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Based on interview and record review, the facility failed to ensure risks, benefits, or alternative therapies were discussed before antibiotic therapy (the use of antibiotics [a medication used to inhibit growth of or destroy harmful microorganisms] to treat infection) was discontinued prior to completion, for one patient of 24 sampled patients (Patient 14).

This failure had the potential for Patient 14 to have an undertreated infection which could lead to severe illness or death.

Findings:

On November 24, 2025, at 3:05 p.m., a review of Patient 14's medical record was conducted with the Sepsis Coordinator (SC). A facility document titled, "History and Physical," dated August 14, 2025, was reviewed. The document indicated Patient 14 was admitted to the facility on August 13, 2025, with a diagnosis of heart failure (when the heart cannot pump enough blood to meet the body's needs).

A facility document titled, "Bacteriology, [the study of bacteria]" dated August 16, 2025, was reviewed. The document indicated Patient 14 had a bacterial infection, Entercoccus Faecalis (specific type of bacteria) in his blood.

A facility document titled, "Order Inquiry," dated August 14, 2025, was reviewed. The document indicated Patient 14 was ordered to have Zosyn (an antibiotic) 3.375 mg (milligrams, a unit of measurement) every six hours.

A facility document titled, "Progress Notes Report," dated August 17, 2025, was reviewed. The document indicated Patient 14 refused a dose of Zosyn, the physician was notified, and the medication was discontinued.

A facility document titled, "Medication Administration Record," dated August 14, 2025, through August 22, 2025, was reviewed. The document indicated the order for Zosyn was prescribed from August 14, 2025, at 8 a.m., through August 17, 2025, at 8:14 p.m. The document indicated Patient 14 had refused multiple doses of the medication.

A review of facility documents titled, "Progress Note," dated August 18, 2025, through August 21, 2025, was conducted. The documents indicated, "...Entercoccus Facalis bacteremia [bacteria in the blood] - keep on Zosyn to complete 5 days therapy..." on each day. There was no documented evidence acknowledging the discontinuation of the antibiotic. There was no documented evidence risks, benefits, or alternative therapies for treatment were discussed with Patient 14.

On November 25, 2025, at 10:50 a.m., an interview and concurrent record review was conducted with the SC. The SC stated Patient 14 did not complete five days of antibiotic therapy.

On November 25, 2025, at 1:15 p.m., an interview was conducted with Medical Doctor (MD) 1. MD 1 stated Zosyn can be an effective antibiotic for treatment of Entercoccus Facalis and the range of treatment days can vary from 5 to 7 days or 10 to 14 days depending on how well the patient is responding to the medication. MD 1 stated if a patient was to refuse the antibiotic therapy, an alternative antibiotic therapy, including oral (pill form) antibiotics could be offered. MD 1 stated, "An attempt should be made to offer an alternative." MD 1 stated if a patient directly told him he didn't want a medication or therapy he would document it in the patient's medical record.

A facility policy and procedure (P&P) titled, "Patient Rights and Responsibilities," dated November 2022, was reviewed. The P&P indicated, "...All patients at [name of facility] have the right to...Make decisions regarding medical care, and receive as much information about any proposed treatment or procedure as they may need in order to give informed consent or to refuse a course of treatment...this information shall include a description of the procedure or treatment, the medical significant risks involved, alternative courses of treatment or non-treatment and the risks involved in each..."

A facility document titled, "Rules and Regulations Professional Medical Staff," dated October 2025, was reviewed. The document indicated, "...Informed Decision Making...There is evidence in the medical record that the patient has been given information necessary to enable him/her to make treatment decision that reflect his/her wishes...The documentation will included the proposed treatment(s) or procedure(s)...This includes any significant alternatives to the course of treatment proposed..."

Based on interview and record review, the facility failed to ensure the facility's policy and procedures (P&P) were implemented by not ensuring a safe environment when one of 24 sampled patients (Patient 10) was unattended on multiple days.

These failures had the potential to impact the health and safety and cause a delay in treatment for Patient 10.

