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Based on interview and record review, the facility's governing body (responsible for guiding the hospital's long-term goals and policies and assisting with strategic planning and decision-making) failed to ensure oversight in ensuring that all facility employees followed the established policies governing safe patient transfers for one of 30 sampled patients (Patient 1) when:

1. The notification of intent to transfer form was not completed by the facility and signed by the patient representative.
2. The Inter-facility transfer summary form was not filled out by the transferring physician and added into the medical record of Patient 1.
3. The Consent for transfer was not obtained from patient representative nor was it documented including any explanation provided regarding the risks, benefits, and alternatives for the transfer
4. There was no documentation by the transferring physician (MD 1) that Patient 1 was stable for transfer.
5. Staff were not aware of the facility's policy regarding the use of the notification of intent transfer form and the inter-facility transfer summary form

These deficient practices had the potential to place Patient 1 at risk for harm due to inappropriate transfer, potential deterioration of Patient 1's condition during transfer, insufficient communication regarding the patient's status and transfer risks.

Findings:

During a review of Patient 1's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 11/20/2023, the H&P indicated, Patient 1 had past medical history (PMH, a record of medical, personal, and family history that may be relevant to their current illness) of liver cirrhosis (a chronic liver disease characterized by the extensive replacement of healthy liver tissue with scar tissue), End-Stage Renal Disease (ESRD, a permanent condition that occurs when the kidneys stop functioning) with peritoneal dialysis (PD) catheter (a soft plastic tube that is surgically inserted into the abdomen to allow for the treatment of kidney failure) and was admitted to the facility on 11/20/2023 with a diagnosis of small bowel obstruction (SBO, a blockage in the small intestine [gut] that prevents the normal flow of intestinal contents).

During a review of Patient 1's Medical Record (MR) titled, "Progress Note-General Surgery," dated 12/22/2023, the MR indicated that the course was complicated by intraabdominal sepsis [a severe abdominal infection, because of intestinal fluid leakage], which also led to contamination (the introduction of pathogens or infectious material) of the PD tube (later removed). The MR indicated, Patient 1 also experienced ileus, a temporary blockage in the intestines [when something prevents food, liquid, stool, or gas from moving through the intestines normally] that has since resolved, but there have been recurring episodes of possible bleeding in the small intestines, four times so far, and still ongoing, and a fistula (an abnormal connection between an organ) in the digestive tract (a series of hollow organs that food and liquids pass through as they are digested and absorbed, and leaves the body) that was first detected on 12/9/2023.

During a review of Patient 1's medical record (MR) titled, "Intensive Care Unit (ICU, a hospital ward that provides specialized care and monitoring for patients who are seriously ill or injured) Progress Note," dated, 12/21/2023, the MR indicated, on 12/21/2023, Patient 1 required full ventilatory support (a life support system that uses a machine to help a patient breathe when they are unable to do so on their own), was on pressors (medications that increase blood pressure), was on antibiotics (medications to treat bacterial infection), was on TPN (total parenteral nutrition, a method of feeding that provides nutrients directly into the bloodstream through a vein), and continued to experience ongoing GI (Gastrointestinal- stomach and the intestines) bleeding requiring ongoing multiple blood transfusions (provides blood or blood components if you've lost blood due to an injury, during surgery or have certain medical conditions that affect blood or its components). The MR also indicated that Patient 1 had to be transferred to another facility to receive a required procedure called double balloon enteroscopy (DBE, a nonsurgical procedure used to diagnose and treat problems deep within the small bowel) but on 12/21/2023 Patient 1 was deemed unstable for transfer.

During a review of Patient 1's Medical Record (MR) titled, "ICU Update Note," dated 12/22/2023 at 2:12 p.m., the MR indicated, on 12/22/2023, Patient 1 was accepted by the receiving facility for transfer.
During a review of Patient 1's medical record (MR) titled, "Nurse Progress Note," dated 12/22/2023, the MR indicated, "Patient 1's primary nurse gave a report to the transport Registered Nurse (RN), and all drips were transferred to the transport pump. Upon transferring the patient to the stretcher, the patient became bradycardic (heart rate that's too slow), and blood pressure could not be obtained. A Code Blue (hospital emergency code indicating that a patient is in cardiac or respiratory arrest and requires immediate resuscitation efforts) was activated.

During further review of Patient 1's medical chart, dated 12/22/2023, there was no documentation indicating that appropriate transfer consent from Patient 1's representative had been obtained and recorded in the medical record on the day of the transfer, on 12/22/2023. Additionally, the medical record contained no documentation showing that the patient (Patient 1) or their legal representative were notified, both verbally and in writing, that they had been given a complete explanation of the reason for the transfer, as well as the associated risks, benefits, and any alternatives. The MR contained no "Notification of Intent to Transfer" form-a written notice that includes the reason for the transfer, the effective date, the location, and the patient's appeal rights- that was completed and signed by Patient 1 and/or their representative. In addition, there was no physician documentation of the determination that Patient 1 was "Medically Fit to Transfer," that would indicate the patient (Patient 1) was medically stable for transfer (the transfer would not create a medical hazard to the patient) at the time of transfer on 12/22/2024. This record review was verified with the Charge Nurse (CN 4) and the Informatics Nurse (IN 1) on 10/16/2024 at 9:49 a.m.

During an interview on 10/16/2024 at 1:06 p.m. with ICU charge nurse (CN 6) regarding the transfer forms and consents that were required prior to a transfer from the ICU, the CN 6 stated "The physicians are the ones who give us the approval for transfer. Typically, no forms or consents are filled out prior to transfers." CN 6 also stated that they were not fully familiar with the content of the facility's current policy regarding transfers, titled "Patient Transfer General Guidelines," dated 9/2020.

During the same interview on 10/16/2024 at 1:24 p.m. with the house supervisor (Sup 1), the Sup 1 said, "The physician decides on the patient's condition. In the inpatient unit, we don't have any specific forms to sign; everything must be documented in the notes. The sending physician should complete the transfer summary before the patient is transferred. In the inpatient setting, the patient or their family should provide consent, and the physician should document this in their notes. It is important to determine whether the patient is stable or unstable, and we need to ensure that the family consents and understands where and why the patient is being transferred. All of this should be documented by the transferring physician. We want to ensure transfers are safe before they occur to avoid compromising the patient's recovery."

During an interview on 10/17/2024 at 10:22 a.m. with ICU charge nurse (CN 5), CN 5 stated, "The transfer order should be placed by the physician, specifying how, where, and when the transfer will occur. The physician should also include an order for transport, detailing what is required during the transfer and what type of transport is necessary. The transport hub is not staffed by an RN; it's a call center.

During the same interview on 10/17/2024 at 10:22 a.m. with CN 5, CN 5 said the charge nurses are responsible for calling the transport hub. I've been working here for 24 years, and sometimes the hub takes a very long time to answer. I document everything, including how many drips and the ventilator settings (the parameters that control how a ventilator [a machine that helps people breathe when unable to breath on their own] delivers air to a patient). The physician's order should outline all of this information."

During an interview on 10/17/2024 at 12:18 p.m. with the critical care physician (MD 1) regarding the transfer procedures and required forms that need to be completed prior to a transfer from the ICU, MD 1 stated, "Typically, we don't fill out any forms when the transfer is within the same organization." MD 1 further said, "At the time I saw the patient, the patient was pretty sick and was bleeding from an unknown source. The patient (Patient 1) needed a procedure that required transfer to another facility. The patient's representative was aware of the transfer. On the day of the transfer, during my shift, the patient (Patient 1) was stable."

During the same interview on 10/17/2024 at 12:18 p.m. with the critical care physician (MD 1), MD 1 stated, "I ordered to discharge Patient 1 with ACLS (Advanced Cardiac Life Support- a set of clinical guidelines for the urgent and emergent treatment of life-threatening conditions that could lead to cardiac arrest [when the heart stops beating], etc.) transport. Since the patient (Patient 1) was on a ventilator, the Respiratory Therapist should have likely accompanied the patient for transport as well." MD 1 also stated, "At the time of transfer, if the patient had not been stable, I would not have approved the transfer. Stability can change, and I don't know what happened after I left the hospital. The telecritical care (TCC) physicians (tele-ICU physicians, are healthcare providers who remotely monitor and manage critically ill patients in intensive care units (ICUs) using telemedicine technology) take over at 7:00 p.m."

During the same interview on 10/17/2024 at 12:18 p.m. with MD 1, the MD 1 stated, "We sign out to the TCC doctor, and once they receive the sign-out, they review the chart and round with the nurses. If there are any issues with the patient, they address them. If there were signs of instability and the patient was decompensating, the nurses would likely notify them."

During an interview on 10/18/2024 at 9:25 a.m. with the Accreditation, Regulatory, and Licensing Director (ARLD) the ARLD stated, "Our facility follows both regional [Organization] and local (specific to one facility) policies. If a regional policy is sent to the hospital, it must be implemented. If we have a local policy, we will have to archive it and adopt the regional one. However, if the local policy is more stringent than the regional one, the more stringent policy is typically implemented. Our facility has a more stringent transfer policy than the regional one which means we have to follow it."

During an interview on 10/18/2024 at 9:25 a.m. with the ARDL (who is a member of the local governing body structure at the facility and a member of the Quality Oversight Committee [QOC]), regarding the facility's local organizational structure and responsibilities for policy reviews, approval, and implementation process, the ARDL stated that the owner of the local transfer policy titled, "Patient Transfer General Guidelines" (dated September 2020), was the Nursing Service Director (NSD). The NSD was responsible for reviewing, approving, and ensuring the implementation of the policy, as well as overseeing that staff follow it. When the policy is due for review, the NSD is tasked with revising and approving the policy before forwarding it to the Quality Oversight Committee for further review and approval.

During the same interview on 10/18/2024 at 9:25 a.m. with the Accreditation, Regulatory, and Licensing Director (ARLD), regarding the local facility's policy and procedure (P&P) titled, "Patient Transfer General Guidelines," dated 9/2020, the ARLD stated, "There is no local policy committee. We are in the process of doing a major overhaul of the policy portal. The policy was due for review in 2023 but it has not come up for a review yet. I have oversight over policies. We had a policy portal, and we are working on uploading all the policies. We have identified the need for some cleanup. The system will notify us when policies are due for review and will update the policy owners. It will highlight which policies are up for review."

During an interview on 10/18/2024 at 10:28 a.m. with the ICU department administrator (DA 1) regarding transport and transfer arrangements for ICU patients, DA 1 stated, "From a nursing perspective, we call the transport hub (a call center that coordinates with contracted ambulance services for transport), provide the patient's status, including drips (a method of delivering fluids, nutrients, or medicine directly into a patient's bloodstream through a vein), and give the necessary information. The transportation hub then decides on the appropriate transport based on that information. When transport team arrives, the primary nurse would give report, and she/he doesn't necessarily need to remain with the patient for the entire process. It may take about 45 minutes for the transport team to check vital signs and complete the transfer. Sometimes, the transport RN may decide not to take the patient and refuse the transfer based on established criteria."

