etc.).

This deficient practice resulted in no documentation of Patient 30 ' s evaluation and condition upon discharge by the physician.

Findings:

During a review of Patient 30 ' s "Pre-procedure Short Note," dated 6/12/23, the Pre-procedure Short Note indicated Patient 30 was admitted to the Gastroenterology (deals with patients with digestive issues such as changes to bowel habits, etc.) Department for a colonoscopy (a procedure to look inside the colon and rectum using a flexible tube). Patient 30 had a history of adenomatous colonic polyps (gland-like growths that develop on the mucous membranes that lines the large intestine). Vital signs: Blood Pressure (BP) was 126/49 (Normal is less than 120/80), Pulse was 68 (Normal is 60-100 beats per minute), Temperature 97.5 degrees Fahrenheit (F) (Normal range is from 97 to 98.6 degrees Fahrenheit), Respiratory rate was 19 (Normal range is 12 to 20 breaths per minute), oxygen saturation (measures how much oxygen is carried in the blood) was 100 percent (%).

During an interview on 6/21/23 at 8:09 a.m., with the Department Administrator for the Outpatient Gastroenterology Department (DAOGD), the DAOGD stated the following: Patient 30 presented for an outpatient colonoscopy on 6/12/2023 to be performed by Physician 1. Patient 30 received procedural sedation (medical technique to calm a person before a procedure using a sedative and pain pills) with Versed (midazolam, a sedative) and Fentanyl (a narcotic used to treat pain). The colonoscopy was performed at 3:15 p.m., and Patient 30 returned to the recovery area (a room where patients are placed after they had an operation under anesthesia [medicine to prevent pain during surgery and other procedures], so that they can be monitored while they recover) at 4:17 p.m.

The DAOGD further said that Patient 30 met the discharge criteria (PASS score [Procedure & Anesthesia Scoring System - an assessment aid indicating the level of recovery and sedation] of over 13 and stable vital signs [heart rate, blood pressure, respiratory rate within normal]). Patient 30 ' s blood pressure was 125/49. The DAOGD stated Patient 30 fell after the procedure (colonoscopy) and was evaluated by Physician 2. Patient 30 was discharged at 5:17 p.m. The DAOGD verified there was no documentation by Physician 2 regarding the fall (an unplanned descent to the floor or the ground with or without injury) and the post-fall evaluation.

During an interview on 6/21/23 at 9:17 a.m., with Registered Nurse (RN) 4, RN 4 stated that Patient 30 arrived at the facility for a colonoscopy on 6/12/23. After completion of the colonoscopy, and Patient 30 met the discharge criteria, he (RN 4) offered Patient 30 assistance to get dressed. However, Patient 30 declined. RN 4 sat Patient 30 in the chair and placed Patient 30 ' s clothes on the bed within Patient 30 ' s reach. RN 4 gave Patient 30 privacy and stepped out of the bay and closed the privacy curtain.

RN 4 also said he (RN 4) heard a noise, RN 4 found Patient 30 on the floor lying on his (Patient 30) right side. Patient 30 was assisted back to the chair. Patient 30 had no obvious injury and denied dizziness. Patient 30 indicated he (Patient 30) hit the back of his head. RN 4 paged Physician 1, but there was no response. RN 4 called Physician 2, who responded and personally assessed Patient 30 at 5:02 p.m. and cleared Patient 30 for discharge. Patient 30 was given post-fall instructions and discharged home at 5:17 p.m.

During a second interview on 6/23/23 at 12:15 p.m., the DAOGD stated Physician 2 evaluated Patient 30 after the fall, on 6/12/23 at 5:02 p.m. However, Physician 2 did not document the evaluation in the patient ' s (Patient 30) medical record. The DAOGD stated the evaluation should have been documented.

During an interview on 6/23/23 at 12:29 p.m., the Chief of Gastroenterology (C. Physician) stated Physician 2 assessed Patient 30 after the fall. C. Physician said, in Patient 30 ' s case who sustained a fall post-procedure, it was expected for the physician (Physician 2) to document the evaluation in the patient ' s (Patient 30) medical record.

During a review of Patient 30 ' s "Colonoscopy Report," dated 6/12/23 at 3:15 p.m., the Colonoscopy Report indicated Patient 30 had a colonoscopy and biopsy (removal of a piece of tissue for laboratory testing). Patient 30 also received Versed IV (in the vein): 2 MG (milligrams), and Fentanyl IV: 50 MCG (micrograms).

During a review of a physician ' s order for Patient 30, dated 6/12/23 at 3:45 p.m., documented by Physician 1, the physician ' s order indicated to discharge Patient 30 home when discharge criteria was met (PASS score over 13 and stable vital signs).

During a review of a Gastroenterology nurse ' s note, dated 6/12/23 at 4:48 p.m., the Gastroenterology nurse ' s note, documented by RN 4, indicated "Patient (Patient 30) sitting on chair by bedside. As patient was changing, patient (Patient 30) states he got up to put pants on and fell back. Patient hit head on wheelchair stirrup. No visible hematoma (pool of blood that forms on tissue) or laceration (cut or tear in the skin). Upon reassessment patient stated he has 0/10 pain (no pain) on head, denies dizziness. MD (Physician 1) paged." The Gastroenterology note further indicated that at 5:02 p.m., Physician 2 evaluated patient ' s (Patient 30) head and noted no break in the skin. Patient (Patient 30) was informed that if he experienced any issues after getting discharged, he (Patient 30) had to go to the Emergency Department (ED-where patients receive immediate medical care).

During a review of a Gastroenterology nurse ' s note, dated 6/12/23 at 5:17 p.m., the Gastroenterology nurse ' s note, documented by RN 10, indicated "patient (Patient 30) met discharge criteria: Patient vital signs stable. Awake, alert, and coherent. PASS (Procedure & Anesthesia Scoring System, an assessment aid indicating the level of recovery and sedation) score of 13 and above are met for post-sedation requirement ...Instructed the patient and niece regarding the signs and symptoms that could indicate post-procedure complications. Additionally, informed niece as of patient ' s fall. Patient (30) and niece instructed that if patient experiences any headache, dizziness, nausea or vomiting to go directly to the Emergency Department or call 911. Patient (30) and niece verbalized understanding."

During a review of the facility ' s "Rules and Regulations of the Professional Staff of the Hospital," dated 2021," the document indicated, in Section III. Record of Operations and High-Risk Procedures: "The medical record contains post-procedure information: Patient vital signs and level of consciousness; any medications administered, including IV fluids and administration of blood, blood products and blood components; and any unanticipated events or complications related to the surgery of procedure."

Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Patient's Rights was met as evidenced by:

1. A copy of the facility's condition of admission (COA - a document that include provisions under which the patient provides informed consent [a process in which patients are given important information, including possible risks and benefits] for treatment and may also require the patient's confirmation of understanding on various arrangements related to the treatment the patient will receive in the facility) and the Important Message from Medicare (IMM - a notice given to the patient with Medicare benefits indicating the patient's rights to a hospital discharge appeal) information was provided for one of 30 sampled patients (Patient 5) in a language that Patient 5 understood.

This deficiency resulted in Patient 5 to not be informed of her (Patient 5) rights as a patient, which may also result in Patient 5's inability to effectively make decision regarding her care or treatment. (Refer to A-0117)

2. A Respiratory Therapist (RT - they care for patients who have trouble breathing) promptly responded within five minutes to a rapid response call (a call made to summon a team of providers at the bedside of a patient to immediately assess and treat the patient for two of three sampled patients (Patients 1 and 14) when Patients 1 and 14, who were admitted in the Medical-Surgical/Telemetry unit (a unit in the hospital where patients undergo continuous cardiac [heart rhythm] monitoring), needed a Rapid Response Team (RRT - a group of clinicians who will bring critical care expertise to the declining patient, the team consist of a Registered Nurse (RN) and RT) due to a change of medical condition, in accordance with the facility's policy and procedure regarding rapid response to a change in patient condition.

This deficient practice had the potential to cause a delay of emergent treatment and care for Patients 1 and 14 which may have led to the patients' worsening breathing medical condition. (Refer to A-0144)

3. An emergency preparedness training was provided upon hire (within 30 days) for one of five sampled staff members (Chief Nurse Executive [CNE]) in accordance with the facility's policies and procedures regarding new employee orientation/training. This deficient practice had the potential for staff not being aware of emergency procedures in the event of an earthquake or fire, and potentially compromising patient safety. (Refer to A-0144)

4. Abuse (intentional maltreatment of an individual that may cause physical or psychological injury) training was provided for three of five sampled staff members (Registered Nurse (RN) 2, RN 4, and the Chief Nurse Executive [CNE]), in accordance with the facility's policies and procedures regarding abuse training.

This deficient practice had the potential for staff not to be informed of abuse, neglect, related reporting requirements, including prevention, intervention, and detection, which could potentially compromise patient safety. (Refer to A-0145)

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

Based on observation, interview, and record review, the facility failed to ensure a copy of the facility ' s condition of admission (COA - a document that include provisions under which the patient provides informed consent [a process in which patients are given important information, including possible risks and benefits] for treatment and may also require the patient ' s confirmation of understanding on various arrangements related to the treatment the patient will receive in the facility) and the Important Message from Medicare (IMM - a notice given to the patient with Medicare benefits indicating the patient ' s rights to a hospital discharge appeal) information was provided for one of 30 sampled patients (Patient 5) in a language that Patient 5 understood.

This deficiency resulted in Patient 5 to not be informed of her (Patient 5) rights as a patient, which may also result in Patient 5 ' s inability to effectively make decisions regarding her care or treatment.

Findings:

During a concurrent observation and interview on 6/20/23 at 12:25 p.m., with Nurse Manager (NM) 1, Patient 5 ' s room was observed to have a LEP sign magnet by the door. NM 1 stated LEP stands for Limited English Proficient (defined by the Office of Civil Rights as anyone who cannot speak, read, or understand the English language at a level that permits the person to interact effectively with healthcare providers).

Patient 5 was also observed in bed, awake, alert, and with oxygen of 5 liters (L) via nasal cannula (a device used to deliver supplemental oxygen to the patient). When Patient 5 was asked a question, the patient answered in Vietnamese language. NM 1 stated Patient 5 spoke Vietnamese, then NM 1 proceeded to get the Video Remote Interpreter service (used to facilitate spoken or signed language communication between users of different language).

