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Based on observation, interview, and record review, the facility failed to ensure patient rooms were used in accordance to what they were licensed for, when 16 patient rooms (Rooms A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, and P), which were licensed as single occupancy rooms in Unit 1, were being used as double occupancy rooms.

This failure had the potential to cause harm and delay of care to patients in the facility.

Findings:

On September 4, 2024, at 10 a.m., a tour of the facility was conducted with the Assistant Chief Nursing Officer (ACNO) and the Quality Coordinator (QC).

On September 4, 2024, at 10:23 a.m., an observation of Unit 1 was conducted with the ACNO and the QC. Rooms A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, and P were observed to have two beds each occupied by patients.

The facility document titled, "Approval of Program Flexibility," was reviewed. The document indicated, "...approved to use the following beds twenty-five (25) additional beds for adult acute care (medical, surgical, telemetry) patients on [Unit 1]...approval shall remain in effect from July 26, 2023, until May 1, 2024..."

The facility document titled, "Vice President of Quality Hospital 1," was reviewed. The document indicated, "...Flex...has been in revision status since 02.01.24 [February 1, 2024]...which means the application was sent back to your facility for more information..."

The facility was not able to provide documented evidence an application was submitted to the Centralized Application Branch (CAB, a branch of the state agency which processes and approves applications for any changes in a facility's license) for the approved license of the additional beds in Rooms A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, and P.

The facility was not able to provide documented evidence a program flex to convert the single occupancy Rooms A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, and P to double occupancy roms was approved.

On September 5, 2024, at 2:20 p.m., an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated the facility's plan is to not place patients in the second beds in the rooms on Unit 1 once the current patients are discharged from the hospital.

Based on observation, interview, and record review, the facility failed to ensure the facility's policies and procedures were implemented, for six of 48 sample patients (Patients 7, 9, 17, 34, 18, and 27), when:

1. For Patient 17, six units of insulin (medication to treat abnormal blood sugar) was administered instead of 10 units as ordered by the physician. In addition, the facility failed to notify the physician of the change in the administered dose (Refer to A0398);

2. For Patient 34, metoprolol (medication used to treat high blood pressure, BP, normal adult BP is 120/80) was administered to Patient 34 who had a BP of 76/42 (Refer to A0398);

3. For Patient 18, the patient was not turned regularly and developed a pressure injury (a wound due to pressure on a body area) on the coccyx (tailbone) (Refer to A0398);

4. For Patient 27, daily weights were not obtained as ordered by the physician (Refer to A0398);

5. For Patient 7, the appropriate personal protective equipment (PPE, equipment worn to minimize exposure to hazards and prevent the spread of germs) was not used by a staff while in the room of a patient in contact isolation (where a set of precautions are used to prevent the spread of germs from a patient to others through direct or indirect contact) (Refer to A0398); and

6. For Patient 9, the intravenous (IV, administered through a vein) medication meropenem (an antibiotic) was not administered as ordered by the physician (Refer to A0405).

The cumulative effects of these systemic failures had the potential to impact the health, safety, and treatment of the patients, and may have contributed to Patient 34's death.

Based on observation, interview, and record review, the facility failed to ensure the facility's policies and procedures were implemented, for five of 48 sample patients (Patients 7, 17, 34, 18, and 27), when:

1. For Patient 17, six units of insulin (medication to treat abnormal blood sugar) was administered instead of 10 units as ordered by the physician. In addition, the facility failed to notify the physician of the change in the administered dose;

2. For Patient 34, metoprolol (medication used to treat high blood pressure, BP, normal adult BP is 120/80) was administered to Patient 34 who had a BP of 76/42;

3. For Patient 18, the patient was not turned regularly and developed a pressure injury (a wound due to pressure on a body area) on the coccyx (tailbone);

4. For Patient 27, daily weights were not obtained as ordered by the physician; and

5. For Patient 7, the appropriate personal protective equipment (PPE, equipment worn to minimize exposure to hazards and prevent the spread of germs) was not used by a staff while in the room of a patient in contact isolation (where a set of precautions are used to prevent the spread of germs from a patient to others through direct or indirect contact).

These failures had the potential to impact the health, safety, and treatment of the patients, and may have contributed to Patient 34's death.

Findings:

1. On September 5, 2024, at 1:22 p.m., a review of Patient 17's record was conducted with the Quality Data Abstractor (QDA). A facility document titled, "History & [and] Physical," dated August 12, 2024, at 4:21 p.m., indicated Patient 17 was admitted to the facility on August 12, 2024, for melena (black stools), dizziness and dyspnea (difficulty breathing). The document indicated Patient 17 had a history of end-stage renal disease (permanent condition in which the kidneys could no longer filter waste from blood) on hemodialysis (HD, procedure to remove the fluids and waste from the blood using a machine). The document also indicated Patient 17's home medications included, "...Insulin Lispro (medication to control high blood sugar) 100 Units/1 [one] ML [milliliter, unit of measurement] Vial 4-8 [four to eight] Units SubQ [subcutaneous, under the skin] BID [two times a day]..."