During the same interview on 10/18/2024 at 10:28 a.m. with DA 1, the DA 1 stated, "The nurse is responsible for assessing whether the patient is deteriorating and for communicating that to the physician to determine if the patient is stable or unstable. As far as I know, we don't have any transfer forms signed by the physician that indicate if the patient is stable or unstable, and I have been working here for 10 years."

During an interview on 10/18/2024 at 12:54 p.m. with the Regional Director for Medical Transportation Services (RDMT), [a title held in 2023], the RDMT stated, "The transportation hub serves as the point of contact for medical centers when a [Organization] member needs a transfer. We coordinate non-emergency medical transportation. Our job is to maintain a network of contracted providers/suppliers to meet [Organization] demand. We receive reports regarding patient status from the medical facility either via phone or digitally. We are essentially a call center that processes the request to ensure the level of service the clinician has requested is fulfilled. The transport supplier then dispatches the appropriate team based on the information provided. They follow their own guidelines, policies, and procedures, as each county may have different requirements for transport."

During an interview on 10/18/2024 at 11:00 a.m. with the Vice President and General Manager of Operations for the contracted transport company (VPGM), the VPGM stated, "We typically receive a patient care report from the transportation hub. We ask if the patient is stable or unstable. We review the transport request, such as whether ACLS (Advanced Cardiovascular Life Support Transport, equipped to handle patients with critical cardiac conditions or other emergencies that may need immediate intervention, such as defibrillation, advanced airway management, and administration of specific medications) or CCT (Critical Care Transport, highly specialized service designed for critically ill or injured patients who need continuous monitoring and treatment during transport.

During the same interview on 10/18/2024 at 11:00 a.m., the VPGM also said "it involves a higher level of care than ACLS transport, including ventilator support, multiple intravenous drips, and complex monitoring. CCT is often staffed by a critical care team, which may include a critical care nurse, respiratory therapist, and sometimes a physician, depending on the patient's needs) is needed, we decide if we agree with the request or if additional staff are required. We follow our own policies and procedures that are based on county's guidelines, and we are not required to check for any forms when we pick up a patient for transport. For example, if the patient is on multiple devices, receiving an excessive number of drips, or on a ventilator, we may send another staff member for monitoring."

During the same interview on 10/18/2024 at 11:00 a.m., the VPGM stated "For patient (Patient 1), we determined that one RN and two EMTs (Emergency Medical Technicians, trained to respond to emergency situations and are skilled in basic life-saving techniques, such as CPR, airway management, wound care, and patient stabilization. EMTs typically work alongside paramedics and other medical personnel during medical emergencies and in transport situations, but they do not perform the more advanced procedures handled by paramedics or critical care teams) were sufficient based on the report we received from the hub. The report indicated that the patient was stable."

During a review of the document provided by the facility titled, "Transport Request," dated 10/22/2023 at 9:21 p.m., the record indicated that the request for the level of service was for Critical Care Transport (CCT) due to Patient 1 being on multiple drips and requiring ventilator support.

During a review of the facility's policy and procedure (P&P) titled, "Patient Transfer General Guidelines," dated 9/2020, the P&P indicated that it applies to all employees of the organization to ensure the continuity of safe and high-quality medical and nursing care for patients being transferred to another facility of equal or higher care level. The P&P indicated the following:

... 5. Before a patient is transferred, both the transferring and receiving facilities must ensure that appropriate consent has been obtained and documented.

1. Steps in the Transfer Process: Transferring physician obtains informed consent from patient and documents on "Notification of Intent to Transfer."

... 7.4. The patient or their legal representative must be notified both verbally and in writing. They must also be given a complete explanation of the reason for the transfer, as well as the risks, benefits, and any alternatives.

7.4. The patient or their legal representative must be notified (of transfer) both verbally and in writing. They must also be given a complete explanation of the reason for the transfer, as well as the risks, benefits, and any alternatives.
8. If the patient has an unstable emergency medical condition but requires transfer for their medical benefit, they must sign a "Notification of Intent to Transfer" form.

... 8.1 The responsible practitioner shall explain and document in the progress notes, the risks and alternatives of the recommended therapeutic course to the patient, including the risks of transfer, and obtain consent.

... 8.8. The "Inter-Hospital Transfer Summary" form must be completed at the time of transfer. In determining that it is to the patient's medical benefit to affect a transfer, the responsible practitioner shall determine that the medical benefits expected from the provision of appropriate medical treatment at the receiving medical facility outweigh any increased risks caused by such transfer. The practitioner shall list such risks and benefits of the transfer as a part of a dictated transfer summary or transfer progress note and on "Inter-hospital Transfer Summary."

... 10. Except as provided in this policy, or unless otherwise agreed upon by both facilities and documented in the patient's medical record, responsibility for the patient during transport shall remain with the facility from which patient is being transferred. Such responsibility shall include:
10.1 The determination of the mode of transportation to be used
10.2 The provision of all equipment, supplies, drugs, and personnel which may be required during the transport; and
10.3 The instruction of transporting attendants relative to the patient's diagnosis, medications, possible untoward reactions and monitoring requirements.

... 12. The transferring physician and facility have specific responsibilities: a. The transferring physician must determine whether the patient is "Medically Fit to Transfer." This decision should follow facility protocols to ensure that the transfer does not pose a medical risk to the patient. The physician must document this determination in the patient's medical record. c. The patient must be informed about the need for the transfer, any alternatives, the proposed transportation plans, and the benefits and risks associated with the transfer. This explanation should focus on risks and benefits specifically related to the patient's condition and the procedure requiring the transfer. The transferring physician must document this discussion in the patient's medical record.

13. Admitting/ED/Nursing Services are responsible for ensuring that this policy and procedure is accurate, relevant, and current.

14. The policy and procedure shall be reviewed at least every three years, and revised periodically, to assure continuing relevance and compliance with regulatory and accrediting standards, hospital bylaws, rules and regulations, legal statues, and current practice.

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

1. The facility failed to ensure one of 30 sampled patients (Patient 27), was provided a copy of the "Condition of Admission (COA, a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.)" in Patient 27's and/or their representative's preferred language, in accordance with the facility's policy and procedure regarding Patient Rights (a subset of human rights).

This deficient practice resulted in Patient 27 and/or Patient 27's representative not being able to fully understand and exercise his rights as patient, which may lead to Patient 27's inability to effectively make decisions regarding own care and treatment in the facility. (Refer to A-0117)

2. The facility failed to ensure for one of 30 sampled patients (Patient 30), Patient 30 and Patient 30's family member, was involved in the patient's plan of care when, Patient 30's education regarding Enoxaparin (blood thinner medication), given by Registered Nurse 1 (RN 1), was not in Patient 30's preferred language (Spanish).

This deficient practice resulted in Patient 30 not being able to fully understand the benefits and use of the medication which may result in Patient 30 to not comply with taking the medication. In addition, this deficient practice resulted in Patient 30 not understanding the possible adverse side effect of the medication which could cause negative effect on the patient's health condition. (Refer to A-0130)

3. The facility failed to ensure that appropriate consent for transfer was obtained and documented for one of 30 sampled patients (Patient 1) and/or Patient 1's representative that would indicate that the patient (Patient 1) and/or their representative was provided, both verbally and in writing, a complete explanation of the reason for transfer, the risks, benefits, and any alternatives to the transfer, in accordance with the facility's policy and procedure regarding patient transfers.

This deficient practice had the potential to compromise Patient 1 and/or Patient 1's representative to make informed decisions (a choice made after gathering all relevant information and analyzing the potential outcomes, benefits, and risks of each option) regarding his care and be able to request or refuse treatment. (Refer to A-0131)

4. The facility failed to ensure that for one out of 30 sampled patients (Patient 1), the process of transfer to another facility was implemented in accordance with the facility's policies and procedures regarding patient transfers when, the facility failed to ensure that the "Notification of Intent to Transfer" form-a written notice that includes the reason for the transfer, the effective date, the location, and the patient's appeal rights-was completed and signed by Patient 1 and/or Patient 1's representative on the day of the transfer. In addition, the facility failed to document (in Patient 1's medical chart) the determination that Patient 1 was "Medically Fit to Transfer," that would indicate that the patient (Patient 1) was medically stable for transfer (the transfer would not create a medical hazard to the patient).

This deficient practice had the potential to place Patient 1's life and safety at risk due to inappropriate transfer or potential deterioration of Patient 1's condition during transfer. (Refer to A-0144)

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

Based on interview and record review, the facility failed to ensure one of 30 sampled patients (Patient 27), was provided a copy of the "Condition of Admission (COA, a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.)" in Patient 27's and/or their representative's preferred language, in accordance with the facility's policy and procedure regarding Patient Rights (a subset of human rights).

This deficient practice resulted in Patient 27 and/or Patient 27's representative not being able to fully understand and exercise his rights as patient, which may lead to Patient 27's inability to effectively make decisions regarding own care and treatment in the facility.

Findings:

During a review of Patient 27's "Face Sheet (a document containing a patient's medical and demographic information)," (undated), the Face Sheet indicated Patient 27 was admitted to the facility on 10/2/2024, with a medical diagnosis of pneumonia (an infection/inflammation in the lungs). The Face Sheet further indicated that Patient 27's preferred language was Spanish.

During a concurrent interview and record review on 10/16/2024 at 10:20 a.m. with Charge Nurse 1 (CN 1), Patient 27's "Hospital Conditions of Admission - COA (a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.)," dated 10/2/2024, was reviewed. Patient 27's COA was written in English and was signed by Patient 27's representative. Patient 27's signed COA did not indicate an interpreter (helps the patient and the provider fully understand each other to reduce the risks associated with misunderstanding a diagnosis or treatment plan) was used.

During the same interview on 10/16/2024 at 10:20 a.m., CN 1 stated Patient 27's preferred language was Spanish, and he (CN 1) was not aware if Patient 27's representative understands English. CN 1 further said, it was important for the patient and their representative to receive legal documents in their preferred language, so they know what they are signing.

During a phone interview on 10/16/2024 at 10:28 a.m., with Patient 27's representative, Patient 27's representative stated Patient 27 and herself do not speak and/or understand English. Patient 27's representative stated she (Patient 27's interpreter) signed Patient 27's COA, given in English, and was not offered a written Spanish COA or use an interpreter prior to signing the COA written in English.

During review of the facility's Policy and Procedure (P&P) titled, "Patient Rights and Responsibilities," revised 10/2022, the P&P indicated, "Patient Rights, you have the right to...Receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms you can understand. 5. Make decisions regarding medical care and receive as much information about any proposed treatment or procedure as you may need in order to give informed consent or to refuse a course of treatment."