During a review of Patient 5's record, the admission form dated 6/14/23, indicated Patient 5 ' s spoken language was Vietnamese.

During a review of Patient 5's record titled, "Admission History and Physical by Medicine Consult," dated 6/14/23, the Admission History and Physical by Medicine Consult record indicated, Patient 5 was admitted to the facility on 6/14/23, with a chief complaint of respiratory failure (a condition that makes it difficult for a patient to breathe on his own).

During a review of the document titled, "Hospital Conditions of Admission (COA - a document that include provisions under which the patient provides informed consent for treatment and may also require the patient ' s confirmation of understanding on various arrangements related to the treatment the patient will receive in the facility)," the document indicated, " ...I as the patient or legal agent of the patient, hereby certify that I have read and understood this agreement, and accept and agree to abide by its terms and conditions ..." was signed by Patient 5 on 6/14/23. There was no documented evidence a language interpreter service was provided when Patient 5 signed the COA. The lack of documented evidence regarding the use of language interpreter service was verified by the Director of Risk Management and Patient Safety (DRMPS).

During a review of the document titled, "Important Message from Medicare (IMM - a notice given to the patient with Medicare benefits indicating the patient ' s rights to a hospital discharge appeal)," the document indicated, " ...I have been notified of my right as a hospital inpatient and that I may appeal my discharge ..." was signed by Patient 5 on 6/14/23. There was no documented evidence a language interpreter service was provided when Patient 5 signed the IMM. The lack of documented evidence regarding the use of language interpreter service was verified by the Director of Risk Management and Patient Safety (DRMPS).

During an interview on 6/22/23 at 12:20 p.m., with the Director of Risk Management and Patient Safety (DRMPS), the DRMPS verified language interpreter services were not provided when Patient 5 was given the information and signed the COA and IMM.

The DRMPS further stated language interpreter services should have been used to ensure Patient 5 was informed of her rights while being admitted in the facility.

During an interview on 6/22/23 at 12:20 p.m., with the Admitting Supervisor (AS), the AS stated when a patient being admitted at the facility was identified as LEP, a language interpreter services should be provided when the COA and IMM information would be given to the patient.

The AS also said it was important to provide the patients with information regarding the COA and IMM in a language the patients understood so they (referring to the patients) would understand the information being relayed, ask questions, and discuss concerns before signing the forms (COA and IMM).

During a review of the facility's policy and procedure (P&P) titled, "Identification and Documentation of Limited English Proficient (LEP) Patients and Clinical Encounters," revised in 7/2021, the P&P indicated, " ...Admitting Responsibilities: At the point of contact, the Admitting staff will ask the patient about their spoken/written language of preference ...If it is determined that the patient is LEP and the staff is not a qualified interpreter for the patient's language, the staff must use the interpreter services ...Important - language interpretation services will be needed during the discussion of the Conditions of Admission with the patient ..."

Based on interview and record review, the facility failed to ensure that a safe environment was provided to patient during care when:

1. A Respiratory Therapist (RT - they care for patients who have trouble breathing) did not promptly respond within 5 minutes to a rapid response call for two of three sampled patients (Patients 1 and 14) when Patients 1 and 14 needed a Rapid Response Team (RRT - a group of clinicians who will bring critical care expertise to the declining patient, the team consist of a Registered Nurse (RN) and RT) due to a change of medical condition. This deficient practice had the potential to cause a delay of emergent treatment for Patients 1 and 14 which may have led to the patients' worsening of medical condition.

2. An emergency preparedness training was not provided upon hire (within 30 days) for one of five sampled staff members (Chief Nurse Executive [CNE]) in accordance with the facility's policies and procedures. This deficient practice had the potential for staff not being aware of emergency procedures in the event of an earthquake or fire, and potentially compromising patient safety.

Findings:

1a. During a concurrent interview and record review on 6/22/23 at 2:51 p.m., with the Department Administrator of Respiratory Care Services (DARCS), Patient 1's record was reviewed. The record titled, "Internal Medicine History and Physical," indicated Patient 1 was admitted to the facility's telemetry unit (a unit in the hospital where patients undergo continuous cardiac [heart rhythm] monitoring) on 5/14/23, with a chief complaint of arm redness and swelling.

During a review of Patient 1's record titled, "Multi-Discipline Progress Note," dated 5/25/23, authored by RN 1, the Multi-Discipline Progress Note indicated, " ...Pt (Patient 1) was taken to the bathroom with sara steady (a non-powered device that is used on patients for sit-to-stand transfers). Pt was trying to have BM (bowel movement) and became lethargic (a condition marked by drowsiness, and an unusual lack of energy and mental alertness) ...RRT (Rapid Response Team - a group of clinicians who will bring critical care expertise to the declining patient, the team consist of a Registered Nurse [RN] and Respiratory Therapist [RT]) was alerted. Patient (Patient 1) was transferred to SDU (step down unit - provides an intermediate level of care between the Intensive Care Unit and the general Medical/Surgical Unit) ..."

During a review of Patient 1's record titled, "Rapid Response Team Record & (and) Survey Tool," dated 5/25/23, the record indicated that the following criteria were selected for calling the RRT:

-Acute (severe and sudden in onset) and persistent change in oxygen saturation (measures how much oxygen is carried in the blood) of less than 90%;

-Acute change in systolic blood pressure (is the first number in blood pressure [BP], below 90 is considered low and may require intervention from healthcare provider) to less than 90; and,

-Unexplained lethargy/difficult to arouse.

During a review of Patient 1's RRT (Rapid Response Team) record, dated 5/25/23, the RRT record indicated RRT was called at 12:01 p.m., then RRT arrived at 12:07 p.m., and the Patient 1 was transferred to SDU for a higher level of care (patients requiring more intense care and monitoring) at 12:11 p.m. The responding RRT members were the primary RN (RN 1) and the RRT RN (RN 5). There was no documented evidence a Respiratory Therapist (RT) responded. The absence of documented evidence on Patient 1 ' s record was confirmed by the DARCS.

During a review of Patient 1's record titled, "Death Note," the record indicated Patient 1's date of death was 5/26/23, the Death Note also indicated " ...Pt (Patient 1) continued to deteriorate (to worsen) and pt (patient 1) remained hypotensive (low blood pressure [BP]) despite maximal doses of 3 vasopressors (medications used to raised BP). Pt's (Patient 1) family is in agreement and focus of care was transitioned to comfort (reducing the intensity of medical care because the burden is outweighing the benefits) ...Pt developed asystole (flat line, absence of electricity or movement in the heart) and was pronounced dead at 11:50 a.m."

During an interview on 6/22/23 at 2:51 p.m. with the Department Administrator of Respiratory Care Services (DARCS), DARCS stated the Respiratory Therapist (RT) was part of the Rapid Response Team (RRT) and should have responded within 5 minutes when RRT was called for the patient (Patient 1). The DARCS stated the Respiratory Therapist in the RRT would assess and intervene with the patient's (Patient 1) respiratory needs. The DARCS said it was the responsibility of the lead RT to respond or to send a RT to the unit where the RRT was needed. The DARCS also stated the RT who responds to the rapid response call should document his/her participation in the RRT log.

The DARCS stated there was no documentation from a Respiratory Therapist who responded when a RRT was called for Patient 1 on 5/25/23.

During an interview on 6/22/23 at 9:51 a.m., with Respiratory Therapist (RT) 2, RT 2 stated she (RT 2) was the lead RT when a Rapid Response Team (RRT) was needed for Patient 1 on 5/25/23 in the Medical-Surgical unit.

RT 2 said she (RT 2) was busy in the Emergency Department when a RRT was called on 5/25/23, and she (RT 2) informed the RT Department to ask RT 1 to respond to the RRT call for Patient 1.

During an interview on 6/21/23 at 4 p.m., with Respiratory Therapist (RT) 1, RT 1 stated she (RT 1) did not respond to RRT call for Patient 1, in the telemetry unit, on 5/25/23, when the RRT call was overhead paged by the operator. RT 1 stated she took care of Patient 1 when the patient (Patient 1) was already transferred to SDU.

During a review of the facility's policy and procedure (P&P) titled, "Rapid Response to Change in Patient's Condition," revised in 5/2020, the P&P indicated, " ...Provide a proactive approach to improve patient stability, provide additional resource education/support, reduce incidence of Code Blues (a hospital emergency code used to described the critical status of the patient) outside of Critical Care Unit (CCU), reduce unplanned transfers to CCU, and decrease mortalities through early evaluation and management of adult patients that maybe or are deteriorating or exhibiting physiologic changes in their condition ...The RRT will consist of ...trained Registered Nurse ...trained Respiratory Therapist ...and the Primary RN caring for the patient ...Respiratory Therapy Responsibilities:

1. Respond when called within five minutes.

2. Perform a complete respiratory assessment and initiate call to physician in coordination with RRT RN.

3. Initiate orders received ..."

1b. During a review of Patient 14's record titled, "Internal Medicine History and Physical," dated 5/29/23, the Internal Medicine History and Physical record indicated Patient 14 was admitted to the facility on 5/29/23, with a chief complaint of dyspnea (difficulty of breathing).

During a review of Patient 14's record titled, "Multi-Discipline Progress Note," dated 5/30/23, authored by Registered Nurse (RN) 7, the record indicated, " ...Rapid response called at 1243 (12:43 p.m.). Patient ' s (Patient 14) HR (heart rate) sustaining in the high 170 ' s fluctuating to 190 ' s (normal HR is between 60 to 100 beats per minute) ...Patient (Patient 14) transferred to SDU (step down unit - provides an intermediate level of care between the Intensive Care Unit and the general Medical/Surgical Unit) ..."

During a review of Patient 14's record titled, "Rapid Response Team Record & (and) Survey Tool," dated 5/30/23, the record indicated the criteria selected for calling the RRT (Rapid Response Team - a group of clinicians who will bring critical care expertise to the declining patient, the team consist of a Registered Nurse (RN) and a Respiratory Therapist [RT]) was an acute (sudden and severe onset) change in heart rate less than 40 or greater than 130 beats per minute.

During a review of Patient 14's RRT (Rapid Response Team) record, dated 5/30/23, the Rapid Response Team record indicated Patient 1 was transferred to SDU for a higher level of care (patients requiring more intense care and monitoring), and the responding RRT members were the primary RN (RN 7) and the RRT RN (RN 5). There was no documented evidence a RT responded. This absence of documented evidence was confirmed by the Department Administrator of Respiratory Services (DARCS).