An untitled facility document, dated September 2, 2024, at 7:48 p.m., was reviewed and indicated, "...Glucose [blood sugar]...372...Reference [normal value]...60-130 mg [milligrams, unit of measurement]/dl [deciliter, unit of measurement]..."

An untitled facility document was reviewed and indicated, "...Given Dose...09/02 [September 2, 2024] 2027 [8:27 p.m.]...6 [six] unit...Humalog [type of insulin medication to control blood sugar] Site: Right Upper Arm...Admin [administration] Comment: pt [Patient 17] request [sic] 6 instead of 10 units...Instructions And Comments...Supplemental Insulin...For blood sugar...351-400 = 10 units... "

There was no documented evidence the physician was notified six units of insulin instead of the ordered dose of 10 units were administered to Patient 17 on September 2, 2024. There was no documented evidence the physician changed the medication order for insulin for Patient 17. There was no documented evidence the physician was notified of the change in the dosage of the administered insulin to Patient 17 on September 2, 2024.

On September 5, 2024, at 2 p.m., an interview was conducted with the QDA. He stated, when the nurse does not follow the physician's instructions or if the patient refuses a medication, the nurse needs to notify the physician about patient's refusal or the change in medication.

2. On September 5, 2024, at 2:05 p.m., a review of Patient 34's record was conducted with Quality Coordinator (QC) 1. A facility document titled, "History and Physical," dated June 3, 2024, indicated Patient 34 was admitted to the facility on June 3, 2024, for bilateral pleural effusion (fluids in both lungs). The document indicated Patient 34 had a history of chronic kidney disease (a long term kidney disease), diabetes (abnormal blood sugar), and high blood pressure.

An untitled facility document was reviewed and indicated, "...View Medication Order...Metoprolol Tartrate [medication to treat high blood pressure] Tab [tablet] PO [by mouth] 50 mg BID 09 [9:00 a.m.], 21 [9:00 p.m.]...Start 06/03 [June 3, 2024] 2100...Stop 08/02 [August 2, 2024]..."

A facility document titled, "Progress Note," authored by Physician 1, dated July 23, 2024, at 12:43 p.m., was reviewed and indicated, "...Patient looks poorly today...discussed case with family. Patient is now a DNR [do not resuscitate, a physician's order instructing the healthcare provider to not do chest compressions in the event the patient stops breathing or the patient's heart stops beating] at this time...Frail, debilitated [weakened] patient, lying in bed, confused, disorientated, not eating or drinking...Try to send the patient to outpatient dialysis and comfort measures to be continued..."

An untitled facility document, dated July 23, 2024, at 7:05 p.m., was reviewed and indicated, "...BP 76/42 and Pulse [number of times the heart beats per minute] rate 54..."

An untitled facility document, dated July 23, 2024, at 9 p.m., was reviewed and indicated the registered nurse (RN) administered metoprolol 50 mg to Patient 34.

A facility document titled, "Multidisciplinary Notes," dated July 23, 2024, at 11:34 p.m., was reviewed and indicated, "...At 23:30 [11:30 p.m.], Patient [Patient 34] found to be unresponsive and expired..."

There was no documented evidence Patient 34's BP was taken prior to the administration of metoprolol on July 23, 2024, at 9 p.m. There was no documented evidence the physician was notified of Patient 34's previous low BP on July 23, 2024, at 7:05 p.m., before the metoprolol was administered on July 23, 2024, at 9 p.m.

On September 6, 2024, at 1:20 p.m., an interview was conducted with the Registered Nurse Manager (RNM) and the Vice President of Quality (VPQ). The RNM stated the standard of practice of the nurses is to take the patient's BP prior to the administration of any BP medication and then call the physician if they have a concern about the BP reading. The RNM stated not all patients have blood pressure parameters, so it is important to call the physician for orders. The VPQ stated there is nothing in the hospital policy that speaks to BP parameters or what the nurse would need to do if there are no parameters for a medication. The VPQ stated, "It is up to the nurse to use her critical thinking skills and nursing judgement in these cases."

On September 10, 2024, at 4:10 p.m., an interview was conducted with the Vice President of Quality (VPQ). The VPQ stated, "Yes, I think RNs must assess." The VPQ stated, "Questioning a physician order would be expected." The VPQ further stated, "I am certified in patient safety so I believe in it for all patients."