Findings:

On November 25, 2025, at 12:15 p.m., a review of Patient 10's medical record was conducted with the Emergency Department/Intensive Care Unit Director (ED/ICUD). A facility document titled, "History and Physical," dated September 22, 2025, was reviewed. The document indicated Patient 10 was admitted for detoxification (the process of removing toxic substances) of Fentanyl (a powerful synthetic drug) and Methamphetamine (a powerful and highly addictive drug).

An undated facility document titled, "Ordering," was reviewed with the ED/ICUD. The document indicated Patient 10 was ordered a sitter (person to watch the patient one on one) on September 24, 2025, at 12:07 a.m., for high risk behavior (actions that increase likelihood of injury), extreme agitation (restlessness) and acute detoxification.

A facility document titled, "SITTER OBSERVATION DOCUMENTATION," dated September 24, 2025, was reviewed. The document indicated, "...observation codes every thirty (30) minutes for Confused/Safety..." The first document dated September 24, 2025, indicated the sitter did not document monitoring the patient at 6:30 a.m.

A second facility document titled, "SITTER OBSERVATION DOCUMENTATION," dated September 24, 2025, was reviewed. The second document dated September 24, 2025, indicated the sitter did not document monitoring the patient at 6:30 a.m.

There was no documented evidence of observation on September 25, 2025.

A facility document titled, "SITTER OBSERVATION DOCUMENTATION," dated September 26, 2025, was reviewed. The document indicated the sitter did not document monitoring the patient at 6:30 a.m.

On November 25, 2025, at 12:35 p.m., an interview with the ED/ICUD was conducted. The ED/ICUD stated, the nurses assigned to be a sitter should have been with the patient (Patient 10) and documented every 30 minutes. The ED/ICUD stated the sitters did not follow the facility policy and left the patient unattended. The ED/ICUD further stated the sitters did not document at 6:30 a.m. on September 24, and 26, 2025. The ED/ICUD the second Sitter Observation Documentation dated September 24, 2025, was mislabeled and should have been dated September 25, 2025.

On November 25, 2025, at 12:40 p.m., an interview with the Registered Nurse House Supervisor (RNHS) was conducted. The RNHS stated there was a Sitter Observation Documentation missing at 6:30 a.m. each day. The RNHS stated there is a gap in the shift between the Certified Nursing Assistant (CNA, a person which provides basic patient care under the supervision of a registered nurse) and the sitters.

A facility Policy and Procedure (P&P) titled "Sitters," dated May 2024, was reviewed. The document indicated, "...Patients who are identified as a risk for harm to self or others shall have increased observation based upon the assessment of observed patient behaviors...Patient confusion, high risk for falls or self-harm other than suicide...the charge nurse will notify the nurse manager or house supervisor for the need of a sitter..."

Based on interview and record review, the facility failed to ensure the facility's policies and procedures (P&P) were implemented, for five of 24 sampled patients (Patients 2, 3, 15, 16, and 21) when:

1. For Patients 2, 15, and 16, oral (mouth) care was not provided every two hours per facility policy;

2. For Patients 2 and 21, Intravenous (IV, small plastic tube inserted into the vein for medication) medication was not labeled according to the facility policy; and

3. For Patient 3, a critical laboratory value was not reported to the physician.

These failures had the potential to compromise patient safety, expose patients to disease causing pathogens (germs), and may cause a delay in the treatment of the patients.

Findings:

1a. On November 25, 2025, at 8:15 a.m., a review of Patient 15's medical record was conducted with the Sepsis Coordinator (SC). A facility document titled, "History and Physical," dated November 17, 2025, was reviewed. The document indicated Patient 15 was admitted to the facility on November 15, 2025, with a diagnosis of sepsis (a life-threatening medical emergency where the body 's extreme response to an infections damages its own tissues and organs) and metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the body). The document further indicated Patient 15 was intubated (a medical procedure of inserting a plastic tube through the mouth and into the airway to keep it open).

A facility document titled, "Daily, Activities of Daily Living," dated November 15, 2025, through November 22, 2025, was reviewed. The document indicated Patient 15 was dependent on oral care. The document further indicated oral care was not performed for Patient 15 on:

-November 17, 2025, from 8 a.m. to 6 p.m. (10 hours);
-November 18, 2025, from 8 a.m. to 6 p.m. (10 hours); and
-November 19, 2025, from 8 a.m. to 6 p.m. (10 hours).

