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Based on interview and record review, the hospital failed to provide written evidence a patient has the right to formulate an advance directive (a written instruction for health care) for two of 31 sampled patients (Patient 12 and 27). This failure had the potential for patients to not have their healthcare rights and wishes known and honored.

Findings:

Patient 12 was admitted to the hospital on 11/8/24 for altered mental status (a change in mental function that leads to changes in awareness, movement, and behaviors).

During a concurrent interview and record review with the Clinical Educator and Informatics Specialist (CEIS) on 11/13/24 at 2:10 p.m., the CEIS reviewed Patient 12's medical record and she confirmed there was no advance directive on file and had no indication the hospital inquired or provided the patient or patient's representative with information regarding advance directive.

During an interview on 11/13/24 at 2:11 p.m., with the Chief Nursing Officer (CNO), the CNO stated advance directive should be offered during admission when a patient does not have any on file.

Patient 27 was admitted to the hospital on 11/11/24 for labor check (monitoring for signs of labor).

During a concurrent interview and record review with the CEIS on 11/14/23 at 2:10 p.m. the CEIS reviewed Patient 27's medical record and confirmed there was no advance directive documented and no indication the hospital inquired or provided the patient or patient's representative with information regarding advance directive.

During a review of the hospital's policy and procedure (P&P), titled "Advance Directives", revised date 12/2018, indicated "As a part of Watsonville Community Hospital's registration process, the person who documents the patient's admission shall provide the patient with information regarding the patient's rights to make decisions concerning treatment ...The document entitled 'Advance Directives: Your Right to Make Medical Treatment Decisions' is designed this purpose and a copy of this document shall be provided to the patient."

Based on interview and record review, the hospital failed to ensure the registered nurse evaluated the nursing care for seven of 31 sampled patients when :

1. Fall risk assessment was not done and fall intervention not implemented for Patient 1. This failure resulted in nursing staff unaware of Patient 1's risk for fall and pain medication effectiveness.

2. Pain assessment and/or reassessment was not done for Patients 1, 9, 22, 23, 28, and 30. This failure had the potential for Patients 1, 9,22,23,28, and 30 to have continued pain.

Findings:

1. Patient 1 was admitted to the hospital on 9/30/24 for seizure (a sudden change in behavior, movement, and/or consciousness due to abnormal electrical activity in the brain).

During a review of Patient 1's medical record, on 11/13/24 at 10:20 a.m., with the Clinical Educator & Informatics Specialist (CEIS), a physician order of fall risk precautions was placed on 9/30/24 at 1:20 p.m.

During a review of Patient 1's medical record, on 11/13/24 at 1:00 p.m., with the CEIS, a fall risk assessment was done on 9/30/24 with a score of 45 indicating high fall risk.

During an interview, on 11/14/24 at 9:20 a.m., with Registered Nurse (RN) A, RN A stated she did not have a chance to assess Patient 1 for fall risk during her shift on 10/1/24. RN A stated bed alarm was not turned on at that time as a fall precaution intervention.

During a review of Patient 1's medical record on 11/14/24 at 11:07 a.m., with Nursing Manager (NM) C, she confirmed there was no fall risk assessment done on dayshift and nightshift on 10/1/24. NM C stated fall risk assessment needs to be done every shift.

During a review of the hospital's policy and procedure (P&P), titled "Fall Prevention", revised date 5/23, indicated "RN/Licensed staff to complete the fall risk assessment in conjunction with the initial assessment ...complete fall risk (re)assessment with every shift assessment ...ensuring interventions for patients 'At Risk' to fall are implemented ..."


2. Patient 1's pain was assessed and rated at 6 of 10 on 10/1/24 at 9:31 p.m., and hydrocodone-acetaminophen (Norco, used to treat for pain) 5-325 milligrams (mg, unit of measurement) tablet was administered.

During a concurrent interview and record review, on 11/13/24 at 11:21 a.m., with the CEIS, she confirmed no pain reassessment was done within one hour of administration of pain medication.

Patient 9 was admitted to the hospital on 11/11/24 for hip pain.

During a concurrent interview and record review, on 11/13/24 at 2:02 p.m., with the CEIS, Patient 9's pain was assessed and rated at 9 of 10 on 11/12/24 at 7:53 p.m. Hydrocodone-acetaminophen tablet was administered at 8:30 p.m.. The CEIS confirmed no pain reassessment was done.

Patient 22 was admitted to the hospital on 11/9/24 for abdominal pain.

During a concurrent interview and record review, on 11/13/24 at 3:05 p.m., with the CEIS, Patient 22's pain was assessed prior to administration of acetaminophen (Tylenol, used to treat mild to moderate pain) and hydromorphone (Dilaudid, used to treat severe pain) on 11/10/24 at 2:33 p.m., 11/11/24 at 6:51 a.m., 11/11/24 at 6:43 p.m., 11/12/24 at 4:31 a.m., 11/12/24 at 10:45 a.m., 11/12/24 at 2:46 p.m., and 11/12/24 at 8:03 p.m. The CEIS confirmed there was no pain reassessment done.