A review of the policy and procedure (P&P) titled, "Medication Administration," dated September 27, 2023, was conducted. The P&P indicated, "...All medications must be ordered by a physician...Medications should only be administered when the licensed healthcare provider giving the medication knows the following...why the patient is receiving medication...what effects to expect...what adverse effects may be expected...Medications shall be administered exactly as ordered by the physician. Dosages or routes of administration shall not be altered without the written order of the physician..."

A review of facility P&P titled, "Standards of Nursing Care and Practice," dated April 2023, was conducted. The policy indicated, "..."Standards of Practice" describe a competent level of nursing care as demonstrated by the nursing process, involving assessment, diagnosis, outcome identification, planning, implementation, and evaluation...(such as providing culturally and ethically relevant care, maintaining a safe environment, educating clients about their illness, treatment, health promotion or self-care activities, and planning for continuity of care)...Assessment: RNs must be able to effectively collect data and patient information that is relative to their condition or situation...Outcomes Identification...RNs should be able to effectively predict outcomes for the patient...Advocacy...Nurses must demonstrate advocacy and support the needs of their patients..."

3. On September 6, 2024, at 9:05 a.m., a review of Patient 18's record was conducted with the QDA. A facility document titled, "History and Physical," dated August 18, 2023, at 11:19 p.m., indicated Patient 18 was admitted to the facility on August 18, 2023, for shortness of breath. The document indicated Patient 18 had a past medical history of congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs), coronary artery disease (a condition that occurs when the heart's blood supply is reduced or blocked), diabetes mellitus (abnormal blood sugar), hypertension (high blood pressure), and kidney disease.

An untitled facility document, dated October 5, 2023, was reviewed and indicated, "...Skin alteration...None..."

An untitled facility document, dated October 5, 2023, was reviewed and indicated, "...Ambulation [walking]: 2 [two] person assist..."

An untitled facility document, dated October 17, 2023, was reviewed and indicated, "...Skin alteration...Present/Exists...Posterior Coccyx...Pressure injury present on admission: No...Pressure injury staging: Stage 3 [wound extending through the skin into the deeper tissue and fat ]..."

An untitled facility document, dated October 18, 2023, through November 2, 2023, was reviewed. The document indicated Patient 18 was not turned nor repositioned on the following dates and times:

-From October 19, 2023, at 2 p.m., to 8 p.m. (six hours);
-From October 21, 2023, at 2 a.m., to 8 a.m. (six hours); and
-From November 1, 2023, at 8 a.m., to 8 p.m. (12 hours).

During a concurrent interview, the QDA stated the patient was not able to turn himself and should have been turned frequently by the registered nurse. The QDAr further stated a skin break down could occur if a patient is not turned frequently.

A review of the P&P titled, "Skin Integrity Management," dated October 2022, indicated, was conducted. The P&P indicated, "...All inpatients will be assessed in regard to integumentary [skin] integrity including admission from the Emergency Department...Pressure injuries identified more than 24 hours after admission are considered hospital acquired...Interventions...Promote early & [and] frequent mobility...Provide/assist the patient with repositioning & turning as needed to offload pressure on dependent areas...For prone [lying face down] patient positioning, assess bony prominences [areas of the body where bones are close to the skin's surface and have limited cushioning] and utilize small shifts to offload pressure..."

4. On September 10, 2024, at 10:45 a.m., a review of Patient 27's record was conducted with the Patient Safety Coordinator (PSC). A facility document titled, "History and Physical," dated August 19, 2023, at 3:16 p.m., indicated Patient 27 was admitted to the facility on August 20, 2023, for diagnoses which included renal failure (kidneys are not functioning) and end stage renal disease (a permanent condition in which the kidneys could no longer filter waste from blood).

A facility document titled, "Order History Data," dated August 21, 2024, at 2:01 p.m., was reviewed and indicated, "...Weight, Obtain...Frequency: Daily..."

A facility document titled, "Query Responses by Group...Height Weight Group," dated July 11, 2024, through September 10, 2024, ws reviewed and indicated, "...HTWT [height/weight] 09/03/2024 [September 3, 2024]...144.900 kg...08/19/2024 [August 19, 2024]...145.455 kg [kilograms, unit of measurement]..."

There was no documented evidence Patient 27's daily weight was taken other than on August 19, 2023, and September 3, 2023.

On September 10, 2024, at 11 a.m., an interview was conducted with the PSC. The PSC stated there were only two weights taken for Patient 27 during the patient's admission on August 20, 2023. The PSC stated the patient should be weighed daily by the RN if the physician placed that order. She stated all nurses should follow the physician's orders per the policy.