During an interview on 6/23/23 at 11:37 a.m., with the DARCS, the DARCS stated the RT was part of the RRT (Rapid Response Team) and should have respond when a rapid response was called for a patient. The DARCS said it was the responsibility of the lead RT to respond or to send a RT to the unit where a RRT was needed. The DARCS stated the RT who responds to the rapid response call should document his/her participation in the RRT log.

The DARCS stated there was no documentation a Respiratory Therapist responded when a RRT was called for Patient 14 on 5/30/23.

During a review of the facility's policy and procedure (P&P) titled, "Rapid Response to Change in Patient ' s Condition," revised in 5/2020, the P&P indicated, " ...Provide a proactive approach to improve patient stability, provide additional resource education/support, reduce incidence of Code Blues (a hospital emergency code used to described the critical status of the patient) outside of Critical Care Unit (CCU), reduce unplanned transfers to CCU, and decrease mortalities through early evaluation and management of adult patients that maybe or are deteriorating or exhibiting physiologic changes in their condition ...The RRT will consist of ...trained Registered Nurse ...trained Respiratory Therapist ...and the Primary RN caring for the patient ...Respiratory Therapy Responsibilities:

1. Respond when called within five minutes.

2. Perform a complete respiratory assessment and initiate call to physician in coordination with RRT RN.

3. Initiate orders received ..."

2. During a concurrent interview and record review on 6/23/23 beginning at 9:41 a.m., with the Director of Human Resources (DHR), the facility ' s staff personnel files were reviewed. The staff personnel file for the Chief Nurse Executive (CNE) indicated that the CNE ' s Emergency Management Training was completed on 10/20/22. The CNE's personnel file also indicated that she (CNE) was hired on 2/14/22.

The DHR stated that the Emergency Management Training was a part of the New Employee Orientation (NEO) program and was provided upon hire (within 30 days) and annually. The DHR said it was mandatory that the Emergency Management Training was completed within 30 days of hire. The DHR verified that the CNE completed the Emergency Management Training on 10/20/22, six months after she (CNE) was hired.

The DHR also stated that the Emergency Management Training consist of workplace safety, emergency codes, fire prevention, etc.

During a review of the facility's policy and procedure (P&P) titled, "Medical Center New Employee Orientation," dated 8/2021, the P&P indicated "it is mandatory that all new employees attend all appropriate phases of the New Employee Orientation (NEO) Program... For all new employees ... Employees transferring from outside the service area must complete the NEO within 30 days of transfer."

The P&P also indicated that the content of the orientation program shall include, but not limited to ...Regulatory and workplace safety, included SAFE (Safety Assessment/Facility Evacuation), workplace safety, security, emergency codes, fire prevention, risk management, infection prevention and control."

Based on interview and record review, the facility failed to provide Abuse (intentional maltreatment of an individual that may cause physical or psychological injury) Training for three of five sampled staff members (Registered Nurse (RN) 2, RN 4, and the Chief Nurse Executive [CNE]), in accordance with the facility's policies and procedures regarding abuse training.

This deficient practice had the potential for staff not to be informed of abuse, neglect, related reporting requirements, including prevention, intervention, and detection, which could potentially compromise patient safety.

Findings:

During a concurrent interview and record review on 6/23/23 beginning at 9:41 a.m., with the Director of Human Resources (DHR), the staff personnel files were reviewed. The DHR stated that Abuse training was provided to staff upon hire and every two years. The DHR verified that RN 2, RN 4, and the CNE had not completed the Abuse training, per the facility's policy and procedure. The files indicated the following:

Registered Nurse (RN) 2 was hired on 1/18/16. RN 2's last Abuse training was completed on 5/26/21.

Registered Nurse (RN) 4 was hired on 5/7/18. RN 4's last Abuse training was completed on 3/25/21.

The Chief Nurse Executive (CNE) was hired on 2/14/22. The Abuse training was completed six months after the hire date, on 10/20/22.

During a review of personnel files, on 6/23/2023 beginning at 10:45 am, the Staff Educator (SEDU) stated abuse training was provided upon hire (within 30 days) and every two years.

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights: Protection from Abuse, Exploitation, Neglect, & Harassment," dated 5/24/23, the P&P indicated the following: "Train: All employees receive abuse training upon hire and ongoing education at least every two years. The training/education provides all employees with information regarding abuse and neglect, and related reporting requirements, including prevention, intervention, and detection."

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

1. Five of 30 sampled patients (Patients 1, 3, 6, 8, and 17) were assessed and reassessed accordingly and provided appropriate nursing care. This deficient practice had the potential to result in delay of patient treatment. (Refer to A-0395)

2. A comprehensive care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) regarding diabetes (high blood sugar level) management and airway clearance (techniques to loosen secretions in the lungs and improve patient breathing) was developed upon admission for three of 30 sampled patients (Patients 2, 7, and 19). This deficient practice had the potential to result in the delay of treatment by not identifying the patients ' needs and risks. (Refer to A-0396)

3. One of five staff (Chief Nurse Executive [CNE]) received new hire orientation within thirty (30) days of hire, in accordance with the facility's policy and procedure regarding new employee orientation. This deficient practice had the potential for the CNE not to be oriented to her assigned location, duties, and responsibilities in the operation of the nursing service, which may compromise the quality of the nursing care provided by the facility's nursing service. (Refer to A-0397)

4. Three of 30 sampled patients' (Patients 5, 6, and 14) cardiac rhythm strips (records the electrical activity of the heart) were printed, recorded, and interpreted in accordance with the facility's policy and procedure regarding cardiac monitoring (records the heart rate and heart rhythm). This deficient practice had the potential to delay provision of care and treatment for Patients 5, 6, and 14, which may lead to complications affecting the patients' heart and lungs, and deterioration of the patients' condition. (Refer to A-0398).

5. One of 30 sampled patients (Patient 28) was assessed every sixty minutes (60) in the Emergency Department (where patients receive immediate medical care), in accordance with the facility's policy and procedure regarding Emergency Department patient assessment (process to identify and treat life-threatening problems) and re-assessment. This deficient practice had the potential for changes in Patient 28's condition to go undetected and untreated. (Refer to A-0398)

6. Oxygen treatment was administered as ordered by the physician for one of 30 sampled patients (Patient 1). This deficient practice had the potential to cause adverse health outcomes which could negatively affect the patient's health and safety due to unsafe administration of supplemental oxygen which may have led to Patient 1's deterioration of medical condition and death. (Refer to A-405)

7. Medications (Morphine - narcotic pain medication, insulin - medication used for treatment of diabetes, nitroglycerin - medication used for treatment of hypertension) were administered as ordered by the physician for three of 30 sampled patients (Patients 3, 7, and 11). This deficient practice had resulted in Patients 3, 7, and 11's delay of treatment and had the potential to cause adverse health outcomes which could negatively affect the patient's health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death; (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 ensure appropriate nursing care was provided for five of 30 sampled patients (Patients 1, 3, 6, 8, and 17) when:

1. Patient 1's mobility status (determining how much a patient can move) was not reassessed prior to transferring the patient to the bathroom using the sit to stand lift (a-non powered device that is used on patients for sit to stand transfers). This deficient practice had the potential to compromise treatment, handling and transfer decisions, including the risk of falls (an unplanned descent to the floor or the ground with or without injury), and the deterioration (to worsen) of the patient's condition.

2. Patient 3's pain assessment (process to identify and treat life-threatening problems) and reassessment were not conducted before and after pain medication was given to the patient (Patient 3). This deficient practice had the potential to result in delay of patient treatment and uncontrolled pain for Patient 3.

3. Patient 6's severe pain (pain score assessment of 10 [10 being the highest] in the pain scale) was not addressed when Patient 6 was not administered pain medication (Percocet -narcotic pain medication) for severe pain. In addition, there was no documented evidence pain assessment and reassessment were conducted before and after pain medication was given to the patient. This deficient practice had the potential to result in delay of patient treatment and uncontrolled pain for Patient 6;

4. Patient 8's neuro check (neurological exam- a physical examination to identify signs of disorders affecting the brain, spinal cord, and nerves) was not conducted every four hours as ordered by the physician. This deficient practice had the potential to delay treatment and necessary adjustments in Patient 8's treatment plan.

5. Patient 17's vital signs (blood pressure, heart rate, respiratory rate, and temperature) were not monitored and documented every four (4) hours for a Telemetry (cardiac [heart] monitoring) patient. This deficient practice had the potential for the patient ' s needs not being addressed in the event of a change of condition.

Findings:

During a concurrent interview and record review on 6/21/23 at 8:30 a.m., with Nurse Manager (NM) 2, Patient 1's record titled, "Internal Medicine History and Physical," was reviewed. The record indicated Patient 1 was admitted to the facility on 5/14/23, with a chief complaint of arm redness and swelling.

Patient 1 had a past medical history of multiple heart conditions, status post CABG (coronary artery bypass surgery - a medical procedure to improve blood flow to the heart) and AICD (Automatic Implantable Cardioverter Defibrillator - a small electronic device that is implanted on the chest to monitor and correct an abnormal heart rhythm), COPD (chronic obstructive pulmonary disease - lung disease that block the airflow and make it difficult for a person to breathe), and chronic respiratory failure (a condition that makes it difficult for a patient to breathe on his own).

Patient 1 continuously used 2L (liter) of oxygen via nasal cannula (a device used to deliver supplemental oxygen) at home and Patient 1 was on hemodialysis (HD - a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) four times a week.

During a review of Patient 1's record titled, "Internal Medicine Progress Note," dated 5/22/23, the Internal Medicine Progress Note indicated, " ...Hospitalization summary:

5/21: "feeling well. Attempted discharge (to home) but was unable to place pt (Patient 1) in car due to weakness. Discharge cancelled."

5/22: "Only able to tolerate edge of bed with PT (Physical Therapy - a medical treatment used to restore functional movements such as standing, walking, and moving different parts of the body). Given severe deconditioning (changes that occur in the body during a period of inactivity) and PT (physical therapy) needs that cannot be met at home, agreeable to dc (discharge) to SNF (skilled nursing facility) ...Problem List ...Deconditioning ...Patient with poor functional baseline (ability to perform basic activities of daily living like toilet use, etc.), as family describes patient at home often just parks in recliner chair and rarely gets up ...Patient states she feels scared to exert herself as she gets anxious and panics when she feels SOB (short of breath) ..."