1b. On November 25, 2025, at 9 a.m., a review of Patient 16's medical record was conducted with the SC. A facility document titled, "History and Physical," dated July 17, 2025, was reviewed. The document indicated Patient 16 was admitted to the facility on July 17, 2025, with a diagnosis of respiratory failure (a condition where the lungs cannot get enough oxygen into the blood). The document further indicated Patient 16 was intubated.

A facility document titled, "Daily, Activities of Daily Living," dated July 17, 2025, through July 22, 2025, was reviewed. The document indicated Patient 16 was dependent on oral care. The document further indicated oral care was not performed for Patient 16 on:

-July 18, 2025, from 8 a.m. to 8 p.m. (12 hours);
-July 19, 2025, from 8 a.m. to 12 p.m. (4 hours);
-July 20, 2025, from 12 p.m. to 6 p.m. (6 hours); and
-July 21, 2025, from 10 a.m. to 4 p.m. (6 hours) and from 4 p.m. to 8 p.m. (4 hours).

On November 25, 2025, at 10:20 a.m., an interview was conducted with the SC. The SC stated the facility expectation is for oral care to be provided every two hours to intubated patients.

1c. On November 24, 2025, at 1:59 p.m., Patient 2's medical record was reviewed with the Emergency Department/Intensive Care Unit Director (ED/ICUD). A facility document titled, "History and Physical," dated October 26, 2025, at 12:53 p.m., was reviewed. The document indicated Patient 2 was admitted to the hospital on October 25, 2025, for respiratory failure and was intubated with bilateral lobe pneumonia (serious infection that can inflame and scar the lungs). The document further indicated Patient 2 was intubated.

An facility document titled, "Activities of Daily Living," dated November 16, 2025, through November 23, 2025, was reviewed. The document indicated oral care was not performed for Patient 2 on:

-November 16, 2025, from 10 a.m. to 2 p.m. (4 hours), from 4 p.m. to 6 p.m. (4 hours) and from 8 p.m. to 12 a.m. (4 hours);
-November 17, 2025, from 12 p.m. to 4 p.m. (4 hours); and
-November 23, 2025, from 6 a.m. to 2 p.m. (8 hours).

On November 24, 2025, at 2:17 p.m., an interview with the ED/ICUD was conducted. The ED/ICUD stated Patient 2 was not given oral care according to the facility policy. The ED/ICUD further stated oral care for the intubated patient is to be provided every two hours.

The facility P&P titled, "Ventilator [a medical machine which assists or takes over breathing for a patient who cannot do it adequately on their own] Associated Pneumonia [an infection of the lungs]," dated December 23, 2023, was reviewed. The document indicated, "...Ventilator-associated pneumonia is a lung infection that develops in a person who is on the ventilator...The care of ventilated patients will follow standards of nursing care...for the prevention of ventilator associated pneumonia...Routine Oral Care...Swab, suction, and rinse oral cavity [mouth] every 2 hours with an alcohol free antiseptic solution..."

2a. A tour of the Intensive Care Unit (ICU) was conducted on November 24, 2025, at 9:35 a.m., with the Quality Administrative Director (QAD). During the tour on Unit I, in Patient 2's room, an IV Meropenem (type of antibiotics) for injection and Sodium Chloride (salt water) injection 1gm/50 ml (gram/milliliter, units of measurement) was observed infusing with no date or time labeled on the medication.

An interview was conducted on November 24, 2025, at 9:38 a.m., with the QAD. The QAD stated the two infusing IV bags were not dated, timed, or labeled. The QAD further stated the nurse assigned to the patient should have dated, timed and labeled according to the facility P&P.

An interview was conducted on November 24, 2025, at 9:40 a.m., with the Registered Nurse (RN) 1. The RN 1 stated the IV medications being administered were not labeled properly based on the facility policy. RN 1 further stated the medication should have been labeled with the patient's name, date, and time the medication was started.