During a review of the facility's policy and procedure (P&P) titled, "Qualified Interpreter Services for limited English Proficient persons," revised 11/2023, the P&P indicated, "Qualified interpreter services are provided during all hours of operation at no cost to members/patients, their medical decision makers, and their companions ...Language assistance is provided 24 hours a day, 7 days a week."

Based on observation, interview, and record review, the facility failed to ensure for one of 30 sampled patients (Patient 30), Patient 30 and Patient 30's family member, was involved in the patient's plan of care when, Patient 30's education regarding Enoxaparin (blood thinner medication), given by Registered Nurse 1 (RN 1), was not in Patient 30's preferred language (Spanish).

This deficient practice resulted in Patient 30 not being able to fully understand the benefits and use of the medication which may result in Patient 30 to not comply with taking the medication. In addition, this deficient practice resulted in Patient 30 not understanding the possible adverse side effect of the medication which could cause negative effect on the patient's health condition.

Findings:

During a review of Patient 30's "Face Sheet (front page of the chart that contains a summary of basic information about the resident)," (undated), the face sheet indicated, Patient 30 was admitted to the facility on 10/14/2024, with a medical diagnosis of Acute (severe and sudden) on chronic (persisting for a long time) hypoxemic (low levels of oxygen in blood) respiratory failure (when lungs cannot exchange oxygen). The face sheet further indicated, Patient 30's spoken, and written language was Spanish.

During a review of Patient's 30's "Medication Detail," dated 10/14/2024, the record indicated, a physician's order of Enoxaparin injection 40 mg every 24 hours SQ (Subcutaneous injection, beneath the skin or under all the layers of the skin).

During an observation on 10/15/2024 at 12:38 p.m. with the Quality Coordinator (QCRN), RN 1 was observed inside Patient 30's room, RN 1 was in the process of administering Enoxaparin 40 milligram (mg, metric unit of measurement, used for medication dosage and/or amount) subcutaneous injection to the patient (Patient 30). Patient 30's family member, who was at the bedside, spoke in Spanish and inquired about Patient 30's medication. RN 1 responded in English and told Patient 30's family member, "it's a blood thinner," no interpreter was observed used.

During the same observation on 10/15/24 at 12:38 a.m., Patient 30 and the patient's family member stated, they did not understand English very well and would like to know what medication was given to Patient 30. Patient 30's family member stated she had a lot of questions regarding the medication.

During an interview on 10/15/24 at 12:50 p.m., with RN 1, RN 1 stated Patient 30's family member can sometimes understand English. RN 1 said she used the language line (a company that provides language services for facilities for interpretation and translation) when she needs to establish line of communication with the patient that do not speak or understand English. RN 1 further stated it was important to use the language line with patients that do not speak or understand English when administrating medication, so the patient could understand what medication was being administered.

During an interview on 10/15/2024 at 1:00 p.m. with the Department Administrator (FDA), the FDA stated the nurses should use the language line if the patient's preferred language was not English.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," revised 10/2018, indicated, "Patient (and/or authorized family members) has the right to be informed of the medication being administered, purpose, action and potential side effects."

During a review of the facility's policy and procedure (P&P) titled, "Qualified Interpreter Services for limited English Proficient persons," revised 11/2023, indicated, "Any member/patient who expresses a preference for a non-English language, including Sign language or demonstrates a need for interpreter services is offered the use of qualified Interpreter Services at all administrative and clinical points of contact during all hours of operation at no charge to the member/patient."

Based on interview and record review, the facility failed to ensure that appropriate consent for transfer was obtained and documented for one of 30 sampled patients (Patient 1) and/or Patient 1's representative that would indicate that the patient (Patient 1) and/or their representative was provided, both verbally and in writing, a complete explanation of the reason for transfer, the risks, benefits, and any alternatives to the transfer, in accordance with the facility's policy and procedure regarding patient transfers.

This deficient practice had the potential to compromise Patient 1 and/or Patient 1's representative to make informed decisions (a choice made after gathering all relevant information and analyzing the potential outcomes, benefits, and risks of each option) regarding his care and be able to request or refuse treatment.

Findings:

During a review of Patient 1's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 11/20/2023, the H&P indicated, Patient 1 had past medical history (PMH, a record of medical, personal, and family history that may be relevant to their current illness) of liver cirrhosis (a chronic liver disease characterized by the extensive replacement of healthy liver tissue with scar tissue), End-Stage Renal Disease (ESRD, a permanent condition that occurs when the kidneys stop functioning) with peritoneal dialysis (PD) catheter (a soft plastic tube that is surgically inserted into the abdomen to allow for the treatment of kidney failure) and was admitted to the facility on 11/20/2023 with a diagnosis of small bowel obstruction (SBO, a blockage in the small intestine [gut] that prevents the normal flow of intestinal contents).

During a review of Patient 1's medical record (MR) titled, "Progress Note-General Surgery," dated 12/22/2023, the MR indicated, during the course of admission (11/20/2023 through 12/22/2023), Patient 1 underwent exploratory laparotomy (ex-lap, a major surgical procedure that involves making a large incision in the abdomen), three (3) repairs of enterotomies (a surgical procedure that involves repairing an incision into the intestine), debridement of midline and port site wounds (removing dead skin and foreign material from a wound), removal of PD catheter, then esophagogastroduodenoscopy (EGD, a diagnostic procedure that allows a doctor to examine the upper gastrointestinal [GI, gastrointestinal- made up of the stomach and the intestines] tract) and colonoscopy (a procedure in which a flexible fiber-optic instrument is inserted through the anus in order to examine the colon) complicated by (c/b) evisceration (protrusion of internal organs through a surgical wound or incision) and laceration by fascial sutures (that the sutures placed in the fascia [the connective tissue layer just below the skin and fat] were either torn or cut, causing a disruption of the wound's closure) of small bowel loop (refers to a segment or loop of the small intestine). The MR indicated, Patient 1 then required another surgery to remove part of the intestine and reconnect it, with the wound being closed only at the skin level.

During further review of Patient 1's MR titled, "Progress Note-General Surgery," dated 12/22/2023, the MR indicated that the course was complicated by intraabdominal sepsis [a severe abdominal infection, because of intestinal fluid leakage, which also led to contamination (the introduction of pathogens or infectious material)] of the PD tube (later removed). The MR indicated, Patient 1 also experienced ileus, a temporary blockage in the intestines that has since resolved, but there have been recurring episodes of possible bleeding in the small intestines, four times so far, and still ongoing, and a fistula (an abnormal connection between an organ) in the digestive tract that was first detected on 12/9/2023.

During a review of Patient 1's medical record (MR) titled, "Intensive Care Unit (ICU, a hospital ward that provides specialized care and monitoring for patients who are seriously ill or injured) Progress Note," dated, 12/21/2023, the MR indicated, on 12/21/2023, Patient 1 required full ventilatory support (a life support system that uses a machine to help a patient breathe when they are unable to do so on their own), was on pressors (medications that increase blood pressure), was on antibiotics (medications to treat bacterial infection), was on TPN (total parenteral nutrition, a method of feeding that provides nutrients directly into the bloodstream through a vein), and continued to experience ongoing GI bleeding requiring ongoing multiple blood transfusions (provides blood or blood components if you've lost blood due to an injury, during surgery or have certain medical conditions that affect blood or its components). The MR also indicated that Patient 1 had to be transferred to another facility to receive a required procedure called double balloon enteroscopy (DBE, a nonsurgical procedure used to diagnose and treat problems deep within the small bowel) but on 12/21/2023 Patient 1 was deemed unstable for transfer.

During a review of Patient 1's medical record (MR) titled, "ICU Progress Note," dated, 12/22/2023 at 8:00 a.m., the MR indicated, Patient 1's possible transfer was still pending.

During a review of Patient 1's MR titled, "ICU Update Note," dated 12/22/203 at 2:12 p.m., the MR indicated, on 12/22/2023, Patient 1 was accepted by the receiving facility for transfer.

During further review of Patient 1's medical chart, dated 12/22/2023, there was no documentation indicating that appropriate transfer consent from Patient 1 or Patient 1's representative had been obtained and recorded in the medical record on the day of the transfer, on 12/22/2023. Additionally, the medical record contained no documentation showing that the patient (Patient 1) or their legal representative were notified, both verbally and in writing, that they had been given a complete explanation of the reason for the transfer, as well as the associated risks, benefits, and any alternatives. This record review was verified on 10/16/2024 at 9:49 a.m. with the Charge Nurse (CN 4) and the Informatics Nurse (IN 1).

During an interview on 10/16/2024 at 1:06 p.m. with ICU charge nurse (CN 6) regarding the transfer forms and consents that were required prior to a transfer in the ICU, the CN 6 stated "The physicians are the ones who give us the approval for transfer. Typically, no forms or consents are filled out prior to transfers." CN 6 also stated that they were not fully familiar with the content of the facility's current policy regarding transfers titled, "Patient Transfer General Guidelines," dated 9/2020.

During an interview on 10/17/2024 at 10:22 a.m. with ICU charge nurse (CN 5) regarding the transfer forms and consents that were required prior to a transfer from the ICU, the CN 5 stated that the facility does not have a flowsheet or specific form that must be completed prior to a patient's transfer to another facility. CN 5 stated that all consents were typically documented in the physician's notes, but it depends on what the physician chooses to document.

During an interview on 10/17/2024 at 12:18 p.m. with the ICU physician (MD 1) regarding the transfer procedures, forms, and consents required prior to a transfer from the ICU, MD 1 stated that typically physicians do not fill out any forms or obtain official consents before a transfer. During the same interview, when discussing Patient 1's transfer process on 12/22/2024, MD 1 stated that no consent for the transfer was obtained from Patient 1 or Patient 1's representative. However, MD 1 said that Patient 1's representative was aware of the transfer and understood that it was necessary because the required procedure could only be performed at a different facility, as Patient 1 continued to experience bleeding from an unknown source. MD 1 also stated that they were not fully familiar with the content of the facility's policy regarding patient transfers titled, "Patient Transfer General Guidelines," dated 9/2020.

During an interview on 10/18/2024 at 10:28 a.m. with the ICU department administrator (DA 1) regarding the transfer procedures, forms, and consents required prior to a transfer in the ICU, the DA 1 stated, "Prior to any patient transfer, nurses should ensure that the physician's documentation reflects whether the physician obtained acceptance from the receiving facility, secured a bed, and communicated with the patient or family regarding the transfer. This conversation should take place on the day of the transfer or discharge." The DA also added, "As far as I know, we don't have any transfer forms or consent for transfer that are signed by the physician, and I have been working here for some time." The DA 1 also stated that they were not fully familiar with the content of the facility's policy regarding patient transfers titled, "Patient Transfer General Guidelines," dated 9/2020.