During a review of Patient 1's "Physical Therapy Inpatient Initial Assessment," dated 5/22/23, authored by Physical Therapist (PT) 1, the Physical Therapy Inpatient Initial Assessment record indicated, "Functional Assessment ...Sit -Stand: Maximum Assist (attempted 2x but patient was unable) ...Balance ...Standing balance ...unable at this time ..."

During a review of Patient 1's "Inpatient Physical Therapy Daily Progress Note," dated 5/23/23, authored by Physical Therapist (PT) 1, the Inpatient Therapy Daily Progress Note record indicated, "Bed Mobility/Transfers ...Sit - Stand: Required Two Person Assistance; Maximum Assist ...Balance ...Sitting balance ...impaired F (fair) ...Standing balance ...impaired P (poor) ...Endurance (ability to do any kind of physical activity): impaired P (poor) ...Assessment ...the patient (Patient 1) is slowly progressing with PT (physical therapy). Her (Patient 1) activity tolerance improved but her ability to ambulate was limited due to her bilateral LE (lower extremities) weakness. She needs to continue working on her bed mobility and gait (walking) endurance ..."

Patient 1 was not seen by a physical therapist (PT) on 5/24/23 and 5/25/23 because Patient 1 was on (Hemodialysis) HD.

During a review of Patient 1's record titled, "Flowsheets," the Flowsheets record indicated the following:

- on 5/25/23, at 8:10 a.m., assessed by Registered Nurse (RN) 3, Patient 1 ' s current level of function was " ...Level II - able to sit (levels of functions: Level I - bed bound; Level II - able to sit; Level III - can stand; Level IV - Walks less than 50 feet; Level V - Walks more than 50 feet) ..." and,

- from 5/23/23 at 8:34 a.m., to 5/25/23 at 8:10 a.m., Patient 1 ' s level of function assessment was between Level I (bed bound) and Level II (able to sit).

There was no documented evidence Patient 1's level of functioning was assessed after 5/25/23 at 8:10 a.m. This absence of documented evidence was confirmed by Nurse Manager (NM) 2.

During a review of Patient 1's record titled, "Multi-Discipline Progress Note," dated 5/25/23, at 12:15 p.m., authored by RN 1, the Multi-Discipline Progress Note indicated, " ...Pt (Patient 1) was taken to the bathroom using a sit to stand lift (a-non powered device that is used on patients for sit to stand transfers). Pt (Patient 1) was trying to have BM (bowel movement) and became lethargic (a condition marked by drowsiness, and an unusual lack of energy and mental alertness) ...RRT (Rapid Response Team - a group of clinicians who will bring critical care expertise to the declining patient) was alerted. Patient (Patient 1) was transferred to SDU (step down unit - provides an intermediate level of care between the Intensive Care Unit and the general Medical/Surgical Unit) ..."

During a review of Patient 1's record titled, "Progress Notes," dated 5/25/23, the Progress Notes indicated, " ...Hospitalization Summary ...5/25 Pt (Patient 1) had walked to bathroom with a walker (Sara Steady) ...Pt became lethargic afterwards. Pt desaturated (low blood oxygen level) ...RRT was called. Pt was transferred to SDU ...Pt was intubated (placing a breathing tube through the mouth and down the throat into the lungs) and transferred to ICU (Intensive Care Unit - specialized unit that provides intensive care to critically ill patients) ..."

During a review of Patient 1's record titled, "Death Note," the Death Note indicated Patient ' s (Patient 1) date of death was 5/26/23. The Death Note further indicated " ...Pt (Patient 1) continued to deteriorate and pt (Patient 1) remained hypotensive (low blood pressure [BP]) despite maximal doses of 3 vasopressors (medications used to raised BP). Pt ' s (Patient 1) family is in agreement and focus of care was transitioned to comfort (reducing the intensity of medical care because the burden is outweighing the benefits ...Pt developed asystole (flat line, absence of electricity or movement in the heart) and was pronounced dead at 11:50 a.m."

During an interview on 6/21/23 at 10 a.m., with Physical Therapist (PT) 1, PT 1 stated he was the Physical Therapist (PT) who completed Patient 1's physical therapy evaluation on 5/22/23 and Patient 1's physical therapy follow-up visit on 5/23/23.

PT 1 said on 5/22/23, Patient 1 had a physical therapy consult ordered for weakness. PT 1 stated Patient 1 was not able to stand even with maximum assist (when one or more people assist patient to perform an activity safely) at that time due to weakness. PT 1 stated he (PT 1) communicated Patient 1's physical therapy (PT) evaluation to the RN (RN 3).

PT 1 stated he made a follow-up physical therapy visit to Patient 1 on 5/23/23. PT 1 stated Patient 1 was able to stand and walk side to side with maximum assistance. PT 1 stated Patient 1 was still weak and just transitioning in getting her strength back.

PT 1 also said, at the time of Patient 1's physical therapy follow-up visit on 5/23/23, Patient 1 was not ready to safely use the sit to stand lift.

PT 1 stated when using the sit to stand lift, the patient needed to pull herself (Patient 1) up while holding on to the sit to stand lift, then balance and hold up her (Patient 1) own weight while in the sit to stand lift. PT 1 stated Patient 1 was not strong enough to do it. PT 1 stated he communicated Patient 1's physical therapy follow-up evaluation to the RN assigned to Patient 1 that day on 5/23/23.

PT 1 stated Patient 1 did not have follow-up physical therapy visit after 5/23/23.

During an interview on 6/22/23 at 8:42 a.m., with Registered Nurse (RN) 3, RN 3 stated she (RN 3) was one of the RNs assigned to Patient 1 on 5/25/23. RN 3 stated she (RN 3) conducted Patient 1's assessment on 5/25/23 at 8:10 a.m.

RN 3 said she documented Patient 1's level of function was a Level II because Patient 1 could only sit and not able to stand on 5/25/23.

RN 3 stated when Patient 1 was assisted to the bathroom, a reassessment for level of function should have been conducted and documented to ensure Patient 1 was able to stand to use the sit to stand lift.

During an interview on 6/21/23 at 10:54 a.m., with Registered Nurse (RN) 1, RN 1 stated she (RN 1) was one of the RNs who assisted Patient 1 to go to the bathroom using the sit to stand lift on 5/25/23 at 12:15 p.m.

RN 1 stated when a patient would be assisted out of bed, the patient's level of function assessment should be checked by the RN. RN 1 stated Patient 1's level of function prior to assisting the patient to the bathroom using the sit to stand lift was Level II (able to sit).

RN 1 further said Patient 1 should have been reassessed for level of function and the assessment should have been documented to ensure Patient 1 was able to stand to use the sit to stand lift to go to the bathroom.

During a review of the facility's policy and procedure (P&P) titled, "Patient Assessment and Reassessment," revised in 10/2021, the P&P indicated, " ...All discipline will participate in the assessment process to provide a comprehensive, collaborative approach to patient care ...Admission Assessment. Upon admission to the patient care unit, each patient will be assessed by an RN to determine any immediate needs ...Each patient's admission assessment includes consideration of the following factors ...Other Pertinent Physician and Psychosocial Status Data. Functional Needs ...The scope and intensity of any further assessments are determined by the patient ' s diagnosis, care setting, the care the patient is seeking ..."

2. During a concurrent interview and record review on 6/22/23 at 10:32 a.m., with the Director of Nursing (DON), Patient 3's record titled, "Internal Medicine History and Physical," was reviewed. The Internal Medicine History and Physical record indicated Patient 3 was admitted to the facility on 6/17/23, with a chief complaint of neck abscess (infection).

During a review of Patient 3's Medication Administration Record (MAR), the MAR indicated a physician ' s order of Morphine (narcotic pain medication) two milligram (2 mg) was to be given intravenous (IV - through the vein) every two hours as needed for moderate pain (4-6 [a pain score of 1-3 is mild pain; 4-6 is moderate pain; 7-10 is severe pain]). The physician's order was given on 6/18/23.

Further review of Patient 3's MAR and the corresponding Patient 3's pain assessment flow sheet indicated:

- Morphine 2 mg IV was given on 6/19/23 at 4:48 a.m., Patient 3's pain score reassessment was 0 at 6:24 a.m. (one hour and 45 minutes after pain medication was given);

- Morphine 2 mg IV was given on 6/19/23 at 12:09 p.m., 4:12 p.m., and 9:21 p.m., there was no documented evidence Patient 3's pain was reassessed after pain medication was given at 12:09 p.m., 4:12 p.m., and 9:21 p.m.;

- Morphine 2 mg IV was given on 6/20/23 at 2:29 a.m., Patient 3's pain score reassessment was 0 at 6:52 a.m. (four hours and 30 minutes after pain medication was given);

- Morphine 2 mg IV was given on 6/20/23 at 9:02 a.m., Patient 3's pain score reassessment was 0 at 12:15 p.m. (three hours after pain medication was given);

- Morphine 2 mg IV was given on 6/20/23 at 12:30 p.m., Patient 3's pain score reassessment was 0 at 2:13 p.m. (one hour and 30 minutes after pain medication was given);

- Morphine 2 mg IV was given on 6/20/23 at 7:50 p.m., and on 6/21/23 at 12:35 a.m., there was no documented evidence Patient 3's pain was assessed and reassessed before and after pain medication was administered on 6/20/23 at 7:50 p.m., and on 6/21/23 at 12:35 a.m.

The absence of documented evidence regarding pain assessment and reassessment on Patient 3's record was confirmed by the DON during an interview.

The DON stated Patient 3's pain should have been assessed prior to giving pain medication to ensure a correct pain intervention would be provided to control Patient 3's pain.

The DON also said Patient 3's pain should have been reassessed one hour after pain medication was given to ensure Patient 3 ' s pain was managed, or additional pain intervention would be needed to control the patient ' s pain.

During a review of the facility's policy and procedure (P&P) titled, "Pain Management," revised in 12/2020, the P&P indicated, " ...Pain assessment, planning, intervention, and evaluation will be adapted to patients of all ages and cognitive function ...Reassess pain within one hour of medication administration ...Documentation should be completed in real time ...The assessment of pain will be based on the patient ' s self-reporting ...The identification of pain initiates the intervention appropriate to the assessment, care setting and services provided. The intervention could include the following ...Medication ...The initial pain assessment, subsequent pain assessments, and patient response to pain interventions must be documented per ...policies ...in the ...pain flow sheet ...The medical record should clearly delineate the plan and rationale for pain treatment ..."