A facility document titled, "History and Physical," dated October 26, 2025, at 12:53 p.m., was reviewed. The document indicated Patient 2 was admitted to the hospital on October 25, 2025, for respiratory failure and was intubated, with bilateral lobe pneumonia.

An untitled and undated facility document was reviewed. The document indicated, "...11/16/2025...[November 16, 2025]...07:39 [7:39 a.m.]...MEROPENEM-0.9% SODIUM CHLORIDE 1 GRAM. 50 ML 1 GRAM/50 ML BAG IV...EVERY 8 HOURS...Order Date/Time... 11/16/2025...[November 16, 2025]...07:39 [7:39 a.m.]... Start... 11/16/2025...[November 16, 2025]...Stop...11/27/2025...[November 27, 2025]..."

An undated facility document titled, "Medical Adminstration Record (MAR)," was reviewed. The document indicated, "...Merophenem 0.9% Sodium Chloride [1 GRAM/50 ML]...Piggy Back...INTRAVENOUS EVERY 8 HOURS...Start...11/16/2025...[November 16, 2025]...08:00 [8 a.m.]...08:00/08:04 [8 a.m./8:04 a.m.]..."

2b. A tour of the Intensive Care Unit (ICU) was conducted on November 24, 2025, at 9:25 a.m., with the QAD. During the tour on Unit I, in Patient 21's room there were two IV medications Propofol (short-acting medication used to induce and maintain sleep) and Heparin (blood thinner) observed infusing. The medications were infusing without a label, date, and time on the IV medications accroding to the P&P.

An interview was conducted on November 24, 2025, at 9:30 a.m., with the QAD. The QAD stated the two infusing IV medications were not dated, timed, or labeled. The QAD further stated the nurse assigned to the patient should have dated, timed and labeled according to the facilities P&P.

An interview was conducted on November 24, 2025, at 9:50 a.m., with RN 2. RN 2 stated the IV medication should have been labeled with name, time, and date the medication was started according to the facility P&P.

A facility document titled, "History and Physical," dated November 25, 2025, at 1:30 p.m., was reviewed. The document indicated Patient 21 was admitted on November 23, 2025, for acute metabolic encephalophy and respiratory failure.

An interview was conducted on November 25, 2025, at 1:35 p.m., with the ED/ICUD. The ED/ICUD stated the nurse that administered the medication should have put Patient 21's name, date, and time the medication was started, name of drug and strength of the medicaiton. The ED/ICUD further stated the nurse did not follow the policy.

An undated, facility document, titled, "Ordering" was reviewed. The document indicated, "...November 23, 2025, at 23:14 [11:14 p.m.]...PROPOFOL 10 mg/mL [unit of measurement] 100 ML Intravenous [IV]...on mechanical ventilator...TITRATE [continuously measure and adjust] PER PROTOCOL..."

3. On November 25, 2025, at 8:49 a.m., a review of Patient 3's record was conducted with the ED/ICUD.

A facility documented titled, "History and Physical (H&P)," was reviewed. The document indicated Patient 3 was admitted to the facility on November 24, 2025, for altered level of consciousness (mental state that differs significantly from a waking state), extreme weakness, hypernatremia (abnormally high concentration of sodium in the blood), dehydration (body loses more fluid than it takes in) and a stage 4 decubitus ulcer (a severe, wound that involves damage to muscle, bone, or tendons) on the right hip.

An undated facility document titled, "Order Inquiry," was reviewed. The document indicated on November 24, 2025, Basic Metabolic Panel Calcium (common blood test), total was ordered.

An undated facility document titled, "FLOWSHEETS," was reviewed with the ED/ICUD. The document indicated, "..Glucose [amount of sugar in a persons blood]...Nov. 24, 2025 [November 24, 2025]...11:25 [11:25 a.m.]...523 [normal range of 70 mg/dL (milligrams/decileters unit of measurement)-140 mg/dL]...C [critical]..."

There was no documented evidence the critical lab result for the high glucose was reported to the physician.

On November 25, 2025, at 9:02 a.m., an interview with the ED/ICUD was conducted. The ED/ICUD stated the nurse did not document the critical lab. The ED/ICUD stated the nurse did not document the critical lab was reported to the physician. The ED/ICUD further stated the nurse should have documented the critical lab and reported to the physician right away.