During a review of the facility's policy and procedure (P&P) titled, "Patient Transfer General Guidelines," dated 9/2020, the P&P indicated that it applies to all employees of the organization to ensure the continuity of safe and high-quality medical and nursing care for patients being transferred to another facility of equal or higher care level. The P&P indicated the following:
... 5. Before a patient is transferred, both the transferring and receiving facilities must ensure that appropriate consent has been obtained and documented.
... 7.4. The patient or their legal representative must be notified both verbally and in writing. They must also be given a complete explanation of the reason for the transfer, as well as the risks, benefits, and any alternatives.

Based on interview and record review, the facility failed to ensure that for one of 30 sampled patients (Patient 1), the process of transfer to another facility was implemented in accordance with the facility's policies and procedures regarding patient transfers when, the facility failed to ensure that the "Notification of Intent to Transfer" form-a written notice that includes the reason for the transfer, the effective date, the location, and the patient's appeal rights-was completed and signed by Patient 1 and/or Patient 1's representative on the day of the transfer. In addition, the facility failed to document (in Patient 1's medical chart) the determination that Patient 1 was "Medically Fit to Transfer," that would indicate that the patient (Patient 1) was medically stable for transfer (the transfer would not create a medical hazard to the patient).

This deficient practice had the potential to place Patient 1's life and safety at risk due to inappropriate transfer or potential deterioration of Patient 1's condition during transfer.

Findings:

During a review of Patient 1's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 11/20/2023, the H&P indicated, Patient 1 had past medical history (PMH, a record of medical, personal, and family history that may be relevant to their current illness) of liver cirrhosis (a chronic liver disease characterized by the extensive replacement of healthy liver tissue with scar tissue), End-Stage Renal Disease (ESRD, a permanent condition that occurs when the kidneys stop functioning) with peritoneal dialysis (PD) catheter (a soft plastic tube that is surgically inserted into the abdomen to allow for the treatment of kidney failure) and was admitted to the facility on 11/20/2023 with a diagnosis of small bowel obstruction (SBO, a blockage in the small intestine [gut] that prevents the normal flow of intestinal contents).

During a review of Patient 1's medical record (MR) titled, "Progress Note-General Surgery," dated 12/22/2023, the MR indicated, during the course of admission (11/20/2023 through 12/22/2023), Patient 1 underwent exploratory laparotomy (ex-lap, a major surgical procedure that involves making a large incision in the abdomen), three (3) repairs of enterotomies (a surgical procedure that involves repairing an incision into the intestine), debridement of midline and port site wounds (removing dead skin and foreign material from a wound), removal of PD catheter, then esophagogastroduodenoscopy (EGD, a diagnostic procedure that allows a doctor to examine the upper gastrointestinal [GI- Gastrointestinal, includes the stomach and the intestines] tract) and colonoscopy (a procedure in which a flexible fiber-optic instrument is inserted through the anus in order to examine the colon) complicated by (c/b) evisceration (protrusion of internal organs through a surgical wound or incision) and laceration by fascial sutures (that the sutures placed in the fascia [the connective tissue layer just below the skin and fat] were either torn or cut, causing a disruption of the wound's closure) of small bowel loop (refers to a segment or loop of the small intestine). The MR indicated, Patient 1 then required another surgery to remove part of the intestine and reconnect it, with the wound being closed only at the skin level.

During further review of Patient 1's Medical Record titled, "Progress Note-General Surgery," dated 12/22/2023, the MR indicated that the course was complicated by intraabdominal sepsis, a severe abdominal infection, because of intestinal fluid leakage, which also led to contamination (the introduction of pathogens or infectious material) of the PD tube (later removed). The MR indicated, Patient 1 also experienced ileus, a temporary blockage in the intestines that has since resolved, but there have been recurring episodes of possible bleeding in the small intestines, four times so far, and still ongoing, and a fistula (an abnormal connection between an organ) in the digestive tract that was first detected on 12/9/2023.

During a review of Patient 1's medical record (MR) titled, "Intensive Care Unit (ICU, a hospital ward that provides specialized care and monitoring for patients who are seriously ill or injured) Progress Note," dated 12/21/2023, the MR indicated, on 12/21/2023, Patient 1 required full ventilatory support (a life support system that uses a machine to help a patient breathe when they are unable to do so on their own), was on pressors (medications that increase blood pressure), was on antibiotics (medications to treat bacterial infection), was on TPN (total parenteral nutrition, a method of feeding that provides nutrients directly into the bloodstream through a vein), and continued to experience ongoing GI bleeding requiring ongoing multiple blood transfusions (provides blood or blood components if you've lost blood due to an injury, during surgery or have certain medical conditions that affect blood or its components). The MR also indicated that Patient 1 had to be transferred to another facility to receive a required procedure called double balloon enteroscopy (DBE), a nonsurgical procedure used to diagnose and treat problems deep within the small bowel) but on 12/21/2023 Patient 1 was deemed unstable for transfer.


During a review of Patient 1's medical record (MR) titled, "Progress Note-General Surgery," dated 12/22/2023, the MR indicated that on 12/22/2023 Patient 1 was stable for transfer when accepted by the receiving facility.

During a review of Patient 1's medical record (MR) titled, "ICU Progress Note," dated 12/22/2023 at 8:00 a.m., the MR indicated, Patient 1's possible transfer was still pending.

During a review of Patient 1's Medical Record titled, "ICU Update Note," dated 12/22/203 at 2:12 p.m., the MR indicated, Patient 1 was accepted by the receiving facility for transfer.

During further review of Patient 1's medical record (MR), dated 12/22/2023, the medical record contained no documentation showing that the patient (Patient 1) or their legal representative were notified, both verbally and in writing, that they had been given a complete explanation of the reason for the transfer, as well as the associated risks, benefits, and any alternatives. The MR contained no "Notification of Intent to Transfer" form-a written notice that includes the reason for the transfer, the effective date, the location, and the patient's appeal rights- that was completed and signed by Patient 1 and/or their representative on the day of the transfer. In addition, there was no physician documentation of the determination that Patient 1 was "Medically Fit to Transfer," that would indicate that the patient (Patient 1) was medically stable for transfer (the transfer would not create a medical hazard to the patient) at the time of transfer on 12/22/2024. This record review was verified with the Charge Nurse (CN 4) and the Informatics Nurse (IN 1) on 10/16/2024 at 9:49 a.m.

During an interview on 10/16/2024 at 1:06 p.m. with ICU charge nurse (CN 6) regarding the transfer forms and consents that are required prior to a transfer in the ICU, the CN 6 stated "The physicians are the ones who give us the approval for transfer. Typically, no forms or consents are filled out prior to transfers." CN 6 also stated that they were not familiar with the content of the facility's current policy regarding transfers.

During the same interview on 10/16/2024 at 1:24 p.m. with Sup 1, the Sup 1 said,
"The physician decides on the patient's condition. In the inpatient unit, we don't have any specific forms to sign; everything must be documented in the notes. The sending physician should complete the transfer summary before the patient is transferred. In the inpatient setting, the patient or their family should provide consent, and the physician should document this in their notes. It is important to determine whether the patient is stable or unstable, and we need to ensure that the family consents and understands where and why the patient is being transferred. All of this should be documented by the transferring physician. We want to ensure transfers are safe before they occur to avoid compromising the patient's recovery."

During an interview on 10/17/2024 at 10:22 a.m. with ICU charge nurse (CN 5) regarding the transfer forms and consents that were required prior to a transfer from the ICU, the CN 5 stated, "All our patients are very critical in the ICU. The transfer order should be placed by the physician, specifying how, where, and when the transfer will occur. For the ICU, we don't have a flowsheet or specific forms. The consent for transfer is documented by the doctor in their notes, and it depends on the physician what gets documented. We print out the Interfacility Transfer form, and everything must be printed out, including the History & Physical (H&P), the summary, and the entire packet. For interfacility transfers between [Organization] locations, they can access the patient's chart and see everything. Some clerks tell me the patient is going to the same organization, and we remind them that we need to prepare the discharge entire packet in case the patient has to be diverted to another facility."

During an interview on 10/17/2024 at 12:18 p.m. with the ICU physician (MD 1) regarding the transfer procedures and required forms that need to be completed prior to a transfer from the ICU, MD 1 stated, "Typically, we don't fill out any forms when the transfer is within the same organization." MD 1 further said, "At the time I saw the patient, the patient was pretty sick and was bleeding from an unknown source. The patient (Patient 1) needed a procedure that required transfer to another facility. The patient's representative was aware of the transfer. On the day of the transfer, during my shift, the patient (Patient 1) was stable. At the time of transfer, if the patient had not been stable, I would not have approved the transfer. Stability can change, and I don't know what happened after I left the hospital. The telecritical care (TCC) physicians (tele-ICU physicians, are healthcare providers who remotely monitor and manage critically ill patients in intensive care units (ICUs) using telemedicine technology) take over at 7:00 p.m."

During the same interview on 10/17/2024 at 12:18 p.m. with MD 1, the MD 1 stated, "We sign out to the TCC doctor, and once they receive the sign-out, they review the chart and round with the nurses. If there are any issues with the patient, they address them. If there were signs of instability and the patient was decompensating, the nurses would likely notify them."

During an interview on 10/18/2024 at 10:28 a.m. with the ICU department administrator (DA 1) regarding the transfer procedures, forms, and consents required prior to a transfer from the ICU, the DA 1 stated, "Prior to any patient transfer, nurses should ensure that the physician's documentation reflects whether the physician obtained acceptance from the receiving facility, secured a bed, and communicated with the patient or family regarding the transfer. This conversation should take place on the day of the transfer or discharge."
During the same interview on 10/18/2024 at 10:28 a.m. with DA 1, the DA stated, "The nurse is responsible for assessing whether the patient is deteriorating and for communicating that to the physician to determine if the patient is stable or unstable. As far as I know, we don't have any transfer forms signed by the physician that indicate if the patient is stable or unstable, and I have been working here for 10 years."