3. During a concurrent interview and record review on 6/22/23 at 1:37 p.m., with the Director of Nursing (DON), Patient 6's record titled, "Hospital Medicine Admission History and Physical," was reviewed. The Hospital Medicine Admission History and Physical record indicated Patient 6 was a transfer from another acute care facility and was admitted on 6/11/23, for severe sepsis (a life- threatening complication of an infection) from the left foot cellulitis (bacterial skin infection).

a. During a review of Patient 6's Medication Administration Record (MAR), the MAR indicated a physician's order of Percocet (narcotic pain medication) one tablet to be given by mouth every four hours as needed for moderate pain (4-6 [a pain score of 1-3 is mild pain; 4-6 is moderate pain; 7-10 is severe pain]). The physician's order was given on 6/11/23.

Further review of Patient 6's MAR and the corresponding Patient 6's pain assessment flow sheet indicated:

- Percocet one tablet was given on 6/13/23 at 2:52 p.m., Patient 6's pain score reassessment was 4 at 5:16 p.m. (two hours after pain medication was given);

- Percocet one tablet was given on 6/16/23 at 11:09 p.m., Patient 6's pain score reassessment was 3 at 3:18 a.m. (four hours after pain medication was given); and,

- Percocet one tablet was given on 6/20/23 at 6:16 a.m., there was no documented evidence Patient 6 ' s pain was assessed prior to pain medication administration on 6/20/23 at 6:16 a.m. The absence of documented evidence on Patient 6 ' s record was confirmed by the DON.

b. During a review of Patient 6's MAR, the MAR indicated a physician's order of Percocet two tablets to be given by mouth every four hours as needed for severe pain (7-10).

Further review of Patient 6's MAR and the corresponding Patient 6 ' s pain assessment flow sheet indicated:

- Percocet two tablets were given on 6/15/23 at 11:52 a.m., Patient 6's pain score reassessment was 2 at 1:43 p.m. (two hours after pain medication was given); and,

- Percocet two tablets were given on 6/17/23 at 11:09 p.m., Patient 6's pain score reassessment was 3 at 3:18 a.m. (four hours after pain medication was given).

c. During a review of Patient 6's pain assessment flow sheet, the pain assessment flow sheet indicated on 6/14/23 at 12:27 p.m., Patient 6's pain score assessment was 10 (severe pain). There was no documented evidence pain intervention was provided to help manage Patient 6's severe pain. The absence of documented evidence on Patient 6's record was confirmed by the DON.

The DON stated Patient 6's pain should have been assessed prior to giving pain medication to ensure a correct pain intervention would be provided to control Patient 6's pain.

The DON stated Patient 6's pain should have been reassessed one hour after pain medication was given to ensure Patient 6 ' s pain was managed, or additional pain intervention would be provided to control the patient ' s pain.

The DON stated Patient 6's severe pain on 6/14/23 at 12:27 p.m., should have been addressed. The DON stated there should be documentation on the type of pain intervention provided to the patient or Patient 6's refusal of the pain intervention.

During a review of the facility's policy and procedure (P&P) titled, "Pain Management," revised in 12/2020, the P&P indicated, " ...Pain assessment, planning, intervention, and evaluation will be adapted to patients of all ages and cognitive function ...Reassess pain within one hour of medication administration ...Documentation should be completed in real time ...The assessment of pain will be based on the patient ' s self-reporting ...Patients with a pain score greater than or equal to 4 ...must have interventions to reduce pain unless the adult patient refuses intervention ...The identification of pain initiates the intervention appropriate to the assessment, care setting and services provided. The intervention could include the following ...Medication ...The initial pain assessment, subsequent pain assessments, and patient response to pain interventions must be documented per ...policies ...in the ...pain flow sheet ...The medical record should clearly delineate the plan and rationale for pain treatment ..."

4. During a review of Patient 8's record, the document titled, "Internal Medicine History and Physical," indicated Patient 8 was admitted to the facility on 6/19/23, with a chief complaint of nausea, vomiting, diarrhea, and weakness. Patient 8 had a medical history of Multiple Sclerosis (an autoimmune disease of the central nervous system). Patient 8's "Assessment and Plan" included, " ...Patient (Patient 8) ...with baseline bilateral weakness and numbness. Leg weakness is worse than baseline. This occur when patient has an acute (sudden and severe onset) illness ...neuro-check (neurological exam- a physical examination to identify signs of disorders affecting the brain, spinal cord, and nerves) q4h (every four hours) ..."

During a review of Patient 8's physician's order dated 6/19/23, the physician's order indicated for Patient 8 to have neuro checks every four hours.

During a review of Patient 8's record titled, "Flowsheet Data," the Flowsheet Data indicated Patient 8 ' s neurological assessment was conducted on the following dates and times:

- on 6/19/23 at 8 p.m.,

- on 6/20/23 at 7:58 a.m.,

- on 6/20/23 at 8:05 p.m., and,

- on 6/21/23 at 8:29 a.m.

During an interview on 6/23/23 at 9:03 a.m., with the Director of Nursing (DON), the DON stated Patient 8's neuro check was not being done every four hours as ordered by the physician.

The DON stated it was important to follow Patient 8's neurological assessment orders to monitor any changes of condition on Patient 8 status that may require adjustment in the patient ' s treatment plan.

During a review of the facility's policy and procedure (P&P) titled, "Patient Assessment and Reassessment," revised in 10/2021, the P&P indicated, " ...All discipline will participate in the assessment process to provide a comprehensive, collaborative approach to patient care ...Admission Assessment. Upon admission to the patient care unit, each patient will be assessed by an RN to determine any immediate needs ...Each patient ' s admission assessment includes consideration of the following factors ...Other Pertinent Physician and Psychosocial Status Data. Functional Needs ...The scope and intensity of any further assessments are determined by the patient ' s diagnosis, care setting, the care the patient is seeking ...Any significant change in patient ' s diagnosis and/or condition necessitates an immediate reassessment ..."

5. During a review of Patient 17's History and Physical (H&P) dated 5/31/23 at 5:48 p.m., the H&P indicated Patient 17's diagnosis included a history of hypertension (high blood pressure), coronary artery bypass surgery (a procedure to remove plaques build up in the arteries), tricuspid valve regurgitation (when a defective heart valve allows blood to flow back), and heart failure (a condition in which the heart does not pump blood as it should), and permanent atrial fibrillation (irregular heart rhythm.

Further review of Patient 17's medical record indicated Patient 17 was admitted to the Telemetry Unit (a unit in the hospital where patients undergo continuous cardiac [heart rhythm] monitoring) on 6/2/23.

During a concurrent interview and record review on 6/22/23 at 1:44 p.m., with the Chief Nurse Executive (CNE) and the Nurse Manager (NM) 3, Patient 17's medical record was reviewed. Both the CNE and the NM 3 stated Patient 17 was admitted for observation on 5/31/23, then transferred and admitted to the Telemetry Unit on 6/2/23 at 10:51 a.m. The CNE and NM 3 stated vital signs (blood pressure, heart rate, respiratory rate, and temperature) should be taken every four hours for Patients in the Telemetry Unit to assess for changes in patient's condition.

The CNE and the NM 3 also said Patient 17 had a history of atrial fibrillation (irregular heart rhythm) and was being monitored for irregular (too fast or too slow) heart rhythms. The CNE and NM 3 verified that vital signs for Patient 17 were not taken every four (4) hours as specified for patients in the Telemetry Unit.

During a review of Patient 17's Vital Signs record, the record indicated vital signs were taken on 6/21/23 at 10 p.m., and 6/22/23 at 4:42 a.m. The vital signs documented was over 6.5 hours from 6/21/23 at 10 p.m. The absence of documented vital signs record every four hours was confirmed by the CNE and the NM 3 during an interview.

During a review of Patient 17's Vital Sign Flowsheet, dated 6/21/223 and 6/22/23, the Vital Sign Flowsheet indicated the following:

On 6/21/23 at 9:05 p.m., the Pulse (heart rate) was 67 and the blood pressure (BP) was 121/72.

On 6/21/23 at 10 p.m., the Pulse was 71, Respirations (Resp) were 16, Oxygen Saturation (O2 sat) was 97 percent (%) on Room Air (RA).

On 6/22/23 at 4:42 a.m., the Temperature (Temp) was 97.2 degrees Fahrenheit (F), Pulse was 92, BP was 131/80, Resp were 18, O2 sat was 93 % on RA.

During a review of the facility's policy and procedure (P&P) titled, "Patient Assessment and Reassessment," revised in 10/2021, the P&P indicated, " ...All discipline will participate in the assessment process to provide a comprehensive, collaborative approach to patient care ...Reassessment; The minimum timeframes for nursing reassessment are as follows: Nursing reassessment and documentation (including vital signs...) according to patient needs/conditions and at least...Telemetry Patients Three times a shift or every four hours...The scope and intensity of any further assessments are determined by the patient ' s diagnosis, care setting, the care the patient is seeking ...Any significant change in patient ' s diagnosis and/or condition necessitates an immediate reassessment ..."

Based on interview and record review, the facility failed to ensure that a comprehensive care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) regarding diabetes (high blood sugar level) management was developed upon admission for three of 30 sampled patients (Patients 2, 7, and 19).

This deficiency had the potential to result in the delayed provision of care to the patients by not identifying the patients' needs and risks.

Findings:

1. During a concurrent interview and record review on 6/22/23 at 10:03 a.m., with the Director of Nursing (DON), Patient 2's record titled, "Internal Medicine History and Physical," was reviewed. The Internal Medicine History and Physical record indicated Patient 2 was admitted to the facility on 6/19/23 with a chief complaint of hyperglycemia (high blood sugar [BS] level).

During a review of Patient 2's "Medication Administration Record (MAR)," the MAR indicated Patient 2 had a physician's order of insulin (medication used for treatment of diabetes [high BS level]). The physician's order started on 6/19/23.

During a review of Patient 2's "Point of Care Test (carrying out a test using a device or test kit in the presence of the patient and without the need to send a sample to a laboratory)," the Point of Care Test record indicated Patient 2's BS level ranges from 140 to 278 milligram per deciliter (mg/dl) (normal BS level was 70 to 100 mg/dl).