A review of the P&P titled, "Standards of Care, Practice Guidelines and Assessment for the Adult Patient (Excluding Maternal/Child)," dated December 2019, was conducted. The P&P indicated, "...The following routine care/practice guidelines are provided to the adult patient. Documentation in the patient's Display Board Queries screen of Computerized documentation system by the licensed nurse confirms that these standards of care/practice guidelines have been met unless otherwise documented in the patient care record...These general standards of care apply to all areas of adult patient care...Routine Monitoring...Height and weight on admission per policy, wight daily if...renal (pertaining to one with kidney conditions)...or as ordered..."

5. On September 4, 2024, at 10 a.m., a tour of the facility was conducted with the Assistant Chief Nursing Officer (ACNO) and the Quality Coordinator (QC).

On September 4, 2024, at 10:23 a.m., an observation of Unit 1 was conducted with the ACNO and the QC. A sign was observed on Patient 7's door indicating contact isolation (when a set of precautions are used to prevent the spread of germs from a patient to others through direct or indirect contact). Registered Nurse (RN) 1 was observed inside Patient 7's room and was observed to be not wearing a gown nor gloves. During a concurrent interview, the ACNO stated RN 1 should have been wearing a gown and gloves while in the patient's room. She stated the patient is on contact isolation based on the sign at the patient's door.

On September 4, 2024, at 3:21 p.m., an interview was conducted with RN 1. RN 1 stated he had PPE but took it off while still in the room next to the patient near the patient's bathroom and not by the patient's room's door. He stated there was a trash can near the door and he should have taken the gown and gloves off by that trash can.

A review of Patient 7's record was conducted with the RNM on September 6, 2024, at 10:03 a.m. The facility document titled, "History and Physical," dated July 26, 2024, indicated Patient 7 was admitted to the facility for acute hypoxemic respiratory failure (low oxygen level in the blood due to inefficient breathing) on July 26, 2024.

An untitled facility document was reviewed and indicated, "...Isolation Precautions...Start 07/27 [July 27, 2024]...Isolation...Contact...Comment...ESBL [Extended-spectrum beta-lactamases, a type of bacteria] E. coli [Escherichia coli, a type of bacteria]..."

A review of the P&P titled, "Isolation & [and] Standard Precautions," dated June 2023, was conducted. The P&P indicated, "...Contact precautions...Personal Protective Equipment...wear a gown every time you enter the patient's room..."

Based on interview and record review, the facility failed to ensure an intravenous (IV, administered through a vein) medication was administered in accordance with the physician's order and the facility's policy and procedure, for one of 48 sampled patients (Patient 9).

This failure had the potential to cause harm and increased risk for infection.

Findings:

A review of Patient 9's record was conducted with the Quality Coordinator (QC) 1 on September 6, 2024, at 11:39 a.m. A facility document titled, "History and Physical," dated August 22, 2024, indicated Patient 9 was admitted to the facility on August 22, 2024, with diagnoses which included leg wound. The document indicated Patient 9 had a medical history of paraplegia (paralysis of lower body and legs) and end stage renal disease (a kidney disease that occurs when the kidneys can no longer function properly) on hemodialysis (machine that filters waste from the body).

A facility document titled, "Medication Data," was reviewed and indicated, "...IV Medication...Volume...100 ml [milliliter, unit of measurement]...Q [every] 24 hr. [hours]...IV...Start date...Aug. 24, 24 [August 24, 2024]...Stop date...Aug. 31, 24 [August 31, 2024]...500 MG [milligram, unit of measurement] Meropenem [an antibiotic]..."

A facility document titled, "Medications Data," was reviewed and indicated, "...Meropenem...Aug. 27, 24 [August 27, 2024] 07:30 [7:30 a.m.]...Not Given IV..."

A facility document titled, "Medications Data," was reviewed and indicated, "...Meropenem...Aug. 27, 24 07:30...Administration comments...Not Given Prior to Shift Change..."

A facility document titled, "Medications Data," was reviewed and indicated, "...Meropenem...Administration queries for Aug. 27, 24, 07:30...Reason...Not Given..."

An interview was conducted with QC 1 on September 6, 2024, at 2:06 p.m. QC 1 stated the meropenem should have been given as ordered by the physician. She stated there was no documentation indicating a reason why the medication was not given.

A review of the facility policy and procedure (P&P) titled, "Medication Administration," dated September 27, 2023, was conducted. The P&P indicated, "...Medications shall be administered exactly as ordered by the physician...If a dose is omitted, the nurse will "Full Document" in eMAR [electronic Medication Administration Record] the appropriated time slot, the reason the patient did not receive the medication with a comment and also notify the physician..."