During a review of the facility's policy and procedure (P&P) titled, "Patient Transfer General Guidelines," dated 9/2020, the P&P indicated that it applies to all employees of the organization to ensure the continuity of safe and high-quality medical and nursing care for patients being transferred to another facility of equal or higher care level. The P&P indicated the following:
... 7.4. The patient or their legal representative must be notified (of transfer) both verbally and in writing. They must also be given a complete explanation of the reason for the transfer, as well as the risks, benefits, and any alternatives.
... 8. If the patient has an unstable emergency medical condition but requires transfer for their medical benefit, they must sign a "Notification of Intent to Transfer" form.
8.1 The responsible practitioner shall explain and document in the progress notes, the risks and alternatives of the recommended therapeutic course to the patient, including the risks of transfer, an obtain consent.
8.8. The "Inter-Hospital Transfer Summary" form must be completed at the time of transfer. In determining that it is to the patient's medical benefit to affect a transfer, the responsible practitioner shall determine that the medical benefits expected from the provision of appropriate medical treatment at the receiving medical facility outweigh any increased risks caused by such transfer. The practitioner shall list such risks and benefits of the transfer as a part of a dictated transfer summary or transfer progress note and on "Inter-hospital Transfer Summary."
... 12. The transferring physician and facility have specific responsibilities: a. The transferring physician must determine whether the patient is "Medically Fit to Transfer." This decision should follow facility protocols to ensure that the transfer does not pose a medical risk to the patient. The physician must document this determination in the patient's medical record. c. The patient must be informed about the need for the transfer, any alternatives, the proposed transportation plans, and the benefits and risks associated with the transfer. This explanation should focus on risks and benefits specifically related to the patient's condition and the procedure requiring the transfer. The transferring physician must document this discussion in the patient's medical record.

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

1. The facility failed to ensure that for one of 30 sampled patients (Patient 4), reported pain was addressed in a timely manner. In addition, nursing staff did not document a complete pain assessment to evaluate the effectiveness of the pain management intervention, as required by the facility's policy and procedure regarding pain assessment and management.

This deficient practice had the potential to leave Patient 4 in prolonged discomfort, which may worsen Patient 4's pain and may also result in psychological distress due to inadequately managed pain. (Refer to A-0395)

2. The facility failed to re-assess one of 30 sampled patient's (Patient 6) temperature after administering acetaminophen (an over-the-counter fever reducer and pain reliever) for fever, in accordance with the facility's policy and procedure regarding assessment and reassessment of interventions. This deficient practice had the potential for inability to determine the medication's effectiveness in resolving Patient 6's fever, which can delay additional treatment if needed that may result in complications such as seizure (a sudden, abnormal burst of electrical activity in the brain). (Refer to A-0395)

3. The facility failed to re-assess one of 30 sampled patient's (Patient 7) pain level after administering acetaminophen and ibuprofen (medications that reduces fever, pain, and inflammation) for pain. This deficient practice had the potential for inability to determine the medication's effectiveness in resolving Patient 7's pain, which may lead to prolonged discomfort, worsening pain, and may also result in psychological distress due to inadequately managed pain. (A-0395)

4. The facility failed to ensure the following for one of 30 sampled patients (Patient 20):

4.a. Patient 20's high blood pressure (BP, blood pressure is the pressure of circulating blood against the walls of blood vessels, a normal blood pressure measurement is 120/90) reading of 191/90 mmHg (millimeters of Mercury, a unit of measurement) was addressed in accordance with the physician's order.

4.b. Patient 20's vital signs (VS, measurement data of the body's essential functions, such as body temperature, BP, rate of breathing, heart rate and level of pain) was checked in accordance with the facilities policy and procedure.

These deficient practices had the potential to result in Patient 20's delay in treatment and may result in further health complications for Patient 20 due to untreated high BP such as heart attack and/or death. (Refer to A-0395)

5. The facility failed to ensure for three of 30 sampled patients (Patients 12, 17, and 19), Patients 12, 17, and 19's individualized nursing care plan (provides a means of communication among health care providers) was initiated in accordance with the facility's policy and procedure regarding developing and implementing care plans.

This deficient practice had the potential to result in delayed provision of care to the patients by not identifying Patients 12, 17, and 19's needs and risks. (Refer to A-0396)

6. The facility failed to validate one of five registered nurses (RN 8) annual skills competency (the level of performance that a nurse is expected to achieve, which combines their knowledge, skills, abilities, and judgment) and education. This deficient practice had the potential for RN 8 to be carrying out nursing duties in which RN 8 may not be competent of performing, thus placing patients at risk for harm. (Refer to A-0397)

7. The facility failed to provide a unit orientation for one of five sampled RNs (RN 9) prior to working in the Intensive Care Unit (provides critical care and life support to patients who are very ill). This deficient practice had the potential for RN 9 to be unfamiliar with the unit process, locations of medical supplies, etc. And, therefore, placing patients at risk for harm. (Refer to A-0397)

8. The facility failed to ensure that for two of 30 sampled patients (Patient 3 and Patient 4), a call light (a system device used by the patient to call for help) was provided to Patient 3 and Patient 4.

This deficient practice had the potential for Patients 3 and 4's needs to not be met since both patients (Patient 3 and Patient 4) were unable to call for help with no nurse call system provided, which may result in a significant safety risk, as patients may be unable to promptly alert staff in emergencies, leading to delays in receiving necessary care and worsening of their conditions. (Refer to A-0398)

9. The facility failed to ensure that for one of 30 sampled patients (Patient 4), a complete pain assessment was conducted and documented in accordance with the facility's policy and procedure regarding nursing pain assessment and management.

This deficient practice had the potential to result in delayed provision of appropriate pain management strategies for Patient 4, which may lead to prolonged discomfort, worsening pain, and may also result in psychological distress due to inadequately managed pain. (Refer to A-0398)

10. The facility failed to ensure one of 30 sampled patient's (Patient 8) pain level was assessed upon arrival to the Emergency Department (provides immediate care to patients with conditions that require urgent attention), when Patient 8's vital signs (includes temperature, heart rate, respiratory rate, blood pressure, and pain level) was assessed, in accordance with the facility's policy and procedure regarding initial pain assessment. This deficient practice resulted in an incomplete nursing assessment and had the potential to affect Patient 8's treatment plan and Patient 8's pain not to be addressed, which can lead to prolonged discomfort and worsening of pain. (Refer to A-0398)

11. The facility failed to ensure for one of 30 sampled patients (Patient 17), Patient 17's neutropenic precautions (precautions for a condition characterized by low white blood cell count to avoid infections) were followed, in accordance with the facility's policy and procedure regarding neutropenic precautions when, two of Patient 17's family member did not wear a mask while inside the patient's room.

This deficient practice had the potential for Patient 17 to be exposed from infection that may worsen Patient 17's health condition, including prolonged hospitalization, and/or death. (A-0398)

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

Based on interview and record review, the failed to:

1. Ensure that for one of 30 sampled patients (Patient 4), reported pain was addressed in a timely manner. In addition, nursing staff did not document a complete pain assessment to evaluate the effectiveness of the pain management intervention, as required by the facility's policy and procedure regarding pain assessment and management.
This deficient practice had the potential to leave Patient 4 in prolonged discomfort, which may worsen Patient 4's pain and may also result in psychological distress due to inadequately managed pain.

2. Re-assess one of 30 sampled patient's (Patient 6) temperature after administering acetaminophen (an over-the-counter fever reducer and pain reliever) for fever, in accordance with the facility's policy and procedure regarding assessment and reassessment of interventions. This deficient practice had the potential for inability to determine the medication's effectiveness in resolving Patient 6's fever, which can delay additional treatment if needed that may result in complications such as seizure (a sudden, abnormal burst of electrical activity in the brain).

3. Re-assess one of 30 sampled patient's (Patient 7) pain level after administering acetaminophen and ibuprofen (medications that reduces fever, pain, and inflammation) for pain. This deficient practice had the potential for inability to determine the medication's effectiveness in resolving Patient 7's pain, which may lead to prolonged discomfort, worsening pain, and may also result in psychological distress due to inadequately managed pain.
4. Ensure the following for one of 30 sampled patients (Patient 20):

4.a. Patient 20's high blood pressure (BP, blood pressure is the pressure of circulating blood against the walls of blood vessels, a normal blood pressure measurement is 120/90) reading of 191/90 mmHg (millimeters of Mercury, a unit of measurement) was addressed in accordance with the physician's order.

4.b. Patient 20's vital signs (VS, measurement data of the body's essential functions, such as body temperature, BP, rate of breathing, heart rate and level of pain) was checked in accordance with the facilities policy and procedure.

These deficient practices had the potential to result in Patient 20's delay in treatment and may result in further health complications for Patient 20 due to untreated high BP such as heart attack and/or death.

Findings:

1. During a review of Patient 4's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 10/15/2024, the H&P indicated, on 10/15/2024, Patient 4 was transferred from outside facility to the facility's Emergency Department (ED, provides medical and surgical to patients arriving in the ED n need of immediate care) for further evaluation and treatment of right ankle fracture (one or more of the bones that make up the ankle joint are broken). The H&P further indicated that Patient 4 had right ankle pain with each movement.

During a review of Patient 4's medical record (MR) titled, "Pain Assessment," dated 10/16/2024, the MR indicated, on 10/16/2024 at 9:00 a.m. Patient 4's pain level was documented as 6 out of 10 (6/10) using the numeric pain scale, a tool used to rate patients' pain on a scale from 0 to 10 (0-no pain, 1-3 - mild pain, 4-6 - moderate pain, 7-10 - severe pain). The record also indicated that there was no documentation of the assessment of Patient 4's acceptable pain level, pain location, character, duration, alleviating factors, aggravating factors, or any pain intervention provided.

During a review of Patient 4's Medication Administration Record (MAR), dated 10/16/2024, the MAR indicated, Patient 4 had an order for Norco 5-325 milligrams (mg, measuring unit) (Norco 5-325 mg is a prescription pain medication that combines two active ingredients: Hydrocodone Bitartrate [5 mg, an opioid pain reliever that helps to reduce moderate to severe pain by acting on specific receptors in the brain and spinal cord] and Acetaminophen [325 mg, a non-opioid pain reliever that enhances the pain-relieving effects of hydrocodone]). The MAR indicated, Norco 5-325 mg can be administered every 4 hours as needed for moderate (4-6) or severe (7-10) pain. The MAR also indicated that on 10/16/2024 Patient 4 was given 1 tablet (tab) Norco 5-325 at 12:29 p.m.

During a review of Patient 4's medical record (MR), titled "Pain Assessment," dated 10/16/2024, the MR indicated that on 10/16/2024 at 1:00 p.m., Patient 4's pain level was recorded as 4 out of 10 (4/10). The assessment was incomplete, as it lacked documentation of Patient 4's acceptable pain level, pain location, character, duration, alleviating factors, aggravating factors, or any pain intervention provided.

During a concurrent interview and record review on 10/17/2024 at 11:56 a.m. with the Assistant Clinical Director (ACD), after reviewing Patient 4's MR titled, "Pain Assessment," dated 10/16/2024 at 9:00 a.m., and Patient 4's Medication Administration Record (MAR), dated 10/16/2024, the ACD stated that, based on the reviewed records, no pain medication was provided to the patient (Patient 4) when Patient 4 reported a pain level of 6/10 on 10/16/2024 at 9:00 a.m. The ACD further said that the administration of 1 tablet of Norco 5-325 mg, recorded in the MAR on 10/16/2024 at 12:29 p.m., was likely in response to the pain level of 6/10 reported earlier that day at 9:00 a.m. The ACD also said that the pain assessment recorded on 10/16/2024 at 1:00 p.m. must have been a re-assessment following the administration of Norco 5-325 mg at 12:29 p.m.