There was no documented evidence a care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for Patient 2's diabetes was developed. The absence of documented evidence on Patient 2's record was confirmed by the DON.

The DON stated Patient 2's care plan should have included diabetes addressing the patient's goal, risks, and needs to manage diabetes.

During a review of the facility's policy and procedure (P&P) titled, "Patient Plan of Care (POC)," revised in 12/2020, the P&P indicated, " ...Authorized individuals of the health care team will document a POC ...for all patients upon admission ...The POC will be utilized by authorized individuals to document problems, goals, interventions, and outcomes that pertain to patient ' s condition ..."

2. During a concurrent interview and record review on 6/22/23 at 3:17 p.m., with the Director of Nursing (DON), Patient 7's record titled, "Internal Medicine History and Physical," was reviewed. The Internal Medicine History and Physical record indicated Patient 7 was a transfer from another acute care facility and was admitted on 6/16/23, for left leg cellulitis (bacterial skin infection). Patient 7 had a medical history of diabetes (high blood sugar level).

During a review of Patient 7's "Medication Administration Record (MAR)," the MAR indicated Patient 7 had a physician's order of insulin (medication used for treatment of diabetes [high BS level]) started on 6/16/23.

There was no documented evidence a care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for Patient 7's diabetes was developed. The absence of documented evidence on Patient 7's record was confirmed by the DON.

The DON stated Patient 2's care plan should have included diabetes addressing the patient's goal, risks, and needs to manage diabetes.

During a review of the facility's policy and procedure (P&P) titled, "Patient Plan of Care (POC)," revised in 12/2020, the P&P indicated, " ...Authorized individuals of the health care team will document a POC ...for all patients upon admission ...The POC will be utilized by authorized individuals to document problems, goals, interventions, and outcomes that pertain to patient's condition ..."

3. During a review of Patient 19's History & Physical (H&P) dated 6/15/2023 at 1:14 a.m., the H&P indicated Patient 19's chief complaint was shortness of breath. Patient 19 reported chest tightness, wheezing (a shrill, coarse, rattling sound the patient's breath makes when the airway is partially blocked) and productive cough. Patient 19 was transferred from another acute care hospital and treated for possible asthma exacerbation (episodes of worsening asthma symptoms and lung function).

Further review of Patient 19's medical record indicated Patient 19 was admitted to the facility on 6/15/2023 at 12:17 a.m.

A review of Patient 19's Plan of Care titled, "Airway Clearance (techniques to loosen secretions from the lungs to improve patient breathing) - Ineffective," indicated the plan of care was initiated on 6/16/2023 at 3:20 a.m.

A review of Patient 19's Plan of Care titled, "Ineffective Breathing Pattern," indicated the plan of care was initiated on 6/16/2023 at 3:20 a.m.

A review of Patient 19's Plan of Care titled, "Ineffective Oxygenation (process of supplying oxygen to the body's organs)," indicated the plan of care was initiated on 6/16/2023 at 3:20 a.m.

During a concurrent interview and record review on 6/22/2023 1:44 p.m. with the Chief Nurse Executive (CNE) and the Nurse Manager (NM) 3, Patient 19's medical record was reviewed. The CNE and the NM 3 stated that care plans (provides a framework for evaluating and providing patient care needs related to the nursing process) should be initiated within twenty-four (24) hours of admission. The CNE and NM 3 verified Patient 19's care plan addressing her initial complaint of shortness of breath was not initiated within in 24 hours of admission, per the facility's policy and procedure.

During a review of the facility's policy and procedure (P&P) titled, "Patient Plan of Care (POC)," revised in 12/2020, the P&P indicated, " ...Authorized individuals of the health care team will document a POC ...for all patients upon admission ...The POC will be utilized by authorized individuals to document problems, goals, interventions, and outcomes that pertain to patient ' s condition ..."

Based on interview and record review the facility failed to ensure that one of five staff (Chief Nurse Executive [CNE]) received new hire orientation within thirty (30) days of hire, in accordance with the facility ' s policy and procedure regarding new employee orientation.

This deficient practice had the potential for the CNE not to be oriented to her assigned location, duties, and responsibilities in the operation of the nursing service, which may compromise the quality of the nursing care provided by the nursing service.

Findings:

During a concurrent interview and record review on 6/23/23 beginning at 9:41 a.m., with the Director of Human Resources (DHR), staff personnel files was reviewed. The DHR verified that the Chief Nurse Executive's (CNE) orientation checklist was completed on 10/20/2022, six months after she (CNE) was hired. The Director of Human Resources (DHR) said that new employee orientation should be completed for new employees within thirty days of hire.

During a review of the CNE's personnel file on 6/23/23 beginning at 9:41 a.m., the CNE's personnel file indicated the CNE was hired on 2/14/22. The orientation check list was completed on 10/20/2022. There was no documented evidence that the new employee orientation was completed within 30 days of hire. This absence of documented evidence was verified by the DHR during an interview.

During a review of the facility's policy and procedure (P&P) titled, "Medical Center New Employee Orientation," dated 8/2021, the P&P indicated "it is mandatory that all new employees attend all appropriate phases of the New Employee Orientation (NEO) Program ...For all new employees ... Employees transferring from outside the service area must complete the NEO within 30 days of transfer."

During a review of the facility's policy and procedure (P&P) titled, "Medical Center New Employee Orientation," dated 8/2021, the P&P further indicated "The content of the orientation program shall include, but not limited to ...Regulatory and workplace safety included SAFE, workplace safety, security, emergency codes, fire prevention, risk management, infection prevention and control."

Based on observation, interview and record review, the facility failed to ensure staff adhered to the facility ' s policies and procedures (P&P) regarding cardiac monitoring (records the heart rate and heart rhythm) for four of 30 sampled patients (Patients 5, 6, 14, and 28) when:

1. Patients 5, 6, and 14's cardiac rhythm strips were not printed in accordance with the P&P. In addition, there was no documented evidence a Registered Nurse (RN) performed the recording and interpretation of the cardiac rhythm strips (records the electrical activity of the heart). This deficient practice had the potential to delay the provision of care and treatment for the patients, which may lead to complications affecting the patients ' heart and lungs, and deterioration of the patients ' condition.

2. One of 30 sampled patients (Patient 28) was not assessed every sixty minutes (60) in the emergency department (ED-where patients receive immediate medical care), in accordance with the facility's policy and procedure regarding Emergency Department patient assessment and re-assessment. This deficient practice had the potential for changes in Patient 28 ' s condition to go undetected.

Findings:

1a. During a review of Patient 5's record titled, "Admission History and Physical by Medicine Consult," the Admission History and Physical record indicated Patient 5 was admitted to the facility on 6/14/23, with a chief complaint of respiratory failure (a condition that makes it difficult for a patient to breathe on his own).

During a review of Patient 5's physician's order, dated 6/16/23, the physician's order indicated Patient 5 was ordered a continuous cardiac monitoring (records the heart rate and heart rhythm) on 6/16/23 and the order was discontinued on 6/19/23.

There was no documented evidence Patient 5's cardiac rhythm strip (records the electrical activity of the heart) was printed and interpreted by an RN when Patient 5's cardiac monitoring was initiated and discontinued.

During an interview on 6/22/23 at 1:55 p.m., with the Director of Accreditation and Licensing (DAL), the DAL stated there was no cardiac rhythm strip (records the electrical activity of the heart) printed for Patient 5 when the patient was on continuous cardiac monitoring.

During an interview on 6/20/23 at 12:34 p.m., with Registered Nurse (RN) 8, RN 8 stated when a patient was on a continuous cardiac monitoring, a cardiac rhythm strip (records the electrical activity of the heart) should be recorded and printed when the patient's cardiac monitoring was initiated and discontinued, when the patient was transferred in and out of the unit, and when there was a change in the patient's cardiac rhythm.

RN 8 stated the printed cardiac rhythm strips would be interpreted by the RN then filed in the patient's (Patient 5) record for the physician to check.

During a review of the facility's policy and procedure (P&P) titled, "Cardiac Monitoring (Adult)," revised on 5/3/22, the P&P indicated, " ...Monitor rhythm strip(s) will be printed when:

- A patient is placed on the monitor (Initial Strip)

- A patient has telemetry discontinued (Final Strip)

- There is any rhythm that results in change in treatment, notification of a physician, intervention or change in level of service for the patient

- Alternative monitoring equipment is used

- Patient is placed back on telemetry (cardiac [heart] monitoring) monitoring, after alternative monitoring equipment use ...

Label rhythm strips with patient name and MRN (medical record number), date, time and lead(s) recorded, PR interval, QRS duration, QT interval, and rhythm interpretation ...The competent Registered Nurse or Monitor technician (MT) can perform the recording and interpretation of rhythm strips as outlined above ...The Registered Nurse will sign all cardiac rhythm strip(s) ..."


1b. During a concurrent interview and record review on 6/22/23, at 1:37 p.m. with the Director of Nursing (DON), Patient 6's record titled, "Hospital Medicine Admission History and Physical," was reviewed. The Hospital Medicine Admission History and Physical record indicated Patient 6 was a transfer from another acute care facility and was admitted on 6/11/23, for severe sepsis (a life-threatening complication of an infection) from the left foot cellulitis (bacterial skin infection).

During a review of Patient 6's physician's orders, conducted on 6/22/23, the physician's orders indicated the following:

- on 6/11/23, Patient 6 was ordered a continuous cardiac monitoring (records the heart rate and heart rhythm);

- on 6/11/23, Patient 6 was allowed to be transferred in and out of the unit for a test without the cardiac monitor; and,

- on 6/16/23, Patient 6 had an MRI (magnetic resonance imaging - an imaging technique that uses a magnetic field and computer-generated radio waves to create detailed images of the organ and tissues in the body).

There was no documented evidence Patient 6's cardiac rhythm strip (records the electrical activity of the heart) was printed and interpreted by a Registered Nurse (RN) when Patient 6's cardiac monitoring was initiated and when Patient 6 was transferred in and out of the unit for an MRI test. The absence of documented evidence on Patient 6's record was confirmed by the DON.