Patient 23 was admitted to the hospital on 11/10/24 for general weakness.

During a concurrent interview and record review, on 11/14/24 at 1:46 p.m., with the CEIS, Patient 23's pain was assessed, and acetaminophen 650 mg tablet was administered on 11/13/24 at 5:18 a.m. Pain reassessment was done at 8:00 a.m.

Patient 28 was admitted to the hospital on 11/7/24 for general weakness, sore throat.

During a concurrent interview and record review, on 11/14/24 at 2:21 p.m., with the CEIS, Patient 28's pain was rated at 1 of 10 on 11/10/24 at 8:51 p.m., and acetaminophen 650 mg tablet was administered. Pain was assessed and rated at 2 of 10 on 11/12/24 at 8:01 p.m., with acetaminophen tablet administered. The CEIS confirmed no pain reassessment was done.

Patient 30 was admitted to the hospital on 11/11/24 for abdominal pain.

During a concurrent interview and record review, on 11/14/24 at 2:42 p.m., with the CEIS, hydromorphone 0.25 mg IVP (IV push, a process of introducing a medication directly into the bloodstream) was administered on 11/12/24 at 2:52 a.m., with no pain assessment and reassessment done.

During a review of the hospital's policy and procedure (P&P), titled "Pain Assessment and Management Plan, including Safe Opioid Prescribing", revised date 7/22, indicated "It is the responsibility of all clinical staff to assess and reassess the patient for pain and relief from pain ...B. Pain Management: 1. Assess for pain for all patients. 6. Re-assess pain intensi-60 minutes for PO/IM ..."

Based on interview and record review, the hospital failed to ensure nursing staff developed individualized and updated care plans (a tool used to provide nursing care to patients) related to seizure (a sudden change in behavior, movement, and/or consciousness due to abnormal electrical activity in the brain), pain, and fall for four of 31 (Patient 1, 5, 15, and 28) sampled patients when:

1. Patient 1 did not have a care plan initiated for seizure, pain, and fall.

2. Patients 5, 15, and 28 did not have a care plan initiated for pain.

These failures had the potential to result in lack of, or delay in appropriate care and monitoring of these patients.

Findings:

1. Patient 1 presented to the Emergency Department (ED) for nausea (feeling an urge to vomit) , vomiting (the forcible emptying of stomach contents), diarrhea (a condition with having several loose, watery, or liquid bowel movements), and dizziness (feeling of lightheadedness) on 9/30/24. While in the ED, Patient 1 had a generalized tonic-clonic seizure (also known as grand mal seizure, a type of seizure that involves a loss of consciousness and violent muscle contractions) and was subsequently admitted as inpatient to the hospital.

During a review of Patient 1's medical record, on 11/13/24 at 10:20 a.m., a physician order of fall risk precautions and seizure precautions was placed on 9/30/24 at 1:20 p.m..

During a concurrent interview and record review of Patient 1's medical record on 11/13/24 at 10:59 a.m., with the Interim Director Quality and Risk (IDQR), he confirmed a care plan for seizure was not initiated. The IDQR stated there should be a care plan for seizure.

During a concurrent interview and record review of Patient 1's medical record, on 11/13/24 at 11:50 a.m., with the Clinical Educator & Informatics Specialist (CEIS), she stated care plan for pain was not initiated after pain was rated at 6 of 10 and hydrocodone-acetaminophen (Norco, used to treat for pain) 5-325 milligrams (mg, unit of measurement) tablet was administered on 10/1/24 at 9:31 p.m..

During an interview, on 11/15/24 at 10:11 a.m., with Chief Nursing Officer (CNO), she confirmed care plan for fall was not initiated.


2. Patient 5 was admitted to the hospital on 11/10/24 for cerebellar stroke syndrome (impaired blood flow to a part of the brain).

During a concurrent interview and record review, on 11/13/24 at 1:39 p.m., with the CEIS, she confirmed Patient 5's care plan for pain was not initiated after pain assessment and administration of acetaminophen (Tylenol, used to treat pain).

Patient 15 was admitted to the hospital on 11/12/24 for abdominal distention (abdomen expands due to buildup of fluid or gas).

During a concurrent interview and record review, on 11/13/24 at 2:23 p.m., with the CEIS, she confirmed care plan for pain was not initiated after Patient 15's pain rated at 8 of 10 and morphine (a non-synthetic narcotic used to treat severe pain) 2 milligrams (mg, unit of measurement) was administered on 11/12/24 at 7:53 p.m..

Patient 28 was admitted to the hospital on 11/7/24 for general weakness and sore throat.

During a concurrent interview and record review, on 11/14/24 at 2:21 p.m., with the CEIS, she confirmed care plan for pain was not initiated after Patient 28's pain rated at 1 of 10 and acetaminophen 650 milligrams was administered on 11/10/24 at 8:51 p.m..

During a review of the hospital's policy and procedure (P&P), revised date 12/2018, indicated "Inpatients will have a plan of care initiated within 8 hours of admission. For each shift worked, the care plan will be reviewed/updated by the RN. An interdisciplinary plan of care will be documented for all inpatients in the patient's medical record."