During an interview on 10/17/2024 at 11:56 a.m. with the Assistant Clinical Director (ACD), the ACD stated that nurses should document a complete pain assessment in the patient's medical records, including pain location, the patient's pain goal, and the intervention provided. The ACD said that pain should be promptly addressed when patients report it, and reassessment should be conducted within sixty (60) minutes after administering any pain medication to ensure the intervention was effective, in accordance with the facility's policy and procedure.

During a review of the facility's policy and procedure (P&P) titled, "Pain Assessment and Management," dated 3/2022, the P&P indicated that patients are to be screened, assessed, and re-assessed for pain using a comprehensive pain assessment based on the patient's condition, age, and ability to understand during their Emergency Department visit. Ongoing pain management includes the assessment and re-assessment of all patients with pain, addressing pain intensity, quality, location, precipitating factors, and responses to interventions. The patient's subjective report of pain is sufficient to initiate treatment, and patients will be re-assessed for their response to pain through evaluation and documentation of the response to pain intervention, including pain medication administration. Reassessment should be conducted within 60 minutes of administering pain medication. Patients have the right to be believed when they report pain, to be treated for pain, and to receive timely treatment.

2. During a review of Patient 6's "Patient Care Time," dated 9/9/2024, the Patient Care Timeline indicated the following: Patient 6 arrived at the Emergency Department (provides immediate care to patients with conditions that require urgent attention) at 5:34 a.m., for complaints of a fever (elevated body temperature). Patient 6's temperature was 101 degrees Fahrenheit (F, [38.3 degrees Celsius] over 100.4 degrees F indicates a fever).

During a review of Patient 6's "ED (Emergency Department) Provider Notes," dated 9/9/2024 at 7:57 a.m., the ED Provider Notes indicated the following: Patient (6) presents with fever.

During a review of Patient 6's "Vital Signs (temperature, blood pressure, pulse, respiratory rate)," dated 9/9/202, the Vital Signs indicated the following:
At 5:43 a.m., Patient 6's temperature was 101 degrees F.
At 10 a.m., Patient 6's temperature was 98.6 degrees F (normal).
At 1:40 p.m., Patient 6's temperature was 99.6 degrees F (normal).

During a review of Patient 6's "Physician's Order," dated 9/9/2024 at 7:07 a.m., the order indicated to give acetaminophen 1000 milligrams (mg - weight unit of measurement) IV (in the vein), one time.

During a review of Patient 6's "Medication Administration Record (MAR)," dated 9/9/2024, the MAR indicated Patient 6 received acetaminophen 1000 mg IV at 7:36 a.m.

During a concurrent interview and record review on 10/15/2024 at 10:22 a.m. with the Associate Clinical Director (ACD) 2, the ACD 2 stated the following: Patient 6 arrived at the Emergency Department on 9/9/2024 at 5:46 a.m., for a fever and feeling dehydrated (loss of body fluids). Patient 6's temperature was 101 degrees F (high, fever) at 5:43 a.m. Patient 6 received acetaminophen 1000 mg for fever at 7:36 a.m. Patient 6's temperature was not re-assessed between 30 to 60 minutes after giving acetaminophen. Patient 6's temperature should have been re-assessed to determine the medication's effectiveness.

During a review of the facility's policy and procedure (P&P) titled, "Nursing Initial Assessment and Re-assessment Documentation Guidelines," dated 8/23/2024, the P&P indicated the following: "Re-assessments are performed to evaluate the effectiveness of health care interventions."

3. During a review of Patient 7's "Flow sheet (a structured and organized method for documenting aspects of patient care)," dated 10/15/2024 at 12:13 p.m., the Flowsheet indicated Patient 7 had pain to the left ear rated at a 10 out of 10 (10, highest level of pain). No further pain assessments /reassessments were documented on the Flowsheet.

During a review of Patient 7's "ED (Emergency Department) Notes," dated 10/15/2024 at 1:13 p.m., the ED Notes indicated the following: Patient 7 " ...presents with left ear pain for one day ...crying 200/10 pain (pain scale 0 - 10, 0 indicates no pain, 10 indicated worst pain)."

During a review of Patient 7's, "Medication Detail," dated 10/15/2024 at 1:13 p.m., indicated to give Acetaminophen oral solution (Tylenol) 293.8 milligrams (mg - weight unit of measurement), one time by mouth.

During a review of Patient 7's, "Medication Detail," dated 10/15/2024 at 1:15 p.m., indicated to give ibuprofen oral suspension 196 mg, one time, by mouth.

During a review of Patient 7's "Medication Administration Record (MAR)," dated 10/15/2024, the MAR indicated Patient 7 received acetaminophen 293.8 mg and ibuprofen 196 mg on 10/15/2024 at 1:26 p.m.

During a review of Patient 7's "Patient Care Time," dated 10/15/2024, the Patient Care Timeline indicated at 1:30 p.m., Patient 7 was discharged home " ... At 1:31 p.m., Patient discharge instructions provided to the parents, verbalized understanding ..."

During a concurrent interview and record review on 10/15/2024 at 10 a.m. with the Associate Clinical Director (ACD) 2, the ACD 2 stated the following: Patient 7 arrived at the Emergency Department for ear pain at 11:48 a.m. Patient 7's pain level was rated at a 10/10 (worst pain) at 12:13 p.m. Patient 7 received acetaminophen 293.8 mg and ibuprofen 196 mg at 1:26 p.m., for ear pain. Patient 7's pain level should have been re-assessed between 30 to 60 minutes after administering the medication to evaluate for effectiveness. Patient 7 was discharged at 1:31 p.m. without having pain re-assessment.

During a review of the facility's policy and procedure (P&P) titled, "Nursing Initial Assessment and Re-assessment Documentation Guidelines," dated 8/23/2024, the P&P indicated the following: "Reassessment of pain will be completed and documented between 30 and 60 minutes of medication administration ..."

4. During a review of Patient 20's "History & (and) Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 10/14/2024, the H&P indicated Patient 20 was admitted to the facility with a diagnosis of acute respiratory failure (results from inadequate gas exchange by the respiratory system). Patient 20's medical history included Hypertension (high blood pressure [BP]).

4.a. During a concurrent interview and record review on 10/17/2024 at 11:45 a.m. with Charge Nurse 4 (CN 4), Patient 20's physician's order, dated 10/14/2024, indicated, "Notify physician for Systolic Blood Pressure (the pressure in arteries when the heart contracts and pumps blood out) greater than 180 or less than 90 and Diastolic Blood Pressure (the pressure in arteries when the heart is at rest between heart beats) greater than 120."

During the same interview and record review on 10/17/2024 at 11:45 a.m., CN 4 stated Patient 20's "Vital Signs Documentation Flowsheet" indicated Patient 20's BP on 10/16/2024 at 7:27 a.m. was 191/90 mmHg (millimeters of mercury, a unit of measurement). CN 4 verified Patient 20's record did not have documentation that Patient 20's BP of 191/90 was addressed/treated, nor the physician was notified.

Furthermore, on 10/17/2024 at 11:45 a.m., CN 4 stated that the importance of assessing the BP was to make sure the patient's BP was under control to avoid the patient suffering from a stroke (loss of blood flow to a part of the brain) or heart attack (when the heart stops beating). CN 4 stated Patient 20's BP of 191/90 should have been reported to the physician as ordered

During a review of the facility's policy and procedure (P&P) titled, "Standard of Care," revised in 10/18/ 2021, the P&P indicated, "Within two hours of beginning the shift, the nurse should: Review the doctor's orders ...The nurse will communicate to physician when the doctor is needed to come to the floor to assess a patient. Physician will be notified of changes in condition, abnormal lab results, abnormal findings or for clarification of the medical plan of care."

4.b. During a concurrent interview and record review on 10/17/2024 at 9:50 a.m. with the Quality Coordinator Registered Nurse (QCRN), the QCRN verified Patient 20's "Vital Signs Documentation Flowsheet," indicated on the following dates and times:

- On 10/16/2024 at 4:00 a.m., Patient 20's VS was not checked.
- On 10/16/2024 at 11:00 p.m., Patient 20's VS was not checked.
During a concurrent interview and record review on 10/17/2024 at 10:58 a.m. with Charge Nurse 4 (CN 4), CN 4 stated the patient's VS in the Step-Down Unit (provides an intermediate level an intermediate level of care between an intensive care unit and general medical surgical ward) were checked every 4 hours. CN 4 stated the Registered Nurse (RN) was responsible in taking the patient's VS.

During the same interview and record review on 10/17/2024 at 10:58 a.m., CN 4 stated it was important for the patient's VS to be checked for accurate record of the patient status and to provide interventions if needed. CN 4 stated Patient 20's VS was not taken every 4 hours per the facility's policy and procedure (P&P).

During a review of the facility's policy and procedure (P&P) titled, "Standard of Care," revised on 10/18/ 2021, the P&P indicated, "Vital signs must be taken every four hours or as ordered."

During a review of the facility's policy and procedure (P&P) titled, "Vital Signs Routine," revised on 10/18/ 2021, the P&P indicated, "Temperature, pulse, blood pressure, and respiration are to be taken every 4 hours for patients who have a cardiac monitoring (continuous monitoring of the heart activity) order ..."

Based on observation, interview and record review, the facility failed to ensure for three of 30 sampled patients (Patients 12, 17, and 19), Patients 12, 17, and 19's individualized nursing care plan (provides a means of communication among health care providers) was initiated in accordance with the facility's policy and procedure regarding developing and implementing care plans. .

This deficient practice had the potential to result in delayed provision of care to the patients by not identifying Patients 12, 17, and 19's needs and risks.

Findings:

1. During a review of Patient 12's "History & (and) Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 10/6/2024, the H&P indicated Patient 12 was admitted to the facility for facial asymmetry (occurs when the features on one side of the face does not reflect the other side in size, shape or position). The H&P further indicated, Patient 12's active hospital problem list included Stroke (a critical condition caused by lack of oxygen to the brain by a clot or bursts that causes permanent damage or death).

During a concurrent observation and interview on 10/15/2024 at 12:52 p.m. with Registered Nurse 3 (RN 3), Patient 12 was observed lying in bed with a percutaneous endoscopic gastrotomy (PEG, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). Patient 12 was receiving enteral tube feeding (method of delivering nutrients and fluids into the stomach to support a person's nutritional needs) at 55 milliliter per hour (ml/hr) via PEG.