During an interview on 6/20/23 at 12:34 p.m., with Registered Nurse (RN) 8, RN 8 stated when a patient was on a continuous cardiac monitoring, a cardiac rhythm strip should be recorded and printed when the patient's cardiac monitoring was initiated and discontinued, when the patient was transferred in and out of the unit, and when there was a change in the patient's cardiac rhythm.

RN 8 stated the printed cardiac rhythm strips would be interpreted by the RN then filed in the patient's (Patient 6) record for the physician to check.

During a review of the facility's policy and procedure (P&P) titled, "Cardiac Monitoring (Adult)," revised on 5/3/22, the P&P indicated, " ...Monitor rhythm strip(s) will be printed when:

- A patient is placed on the monitor (Initial Strip)

- A patient has telemetry discontinued (Final Strip)

- There is any rhythm that results in change in treatment, notification of a physician, intervention or change in level of service for the patient

- Alternative monitoring equipment is used

- Patient is placed back on telemetry monitoring, after alternative monitoring equipment use ...

Label rhythm strips with patient name and MRN (medical record number), date, time and lead(s) recorded, PR interval, QRS duration, QT interval, and rhythm interpretation ...The competent Registered Nurse or Monitor technician (MT) can perform the recording and interpretation of rhythm strips as outlined above ...The Registered Nurse will sign all cardiac rhythm strip(s) ..."

1c. During a review of Patient 14's record on 6/21/23, the following were reviewed:

- The document titled, "Internal Medicine History and Physical," dated 5/14/23, indicated Patient 14 was admitted to the facility on 5/29/23, with a chief complaint of dyspnea (difficulty of breathing);

- Patient 14 ' s physician's order indicated Patient 14 had an order for a continuous cardiac monitoring (records heart rate and heart rhythm) on 5/29/23; and,

- The document "Multi-Discipline Progress Note," dated 5/30/23, authored by RN 7, indicated, " ...Rapid response called at 1243 (12:43 p.m.). Patient's (Patient 14) HR (heart rate) sustaining in the high 170 ' s fluctuating to 190 ' s (normal HR is between 60 to 100 beats per minute) ...Patient transferred to SDU (Step Down Unit - provides an intermediate level of care between the Intensive Care Unit and the general Medical/Surgical Unit) ..."

There was no documented evidence Patient 14's cardiac rhythm strip (records the electrical activities of the heart) was printed and interpreted by an RN when Patient 14's cardiac monitoring was initiated and when Patient 14 needed RRT (Rapid Response Team - a group of clinicians who will bring critical care expertise to the declining patient) for cardiac (heart) problem on 5/30/23.

During an interview on 6/23/23 at 11:40 a.m., with Registered Nurse (RN) 6, RN 6 stated there was no cardiac rhythm strip printed for Patient 14.

RN 6 further stated Patient 14's cardiac rhythm strips should have been recorded and printed when the patient's cardiac monitoring was initiated and when Patient 14 had a Rapid Response Team (RRT) responded for the patient's cardiac problem.

During a concurrent interview and record review on 6/22/23 at 1:37 p.m., with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, "Cardiac Monitoring (Adult)," revised on 5/3/22, was reviewed. The P&P indicated, " ...Monitor rhythm strip(s) will be printed when:

- A patient is placed on the monitor (Initial Strip)

- A patient has telemetry discontinued (Final Strip)

- There is any rhythm that results in change in treatment, notification of a physician, intervention or change in level of service for the patient

- Alternative monitoring equipment is used

- Patient is placed back on telemetry monitoring, after alternative monitoring equipment use ...

Label rhythm strips with patient name and MRN (medical record number), date, time and lead(s) recorded, PR interval, QRS duration, QT interval, and rhythm interpretation ...The competent Registered Nurse or Monitor technician (MT) can perform the recording and interpretation of rhythm strips as outlined above ...The Registered Nurse will sign all cardiac rhythm strip(s) ..."

The DON stated the P&P for cardiac monitoring was not followed for the patients (referring to Patients 5, 6 and 14) who had continuous cardiac monitoring.

2. During an observation and interview, in the Emergency Department (ED -where patients receive immediate medical care) on 6/22/2023 at 9 a.m., Registered Nurse (RN) 9 was observed in a room, monitoring patients on the computer. RN 9 stated she (RN 9) was the "emergency flow coordinator" and her (RN 9) primary job was to periodically reassess patients waiting in the waiting room, and check for bed availability. RN 9 stated she (RN () tried to reassess patients every two hours.

During a concurrent interview and review record review, on 6/22/2023 at 9:47 a.m., with the Director of the Emergency Department (DED) Patient 28's medical record was reviewed. The DED stated the following: Patient 28 arrived at the Emergency Department (ED) on 6/19/23 with complaints of abdominal pain, headache, and nausea. Patient 28 was assigned a Level 3 (urgent) on the Emergency Severity Index (ESI, a five-level triage algorithm that provides clinically relevant stratification of patients into five groups from 1 [most urgent] to 5 [least urgent] based on acuity (measures the severity of patient illness and the intensity of nursing care that the patient requires) and resource needs).

The DED further stated that patients with an ESI Level 3 who are waiting in the waiting room, should be reassessed every sixty (60) minutes, as indicated in the facility's policy, to assess for changes in the patient's condition. The DED verified Patient 28 had not been reassessed every sixty (60) minutes for any changes in condition.

During a review of Patient 28's "Patient Care Timeline," dated 6/19/23 at 10:29 p.m. to 6/20/23 at 1 p.m., The Patient Care Timeline indicated the following: Patient 28 presented to the Emergency Department (ED) on 6/19/23 at 10:29 p.m. with complaints of abdominal pain, headache, and nausea. Patient 28 was assigned an Emergency Severity Index (ESI, a five-level triage algorithm that provides clinically relevant stratification of patients into five groups from 1 [most urgent] to 5 [least urgent] based on acuity and resource needs) level of three (3, indicating it was urgent).

On 6/19/23 at 10:46 p.m., Patient 28's vital signs (blood pressure, heart rate, respiratory rate, and temperature) were taken.

On 6/19/23 at 10:48 p.m., a nursing assessment was performed.

On 6/20/23 at 3:51 am, Patient 28's vital signs, including a pain assessment was performed by nursing staff.

On 6/20/23 at 10:15 a.m., Patient 28's vital signs were taken and a nursing assessment was performed.

On 6/20/23 at 11 a.m., Patient 28's vital signs and pain were reassessed.

On 6/20/23 at 12:30 p.m., Patient 28's vital signs and pain were reassessed.

On 6/20/23 at 1 p.m., Patient 28 was discharged.

During a review of the facility's policy and procedure (P&P) titled, "Emergency Department Patient Flow," dated 7/2021, the P&P indicated an ESI level of 3 = Urgent conditions - conditions that could potentially progress to a serious problem requiring emergency intervention given chief complaint or injury will determine number of resources (3 resources: x-ray, lab and intravenous - IV medications) needed to determine diagnosis ...Assessment by an RN:.. All patients waiting to be seen by a physician shall be reassessed by an RN as their condition warrants, for any change in condition. Reassessments will be documented on the HealthConnect (Electronic documentation) record at sixty (60) minute intervals for Level 3 patients ..."

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

1. A physician's order was obtained for one of 30 sampled patients' (Patient 1) use of supplemental oxygen (a treatment that provides extra oxygen to breathe). This deficient practice had the potential to cause adverse health outcomes (an event in which care results in an undesirable outcome) which could negatively affect the patient's health and safety due to unsafe administration of supplemental oxygen and may lead to Patient 1's deterioration of medical condition and death;

2. Morphine (narcotic pain medication) was administered as ordered by the physician for one of 30 sampled patients (Patient 3). This deficient practice resulted in delay of treatment of Patients 3 and 6's pain and had the potential to cause adverse health outcomes which could negatively affect the patient's health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death;

3. Insulin (medication used for treatment of diabetes [high blood sugar level]) was administered as ordered by the physician for one of 30 sampled patients (Patient 7). This deficient practice resulted in delay of treatment and had the potential to cause adverse health outcomes which could negatively affect the patient's health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death; and,

4. The medication titration (increase or decrease the amount) for nitroglycerin drip (medication used for treatment of hypertension [high blood pressure - BP]) was in accordance with the physician's order for one of 30 sampled patients (Patient 11). This deficient practice resulted in delay of treatment and had the potential to cause adverse health outcomes which could negatively affect the patient's health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death.

Findings:

1. During a concurrent interview and record review on 6/21/23 at 8:30 a.m., with Nurse Manager (NM) 2, Patient 1's record titled, "Internal Medicine History and Physical," was reviewed. The Internal Medicine History and Physical record indicated Patient 1 was admitted to the facility on 5/14/23, with a chief complaint of arm redness and swelling.

Patient 1 had a past medical history of multiple heart conditions, status post CABG (coronary artery bypass surgery - a medical procedure to improve blood flow to the heart) and AICD (Automatic Implantable Cardioverter Defibrillator - a small electronic device that is implanted on the chest to monitor and correct an abnormal heart rhythm), COPD (chronic obstructive pulmonary disease - lung disease that block the airflow and make it difficult for a person to breathe), and chronic respiratory failure. Patient 1 continuously uses 2L (liter) of oxygen via nasal cannula (NC - a device used to deliver supplemental oxygen) at home.

During a review of Patient 1's record titled, "Progress Notes," dated 5/24/23, the Progress Notes indicated, " ...Hospitalization summary ...

5/17: increased SOB (shortness of breath) and cough ...

5/19: worsening SOB ...

5/21: feeling well. Attempted discharge (to home) but was unable to place pt (Patient 1) in car due to weakness. Discharge cancelled ...

5/23 ...still requiring 4L on O2 (oxygen) ...

Subjective: No acute events overnight. Feels tired and shortness of breath with movement ...Objective ...O2 ...4 LPM (liter per minute) ...NC (nasal cannula) ...

Assessment and Plan ...Wean (gradual reduction of oxygen rate) as tolerated, need < (less than) 4L requirement for SNF (skilled nursing facility-a facility that provides rehabilitation services and primary medical care with the goal of the patient returning to normal function) discharge ...Deconditioning (changes that occur in the body during a period of inactivity) ...Patient with poor functional baseline (ability to perform basic activities of daily living like toilet use, etc., as family describes patient at home often just parks in recliner chair and rarely gets up ...Patient states she feels scared to exert herself as she gets anxious and panics when she feels SOB (short of breath) ..."