A facility Policy and Procedure (P&P) titled, "Critical lab values and diagnostic test results; notification," dated May 2025, was reviewed. The P&P indicated, "the responsible physician...will be notified as soon as possible, but no later than 60 min..."

Based on interview and record review, the facility failed to maintain a complete medical record for one of 24 sampled patients (Patient 14) when a physician progress note (a medical record created by healthcare providers to document a patient's condition, treatment, and progress on a given day) was not entered into the electronic medical record (EMR).

This failure had the potential to result in medical errors and affect continuity of care (ongoing, consistent, and coordinated care).

Findings:

On November 24, 2025, at 3:05 p.m., a review of Patient 14's medical record was conducted with the Sepsis Coordinator (SC). A facility document titled, "History and Physical," dated August 14, 2025, was reviewed. The document indicated Patient 14 was admitted to the facility on August 13, 2025, with a diagnosis of heart failure (a condition when the heart cannot pump enough blood to meet the body's needs).

A review of Patient 14's daily physician progress notes from August 14, 2025, through August 21, 2025, was conducted with the SC. There was no documented evidence of a progress note on August 17, 2025.

On November 24, 2025, at 3:53 p.m., and interview was conducted with the SC. The SC stated physicians are expected to see their patients daily and document it in the EMR.

A facility document titled, "Rules and Regulations Professional Medical Staff," dated October 2025, was reviewed. The document indicated, "...Progress notes shall be written daily for each patient..."

Based on observation, record review, and interview, the facility failed to maintain accessibility to the emergency department (ED) when the automatic door failed and would not open.

This failure had the potential to delay patient care for patients requiring emergency services at the facility.

Findings:

On November 25, 2025, at 3:15 a.m., the automatic ED access door was observed to not open when approached. There was no signage observed to indicate how patients and visitors could gain access to the ED. There was no observed staff member present at the desk inside the entry way.

On November 25, 2025, at 3:35 a.m., an interview and observation were conducted with the Nursing Supervisor (NS). The NS stated the ED entry door was broken.

A facility document titled, "Work Order," dated November 20, 2025, was reviewed. The document indicated, "...Problems with ER [emergency room] lobby automatic door...needs new controller will order..."

On November 25, 2025, at 5:42 a.m., an interview was conducted with the NS. The NS stated the facility was aware the ED entry door was broken. The NS stated a patient with a disability would probably not have been able to gain access to the facility if they had presented for services.

On November 25, 2025, at 5:53 a.m., an interview was conducted with Patient 24. Patient 24 stated he had to knock on the door and wait for someone to come let him into the facility.

On November 25, 2025, at 5:55 a.m., an interview was conducted with RN 5. RN 5 stated the ED entry door had been broken "off and on." RN 5 stated patients and visitors knock on the door and when registration staff hears them knocking, they go to assist them into the ED.

On November 25, 2025, at 6 a.m., an interview was conducted with Visitor 1. Visitor 1 stated she did not know how to gain entry to the facility when she arrived. Visitor 1 stated she knocked on the window to the waiting room and a patient inside alerted staff to let her in.

On November 25, 2025, at 7:10 a.m., an interview was conducted with the Director of Facilities Management (DFM). The DFM stated a work order had been received on November 20, 2025. The DFM stated the door had been looked at by an electrician the same day. The DFM stated it was determined a replacement part was required; however, it had not been ordered.

The Americans with Disabilities Act (ADA, a civil rights law requiring reasonable accommodations and accessibility in public places) Title III [three] Regulations, dated March 8, 2012, were reviewed. The regulations indicated, "...A public accommodation shall maintain in operable working condition those features of facilities and equipment that are required to be readily accessible to and usable by persons with disabilities..."

The facility policy and procedure (P&P) titled, "Utilities Systems Management Plan," dated January 2025, was reviewed. The P&P indicated, "...The Utility Systems Program provides a process for...maintenance of...equipment to support a safe patient care and treatment environment...The Engineering Department will respond to assess the situation and contact additional assistance if needed..."