During a concurrent interview and record review on 10/15/2024 at 12:55 p.m. with Registered Nurse 3 (RN 3), RN 3 stated Patient 12's record indicated the patient (Patient 12) had difficulty of swallowing and poor oral intake (not consuming enough food or drinks to meet physiological needs) on 10/8/2024, and a nasogastric tube (a thin, flexible tube inserted through the nose and into the stomach to deliver food or fluids for people with swallowing problems) was inserted. RN 3 stated on 10/14/2024, Patient 12's PEG was inserted.

During the same interview and record review on 10/15/2024 at 12:55 p.m., RN 3 verified Patient 12's "care plan (provides a means of communication among health care providers)" did not include a care plan that addressed Patient 12's enteral tube feeding nutrition that started on 10/8/2024. RN 3 stated the nurses were responsible in developing a personalized care plan that meets the patient's needs.

During a concurrent interview and record review on 10/16/2024 at 10:26 a.m. with the Quality Coordinator Registered Nurse (QCRN), the QCRN verified Patient 12 had a care plan for enteral nutrition and it was developed on 10/15/2024 at 5:51 p.m. (7 days after Patient 12's enteral tube feeding started).

During a review of the facility's policy and procedure (P&P) titled, "Patient Assessment and Re-assessment and Plan of Care," revised in 10/2022, the P&P indicated, "All patients admitted to the facility will receive a complete initial assessment and reassessments by a qualified staff or licensed independent practitioners to allow development and implementation of a plan of care that will best meet the individualized health care needs of the patient ...the patient's plan of care/treatment/services will be based on needs identified by the patient's assessment, reassessment and results of diagnostic testing. The plan and goals for care, treatment and services will be revised based on patient's needs, patient goals, timeframes, settings, and services required to meet those goals."

During a review of the facility's policy and procedure (P&P) titled, "Regional Care Plan Guideline," dated 8/19/21, the P&P indicated, "Diagnose (Nursing) Based on assessment, determine which problem templates should be on the Patient Plan. A problem template must be applied within 8 hours of admission ...A template includes problems, associated goals, potential interventions, documentation rows/individualization opportunities, and Care Plan Guide (CPGs) as applicable ...Include templates for problems actively treated during the hospitalization."

2. During a review of Patient 17's "History & (and) Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/24/2024, the H&P indicated Patient 17 was admitted to the facility with a chief complaint of vomiting. The H&P further indicated Patient 17 had a medical history of AML (Acute Myeloid Leukemia, a type of cancer that affects the blood and bone marrow [a soft, spongy tissue in the center of most bones]).

During a concurrent observation, interview, and record review on 10/15/2024 at 2:39 p.m. with Registered Nurse (RN) 4, Patient 17's room door was observed to have a neutropenic precaution (precautions for a condition characterized by low white blood cell count to avoid infections) signage that indicated "please wear a face mask, strict hand hygiene, no fresh-cut flowers or plants." RN 4 stated patient was on neutropenic precautions due to Acute Myeloid Leukemia medication.

During the same interview and record review on 10/15/2024 at 2:39 p.m., RN 4 stated Patient 17's "Care Plan" did not include a plan that addresses the patient's neutropenic condition. RN 4 stated Patient 17 should have a care plan for nursing guidance on how to protect Patient 17 from getting an infection.

During a concurrent interview and record review on 10/16/2024 at 3:20 p.m. with the Quality Coordinator Registered Nurse (QCRN), the QCRN verified Patient 17 had an order on 9/24/2024 for "Implement Neutropenic Isolation Precautions." The QCRN verified Patient 17 had a neutropenic precautions care plan that was developed on 10/16/2024 at 3:01 p.m. (22 days after Patient 17's admission and neutropenic precaution was in place).

During a review of the facility's policy and procedure (P&P) titled, "Patient Assessment and Re-assessment and Plan of Care," revised in 10/2022, the P&P indicated, "All patients admitted to the facility will receive a complete initial assessment and reassessments by a qualified staff or licensed independent practitioners to allow development and implementation of a plan of care that will best meet the individualized health care needs of the patient ...the patient's plan of care/treatment/services will be based on needs identified by the patient's assessment, reassessment and results of diagnostic testing. The plan and goals for care, treatment and services will be revised based on patient's needs, patient goals, timeframes, settings, and services required to meet those goals."

During a review of the facility's policy and procedure (P&P) titled, "Regional Care Plan Guideline," dated 8/19/21, the P&P indicated, "Diagnose (Nursing) Based on assessment, determine which problem templates should be on the Patient Plan. A problem template must be applied within 8 hours of admission ...A template includes problems, associated goals, potential interventions, documentation rows/individualization opportunities, and Care Plan Guide (CPGs) as applicable ...Include templates for problems actively treated during the hospitalization."

3. During a review of Patient 19's "History & (and) Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 10/12/2024, the H&P indicated Patient 19 was admitted to the facility for weakness. The H&P further indicated, Patient 19's active hospital problem list included Urinary tract infection (UTI, an infection in the bladder [a muscular, hollow organ that stores urine]/urinary tract [the body's drainage system for removing urine).

During a concurrent interview and record review on 10/15/2024 at 2:53 p.m., RN 5 verified Patient 19's "Care Plan" did not include a plan that addresses Patient 19's UTI. RN 5 stated the patient's care plan for UTI was important to know the plan and interventions for nursing care guidance.

During a concurrent interview and record review on 10/16/2024 at 3:33 p.m. with the Quality Coordinator Registered Nurse (QCRN), the QCRN stated the development of the patient's care plan was part of the admission process. The QCRN stated Patient 19 had a care plan on UTI that was developed on 10/15/2024 at 2:57 p.m. (3 days after Patient 19 was admitted for UTI).

During a review of the facility's policy and procedure (P&P) titled, "Patient Assessment and Re-assessment and Plan of Care," revised in 10/2022, the P&P indicated, "All patients admitted to the facility will receive a complete initial assessment and reassessments by a qualified staff or licensed independent practitioners to allow development and implementation of a plan of care that will best meet the individualized health care needs of the patient ...the patient's plan of care/treatment/services will be based on needs identified by the patient's assessment, reassessment and results of diagnostic testing. The plan and goals for care, treatment and services will be revised based on patient's needs, patient goals, timeframes, settings, and services required to meet those goals."

During a review of the facility's policy and procedure (P&P) titled, "Regional Care Plan Guideline," dated 8/19/21, the P&P indicated, "Diagnose (Nursing) Based on assessment, determine which problem templates should be on the Patient Plan. A problem template must be applied within 8 hours of admission ...A template includes problems, associated goals, potential interventions, documentation rows/individualization opportunities, and Care Plan Guide (CPGs) as applicable ...Include templates for problems actively treated during the hospitalization."

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

1. Validate one of 5 registered nurses (RN 8) annual skills competency (the level of performance that a nurse is expected to achieve, which combines their knowledge, skills, abilities, and judgment) and education. This deficient practice had the potential for RN 8 to be carrying out nursing duties in which RN 8 may not be competent of performing, thus placing patients at risk for harm.

2. Provide a unit orientation for one of five sampled RNs (RN 9) prior to working in the Intensive Care Unit (provides critical care and life support to patients who are very ill). This deficient practice had the potential for RN 9 to be unfamiliar with the unit process, locations of medical supplies, etc. And, therefore, placing patients at risk for harm.

Findings:

1. During a concurrent interview and personnel file review on 10/17/2024 at 2:48 p.m. with the Director of Operations (DOP), Department Administrator (DA), Program Manager for Human Resources (PMHR), Clinical Director of Education (CDED), and the Staff Educator (SED), the DOP, DA, PMHR, CDED, and SED stated the following: Registered Nurse (RN 8)'s Competency (the level of performance that a nurse is expected to achieve, which combines their knowledge, skills, abilities, and judgment) and Education Summary dated 10/3/2024 was missing a validator's signature. The validator should have signed the competency to validate that RN 8 was proficient in her (RN 8) nursing duties. The PMHR stated the facility did not have policy indicating that a validator's signature was required for the annual competencies validation, however, it was part of the Human Resources Department process to check and ensure the validator's signatures were present on the documents.

During a review of RN 8's personnel file, the personnel file indicated the following: RN 8 was hired on 2/18/2024. RN 8's "2023 Annual Mandatory Competency and Education Validation Summary in Emergency Department," dated 10/3/2024, indicated competencies required to work in the Emergency Department. Competencies included knowledge of medical equipment, skills demonstration ...safe patient handling ...care of a behavior health patient, care of a stroke patient, care of sepsis patient ... RN 8's and a validators initials were documented on 11/8/2028. The page titled "Validator," was blank. It did not contain the name, signature, initials of the validator, or the date validation.

2. During a concurrent interview and personnel file review on 10/17/2024 at 3:02 p.m., with the Director of Operations (DOP) and the Department Administrator (DA), the DOP and DA reviewed RN 9's file and stated the following: RN 9 worked in the Intensive Care Unit (provides critical care and life support to patients who are very ill) from 11/1/2023 to 2/3/2024. RN 9 was "contingent," or working under a contract. The DA stated that contracted nurses should receive an orientation to the unit the nurse was assigned to. The orientation should be done before the nurse works on the unit, on her own or solo.
The DA stated she (DA) could not locate evidence in RN 9's personnel file, that RN 9 received an orientation to the ICU prior to working by herself on the unit. The unit orientation consists of a tour, location of medical equipment, supplies, hospital processes (nursing practice, patient safety, policies and procedures, skills validation (a process that ensures nurses have the knowledge and skills to perform their tasks), and charting frequency. The DA stated that the unit orientation was necessary to orient new nurses on hospital process, patient safety, etc.

During a review of RN 9's Personnel file, RN 9's personnel file indicated the following: RN 9 was a contracted (not a permanent employee, an individual hired by a company to complete a specific project or assignment for a defined period) staff. There was no documentation that an orientation to ICU was provided by the facility.

During a review of the facility's policies and procedure (P&P) titled, "Orientation of New Employees (Medical Center Orientation and Department)," dated 8/23/2024, the P&P indicated the following: "The organization provides an individual who is new to the organization ...with an orientation of sufficient scope and duration to inform the individual about the organization's promise, mission, goals ... patient safety and other pertinent topics."

Based on observation, interview and record review, the facility failed to adhere to the facility's policies and procedures when:

1.The facility failed to ensure that for two of 30 sampled patients (Patient 3 and Patient 4), a call light (a system device used by the patient to call for help) was provided to Patient 3 and Patient 4.
This deficient practice had the potential for Patients 3 and 4's needs to not be met since both patients (Patient 3 and Patient 4) were unable to call for help with no nurse call system provided, which may result in a significant safety risk, as patients may be unable to promptly alert staff in emergencies, leading to delays in receiving necessary care and worsening of their conditions.

2. The facility failed to ensure that for one of 30 sampled patients (Patient 4), a complete pain assessment was conducted and documented in accordance with the facility's policy and procedure regarding nursing pain assessment and management.