During a review of Patient 1's record titled, "Flowsheet Data," dated from 5/21/23 through 5/25/23, the Flowsheet Data indicated Patient 1 had received oxygen at 2L and was titrated (increase or decrease the amount) up to 4L via NC (nasal cannula).

There was no documented evidence that Patient 1's use of supplemental oxygen and titration of the oxygen was ordered by the physician. This absence of documented evidence was confirmed by NM 2 during an interview.

During a review of Patient 1's record titled, "Multi-Discipline Progress Note," dated 5/25/23, at 12:15 p.m., authored by RN 1, the Multi-Discipline Progress Note indicated, " ...Pt (Patient 1) was taken to the bathroom with sara steady (a non-powered device that used on patient from sit-to-stand transfers). Pt was trying to have BM (bowel movement) and became lethargic (a condition marked by drowsiness, and an unusual lack of energy and mental alertness) ...RRT (Rapid Response Team - a group of clinicians who will bring critical care expertise to the declining patient) was alerted. Patient (Patient 1) was transferred to SDU (step down unit - provides an intermediate level of care between the Intensive Care Unit and the general Medical/Surgical Unit) ..."

During a review of Patient 1's record titled, "Progress Notes," dated 5/25/23, the Progress Notes indicated, " ...Hospitalization Summary ...5/25 Pt (Patient 1) had walked to bathroom with a walker (sit to stand lift) ...Pt became lethargic afterwards. Pt desaturated (low blood oxygen level) ...RRT was called. Pt was transferred to SDU ...Pt was intubated (placing a breathing tube through the mouth and down the throat into the lungs) and transferred to ICU (Intensive Care Unit - specialized unit that provides intensive care to critically ill patients) ..."

During a review of Patient 1's record titled, "Death Note," the Death Note indicated Patient's date of death was 5/26/23. The Death Note further indicated " ...Pt (Patient 1) continued to deteriorate (to worsen) and pt remained hypotensive (low blood pressure [BP]) despite maximal doses of 3 vasopressors (medications used to raised BP). Pt's (Patient 1) family is in agreement and focus of care was transitioned to comfort (reducing the intensity of medical care because the burden is outweighing the benefits) ...Pt developed asystole (flat line, absence of electricity or movement in the heart) and was pronounced dead at 11:50 a.m."

During an interview on 6/21/23 at 8:30 a.m. with Nurse Manager (NM) 2, NM 2 stated oxygen was considered a medication and administration of oxygen to the patient should have a physician ' s order. NM 2 stated Patient 1's use of supplemental oxygen and titration of the oxygen should have a physician's order. NM 2 confirmed there was no physician's order regarding the use and titration of oxygen for Patient 1.

During a review of the facility's policy and procedure (P&P) titled, "Oxygen Therapy Administration and Humidifiers," revised in 6/2020, the P&P indicated, " ...Procedure ...Verify physician ' s order ..."

2. During a concurrent interview and record review on 6/22/23 at 10:32 a.m. with the Director of Nursing (DON), Patient 3's record titled, "Internal Medicine History and Physical," was reviewed. The Internal Medicine History and Physical indicated Patient 3 was admitted to the facility on 6/17/23, with a chief complaint of neck abscess (infection).

During a review of Patient 3's Medication Administration Record (MAR), the MAR indicated a physician's order of Morphine (narcotic pain medication) two milligram (2 mg) to be given intravenous (IV - through the vein) every two hours as needed for moderate pain (4-6 [a pain score of 1-3 is mild pain; 4-6 is moderate pain; 7-10 is severe pain]). The physician order started on 6/18/23.

Further review of Patient 3's MAR and the corresponding Patient 3's pain assessment flow sheet indicated:

- Morphine 2 mg IV was given on 6/19/23 at 9:21 p.m., Patient 3 ' s pain score assessment was 7 (severe pain); and,

- Morphine 2 mg IV was given on 6/20/23 at 2:29 a.m., Patient 3's pain score assessment was 7 (severe pain).

The DON stated Morphine 2 mg IV was ordered for Patient 3's moderate pain. The DON stated Morphine was not administered in accordance with the physician's order.

The DON also said there was no pain medication ordered for Patient 3's severe pain. The DON stated the physician should have been called for an order of pain medication for Patient 3's severe pain.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," dated 8/16/21, the P&P indicated, " ...Medications are administered according to the Five (5) Rights of Medication Administration ...Right medication. Right dose ...Licensed personnel are responsible for the following related medication administration ...Verifying that medication selected matches the medication order ...Verifying the medication is being administered at the ...prescribed dose ..."

3. During a concurrent interview and record review on 6/22/23 at 3:17 p.m., with the Director of Nursing (DON), Patient 7's record titled, "Internal Medicine History and Physical," was reviewed. The Internal Medicine History and Physical indicated Patient 7 was a transfer from another acute care facility and was admitted on 6/16/23, for left leg cellulitis (bacterial skin infection). Patient 7 also had a medical history of diabetes (high blood sugar level).

During a review of physician's order for Patient 7, dated 6/16/23, the physician's order indicated the following:

Humulin R (a short acting insulin which means it can cover insulin needs for meals eaten within 30 minutes) 0-8 units to be given subcutaneously (to administer the drug in the tissue layer between the skin and the muscle) before meals and at bedtime for the following blood glucose:

70 - 180: no action

181 - 200: give 2 units except for bedtime, no action

201 - 250: give 3 units

251 - 300: give 4 units

301 - 350: give 6 units

351 - 400: give 8 units

Greater than 400: call physician. Insulin to be given even if Patient 7 was NPO (nothing by mouth) or not eating.

During a review of Patient 7's "Medication Administration Record (MAR)," the MAR indicated the following when Humulin R, 0-8 unit doses, were held or not given to Patient 7:

- on 6/16/23 at 10 p.m., dose was held due to "patient (Patient 7) is already getting 80 units;" and,

- on 6/20/23 at 11:30 a.m., Patient 7 ' s blood sugar (BS) level was 333, 6 units dose was held.

The DON stated the reason for not giving the insulin dose was not valid. The DON stated if the RN had questions or concern regarding the administration of the insulin, the RN should have called the physician or the pharmacist for clarification of orders.

During an interview on 6/22/23 at 4:11 p.m., with Pharmacy Supervisor (PS), the PS stated Patient 7 had two orders of Humulin R, one was a maintenance dose of 80 units and one was a sliding scale order (varies the dose of insulin based on blood glucose level). The PS stated the Humulin R sliding scale dose should have been given as ordered regardless of if Patient 7 was receiving his maintenance dose.

The PS stated if the RN had concerns with the Humulin R sliding scale dose, the RN should have called the physician or the pharmacist for clarification.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," dated 8/16/21, the P&P indicated, " ...Licensed personnel are responsible for the following related medication administration. Questioning and clarifying unclear, incomplete, or inappropriate orders ...Discusses any unresolved concerns about the medication with the patient's license independent practitioner, prescriber ..."

4. During a concurrent interview and record review on 6/23/23 at 10:20 a.m. with Registered Nurse (RN) 5, Patient 11's record was reviewed. The document titled, "History and Physical - Standard Hospital Admit," indicated Patient 11 was admitted to the facility with a chief complaint of chest pain.

A review of the medication order indicated the following:

- " ...Nitroglycerin 0-200 mcg/min (microgram/minute) IV (intravenous) continuous ...Admin (administration) Instructions: start at 5 mcg/min. Titrate (increase or decrease the amount) to maintain a systolic (is the first number in blood pressure [BP], below 90 is considered low and may require intervention from healthcare provider) BP range of 160 ...Increase by 5 mcg/min every 5 minutes as needed to 20 mcg/min. If no response at 20 mcg/min, increase by 10 mcg/min every 5 minutes as needed ...Start 6/19/2023 End 6/20/2023 ..." and,

- " ...Nitroglycerin 0-200 mcg/min (microgram/minute) IV (intravenous) continuous ...Admin (administration) Instructions: start at 5 mcg/min. Titrate to maintain a systolic BP (SBP) range of 170 ...Increase by 5 mcg/min every 5 minutes as needed to 20 mcg/min. If no response at 20 mcg/min, increase by 10 mcg/min every 5 minutes as needed ...Start 6/20/2023 End 6/21/2023 ..."

During a review of Patient 11's record titled, "Flowsheet Data," the Flowsheet Data indicated the following Nitroglycerin titration dose and corresponding SBP for Patient 11:

- On 6/19/23 at 7:20 p.m., Nitroglycerin drip was started at 5 mcg/min. There was no documentation of Patient 11 ' s BP reading.

At 7:34 p.m., Nitroglycerin drip was increased to 10 mcg/min. There was no documentation of Patient 11 ' s BP reading;

- On 6/19/23 at 7:56 p.m., Nitroglycerin drip was increased to 20 mcg/min. Patient 11 ' s BP was 183/88.

At 8:29 p.m., Nitroglycerin drip was increased to 25 mcg/min. Patient 11 ' s BP was 179/81 (a total of 30 minutes since nitroglycerin drip was last titrated); and,

- On 6/20/23 at 9:54 a.m., Nitroglycerin drip was increased to 30 mcg/min.

At 10:22, Nitroglycerin drip was increased to 40 mcg/min (a total of 30 minutes since nitroglycerin drip was last titrated).

Patient 11's SBP had been above 170 from 9:39 a.m. to 11:59 a.m.

RN 5 stated Patient 11's Nitroglycerin drip titration dose was not in accordance with the physician's order.

RN 5 said when initiating and adjusting the Nitroglycerin dose, Patient 11's BP should have been taken to ensure the correct dose of medication would be given.

RN 5 stated Patient 11's BP should have been taken every five minutes to know if Nitroglycerin drip dose needed to be titrated as indicated in the physician ' s order.

RN 5 further stated if Patient 11's SBP was above the parameter as ordered, the Nitroglycerin drip should have been titrated every five minutes as indicated in the physician ' s order.

During a review of the facility's policy and procedure (P&P) titled, "Intravenous Medications Administration, Inpatient," revised in 6/2022, the P&P indicated, " ...Carefully review physician ' s order. Reference IV medication guidelines for ...Monitoring parameters ..."

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," dated 8/16/21, the P&P indicated, " ...Medications are administered according to the Five (5) Rights of Medication Administration ...Right dose. Right Time ...Verifying the medication is being administered at the proper time, at the prescribed dose ..."