This deficient practice had the potential to result in delayed provision of appropriate pain management strategies for Patient 4, which may lead to prolonged discomfort, worsening pain, and may also result in psychological distress due to inadequately managed pain.

3. The facility failed to ensure one of 30 sampled patient's (Patient 8) pain level was assessed upon arrival to the Emergency Department (provides immediate care to patients with conditions that require urgent attention), when Patient 8's vital signs (includes temperature, heart rate, respiratory rate, blood pressure, and pain level) was assessed, in accordance with the facility's policy and procedure regarding initial pain assessment. This deficient practice resulted in an incomplete nursing assessment and had the potential to affect Patient 8's treatment plan and Patient 8's pain not to be addressed, which can lead to prolonged discomfort and worsening of pain.

4. The facility failed to ensure for one of 30 sampled patients (Patient 17), Patient 17's neutropenic precautions (precautions for a condition characterized by low white blood cell count to avoid infections) were followed, in accordance with the facility's policy and procedure regarding neutropenic precautions when, two of Patient 17's family member did not wear a mask while inside the patient's room.

This deficient practice had the potential for Patient 17 to be exposed from infection that may worsen Patient 17's health condition, including prolonged hospitalization, and/or death.

Findings:

1.a. During a review of Patient 3's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 10/15/2024, the H&P indicated, Patient 3 had past medical history of hypertension (HTN, when the pressure in your blood vessels is too high [140/90 mmHg or higher]) and dementia (a range of neurological conditions that cause a person to lose the ability to think, remember, and reason to the point that it interferes with daily life) and was diagnosed with altered mental status (AMS, a significant change from a person's baseline level of consciousness, awareness, cognitive function (anything related to thinking, learning and understanding), and behavior).

During a concurrent observation and interview on 10/15/2024 at 12:48 p.m. with the Assistant Clinical Director (ACD) in the Emergency Department (ED, a hospital area that provides immediate care to patients with urgent conditions), Patient 3 was observed in the patient's room. Patient 3's monitor was alarming (an automatic warning that sounds when a patient's vital signs, such as heart rate, blood pressure, or oxygen levels, fall or rise outside of a healthy range), and a family member (FM) was standing at the bedside. The FM stated that the monitor had been alarming for some time and that they wanted to notify the nurse. The ACD confirmed that all patient rooms should have a call light available to call for help when needed, but there was no call light observed attached to the wall in Patient 3's room.

During an interview on 10/15/2024 at 12:50 p.m., the Assistant Clinical Director (ACD) stated that the facility admits many psychiatric (patients with mental, emotional, and behavioral disorders) patients throughout the day, and the rooms are often stripped of equipment, such as call light cords, that may pose a safety risk for psychiatric patients. The ACD explained that Patient 3's room was likely used for a psychiatric patient previously, and the staff must have forgotten to return the call light when Patient 3 was admitted. The ACD further stated that the call light should have been provided for Patient 3 upon admission, but the ED staff likely forgot.

During a review of the facility's policy and procedure (P&P) titled, "Activities of Daily Living," dated 8/19/2021, the P&P indicated that to ensure a safe environment for patients, visitors, and employees, each patient must have a properly functioning and easily accessible nurse call system.

1.b. During a review of Patient 3's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 10/15/2024, the H&P indicated, on 10/15/2024, Patient 4 was transferred from outside facility to the facility's Emergency Department for further evaluation and treatment of right ankle fracture (one or more of the bones that make up the ankle joint are broken).

During a concurrent observation and interview on 10/15/2024 at 12:55 p.m. with the Assistant Clinical Director (ACD) in the Emergency Department (ED), Patient 4 was observed sleeping in their (Patient 4's room) room. There was no call light attached to the wall and placed within Patient 4's reach. The ACD confirmed that Patient 4's room had no call light available for the patient to use to call for help if needed and stated that the ED staff should have provided the call light system when Patient 4 was admitted to the room.

During a review of the facility's policy and procedure (P&P) titled, "Activities of Daily Living," dated 8/19/2021, the P&P indicated that to ensure a safe environment for patients, visitors, and employees, each patient must have a properly functioning and easily accessible nurse call system.

2. During a review of Patient 4's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 10/15/2024, the H&P indicated, on 10/15/2024, Patient 4 was transferred from outside facility to the facility's Emergency Department for further evaluation and treatment of right ankle fracture (one or more of the bones that make up the ankle joint are broken). The H&P further indicated that Patient 4 had right ankle pain with each movement.

During a review of Patient 4's medical record (MR) titled, "Pain Assessment," dated 10/15/2024 and 10/16/2024, the MR indicated the following:

On 10/15/2024 at 4:00 p.m., Patient 4's pain level was documented as 2 out of 10 (2/10) using the numeric pain scale, a tool used to rate patients' pain on a scale from 0 to 10 (0-no pain, 1-3 - mild pain, 4-6 - moderate pain, 7-10 - severe pain). The record also indicated that the patient's (Patient 4) acceptable pain level was documented as 2, but there was no documentation of the pain's location, character, duration, alleviating factors, aggravating factors, or any pain intervention provided.

On 10/16/2024 at 9:00 a.m., Patient 4's pain level was recorded as 6 out of 10. The record also indicated that there was no documentation of the assessment of Patient 4's acceptable pain level, pain location, character, duration, alleviating factors, aggravating factors, or any pain intervention provided.

On 10/16/2024 at 1:00 p.m., Patient 4's pain level was recorded as 4 out of 10 (4/10). The record also indicated that there was no documentation of the assessment of Patient 4's acceptable pain level, pain location, character, duration, alleviating factors, aggravating factors, or any pain intervention provided.

On 10/16/2024 at 5:00 p.m., Patient 4's pain level was recorded as 3 out of 10 (3/10). The record also indicated that there was no documentation of the assessment of Patient 4's acceptable pain level, pain location, character, duration, alleviating factors, aggravating factors, or any pain intervention provided.

During an interview on 10/17/2024 at 11:56 a.m. with the Assistant Clinical Director (ACD) in the Emergency Department (ED), after reviewing Patient 4's medical record (MR) titled, "Pain Assessment," dated 10/15/2024 and 10/16/2024, the ACD stated that the patient's (Patient 4) acceptable pain level, pain location, and the patient's pain goal should have been documented. The ACD further stated that nurses should have completed a thorough pain assessment, as a complete assessment is essential for determining the appropriate intervention.

During a review of the facility's policy and procedure (P&P) titled, "Pain Assessment and Management," dated 3/2022, the P&P indicated that patients are to be screened, assessed, and re-assessed for pain utilizing a comprehensive pain assessment based on the patient's condition, age, and ability to understand during their Emergency Department visit. Ongoing pain management includes the assessment and re-assessment of all patients with pain, addressing pain intensity, quality, location, precipitating factors, and responses to interventions.

3. During a review of Patient 8's "Patient Care Timeline," dated 10/9/2024, the Patient Care Timeline indicated the following:

On 10/9/2024 at 7:39 p.m., Patient 8 arrived at the Emergency Department for seizures (a sudden, uncontrolled burse of electrical activity in the brain).

At 7:52 p.m., Patient 8's Vital Signs (temperature, blood pressure, pulse, Respiratory Rate) were as follows: Temperature 97.6 (normal), pulse: 115 (high, normal range is 60-100 beats per minute), blood pressure: 225/151 (high, normal range is 20/90), Respiratory Rate: 26 (high, normal range is 12-20 breaths per minute), Oxygen saturation (measures the amount of oxygen in the blood): 99 % (normal) on Room air. Patient 8's pain level was not documented.

At 9:17 p.m., Patient 8's pain level was assessed at 3 (indicated mild discomfort) on a FLACC (Face, Legs, Activity, Cry, Consolability- a behavior scale for scoring pain, used on non-verbal patients) scale.

During a concurrent interview and record review on 10/16/2024 at 1:15 p.m. with the Associate Clinical Director (ACD) 2, the ACD 2 reviewed Patient 8's "Patient Care Timeline, dated 10/9/2024, and stated the following: Patient 8 arrived at the Emergency Department at 7:39 p.m., for seizures. Patient 8's pain level was not assessed initially at 7:52 p.m., when Patient 8's vital signs were checked. Patient 8 was unresponsive (not reacting normally to touch, sound, or other stimulation) upon arriving at the ED. Nursing staff could have assessed the pain level by using a FLACC scale for Patient 8. All patients should be assessed for pain upon arrival to the Emergency Department (ED) to ensure a complete assessment of patients.

During a review of the facility's policies and procedures (P&P) titled, "Nursing Initial Assessment and Re-Assessment Documentation Guidelines," dated 8/23/2024. The P&P indicated the following. Initial pain assessment should include: the Pain Scale Type used as appropriate to the patient's status and developmental age ..."

4. During a record review of Patient 17's "History & (and) Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/24/2024, the H&P indicated Patient 17 was admitted to the facility with a chief complaint of vomiting. The H&P further indicated Patient 17 had a medical history of Acute Myeloid Leukemia (AML, a type of cancer that affects the blood and bone marrow).

During a concurrent observation and interview on 10/15/2024 at 2:39 p.m. with Registered Nurse (RN) 4, Patient 17's room door was observed to have a neutropenic precautions signage that indicated, "please wear a face mask, strict hand hygiene, no fresh-cut flowers or plants." RN 4 stated patient (Patient 17) was on neutropenic precautions (precautions for a condition characterized by low white blood cell count to avoid infections) due to immunocompromised (a condition in which the immune system ability to fight infectious disease is compromised) condition due to AML medication. RN 4 verified that Patient 17's two family members (FM 1 and FM 2), who were inside Patient 17's room, were not wearing a face mask.

During the same interview on 10/15/2024 at 2:39 p.m., RN 4 stated there was no documented evidence Patient 17's family members were given education regarding the patient's neutropenic precaution. RN 4 stated it was important to follow the neutropenic precaution like the wearing of face mask in Patient 17's room to prevent the patient from getting an infection.

During an interview on 10/16/2024 at 3:02 p.m. with Patient 17's family members (FM 1 and FM 2), FM 1 stated she (FM 1) spends the entire day with Patient 17 at the bedside and she was not sure of the neutropenic precaution measures, its risk and consequences. FM 2 stated, he (FM 2) was not aware of the risk of not wearing the mask when with Patient 17.

During a review of the facility's policy and procedure (P&P) titled, "Neutropenic Precautions," revised on 8/19/2021, the P&P indicated, "Strict adherence to infection prevention and control is important due to patients with compromised immunological systems resulting in neutropenia. When a patient's absolute neutrophil count (ANC) falls below 500 or the WBC falls below 1,000, the patient will be placed on Neutropenic Precautions ...Patients and families will be instructed about neutropenic precautions by nursing staff upon implementation and will reinforce as necessary. Patient/family teaching will include instruction on good hand hygiene guidelines and prophylactic oral hygiene."