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Based on interview and record review, the facility failed to ensure one of 30 sampled patient's (Patient 27) informed consent (a process where a patient gives their permission to undergo a procedure after being informed of the risks, benefits, and alternatives) was obtained in patient's (Patient 27) preferred language (language the patient choose to communicate in) in Spanish, in accordance with the facility's policy and procedure regarding consents and Patient Rights (a subset of human rights. Example: the right to considerate and respectful care).

This deficient practice had the potential for Patient 27 not to fully understand the treatment plan and associated risks and benefits of the surgery before giving the consent to the providers, which may result in poor patient outcomes.

Findings:

During a review of Patient 27's history and physical (H&P, a formal and complete assessment of the patient and the problem), dated 12/19/2024, the H&P indicated that Patient 27 was a 70 year old female who came from an assisted living facility (a type of housing designed for older adults who need some help with daily activities like bathing, dressing, or medication management) with complaints of headache, nausea (the urge to vomit)/vomiting, and altered mental status (a change in cognitive function, level of consciousness, or behavior, often presenting as confusion). Patient 27 also had right eyebrow abrasion (a superficial rub or wearing off of the skin, usually caused by a scrape). The H&P also indicated Patient 27 did not remember if she fell or hit her head. Computed tomography (CT, a medical imaging procedure that uses X-rays to create detailed images of the inside of the body) of the head revealed subarachnoid hemorrhage (or SAH, is when there's bleeding in the space between the brain and the membranes that cover it).

During a concurrent interview and record review on 1/8/2025 at 11:40 a.m. with the Nurse Educator 1 (NE1), Patient 27's electronic medical record (EMR, a digital version of paper charting), was reviewed. The EMR indicated that Patient 27 preferred language was Spanish. On 12/20/2024, Patient 27 underwent right frontal (front part of brain) external ventricular drainage (or EVD, is a temporary method surgically draining fluid from the ventricles [fluid-filled cavity] in the brain). An electronic informed consent (a legal document that a patient signs after a doctor thoroughly explains the details of a proposed surgery, including its risks, benefits, potential complications, and alternative treatments) for right external ventricular drain placement (surgical insertion of a catheter into the brain to drain fluid) in English language format, was signed by patient on 12/19/2024 at 4:44 p.m. NE1 stated that Patient 27's preferred language was Spanish and that the facility do provide the option of having the informed consent in Spanish language format. There was no documentation that an interpreter was utilized.

During an interview on 1/8/2025 at 11:49 a.m. with the Director of Office of Licensing, Accreditation and Regulatory (DOLAR), DOLAR stated that Patient 27's preferred language was Spanish, unless an interpreter was utilized, then her informed consent should have been in Spanish language format, not English.

During a review of the facility's policy and procedure (P&P) titled, "Consent: Informed Policy Clinical/ Administrative," with effective date of 12/04/2024, the P&P indicated the following:
"Self-determination Right
The patient's right to informed consent to hospital services is recognized by California law.
-An adult patient with capacity has a fundamental right of self-determination over his/her body with respect to medical care.

"Securing Consent When Communication Barriers Exist
-If a patient or his/her legal representative cannot communicate with the physician, or prefers to have the information communicated in a preferred language other than English, a competent interpreter in that language must be provided.
-The interpreter's responsibilities will include translating the information regarding the recommended medical treatment that the patient or patient's legal representative needs to receive before deciding whether to give consent, as well as instructions regarding medical care.

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibilities Policy: Clinical Manual/Administrative," with effective date of 12/01/2024, the P&P indicated the following:
"Receive information about his/her health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms he/she can understand. The patient has the right to effective communication and to participate in the development and implementation of his/her plan of care. The patient has the right to participate in ethical questions that arise in the course of his/her care, including issues of conflict resolution, withholding resuscitative services, and forgoing or withdrawing life¿ sustaining treatment."

Based on observation, interview, and record review, the facility failed to provide privacy for two of 30 sampled patients (Patient 9 and Patient 12) in accordance with the facility's policy and procedure regarding patient's rights, when the facility did not provide a privacy curtain during patient treatment in Patient 9's and Patient 12 's room.

This deficient practice resulted in Patient 9's and Patient 12's privacy rights not being respected as random people on the unit could see Patient 9 and Patient 's 12's activities such as dressing changes, medical and nursing treatments.

Findings:

1.a. During a review of Patient 12's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/27/2024, the H&P indicated Patient 12 was admitted on 4/26/2024 for seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). Patient was admitted to the Intensive Care Unit (ICU, provides critical care and life support for patients who are very sick or injured) due to respiratory failure (a serious condition that makes it difficult to breath on your own) and was intubated (a medical procedure that involves inserting a tube into the windpipe [trachea]).

During a concurrent observation and interview on 1/07/2025 at 2:37 p.m. with Associate Director (AD) 2 outside of Patient 12's room, Registered Nurse (RN) 9 was observed in the room lifting Patient 12's gown and providing care to abdomen of Patient 12. No curtains were provided for privacy. AD 2 stated the following: Confirmed that RN 9 was changing the G-tube (Gastrostomy tube, a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) dressing of Patient 12 and did not provide privacy for Patient 12. It is important staff provide privacy for Patient 12 when doing G-tube dressing change, so that patient (Patient 12) is not exposed to other people on the unit. AD will provide education to staff about providing privacy to patients.

During an interview on 1/07/2025 at 2:45 p.m. with Registered Nurse (RN) 9, RN 9 stated the following: Confirmed RN 9 was doing dressing change for G-tube of Patient 12 and did not provide privacy. Forgot to pull the curtain for privacy. Will make sure to provide privacy and not expose Patient 12 to others. Patient 12 is confused and cannot voice concerns for himself if someone is looking at him (Patient 12).

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibility Policy," dated 12/1/2024, the P&P indicated, "Patients' Rights: Considerate and respectful care and to be made comfortable patient has the right to respect for his/her personal values and beliefs. Have personal privacy respected. Privacy curtains will be used."

1.b. During a review of Patient 9's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 1/02/2025, the H&P indicated Patient 9 was admitted on 1/02/2025 for bilateral (both) foot wounds with reports of blisters to both feet and treatment plan of antibiotics.

During a concurrent observation and interview on 1/07/2025 at 2:42 p.m. with Associate Director (AD) 2 outside of Patient 9's room, two medical doctors entered Patient 9's room and removed the foot dressing of Patient 9. No curtains were provided for privacy. AD 2 stated the following: Confirmed the two individuals entering Patient 9's room were staff medical doctors. The two staff should have provided privacy to the patient before removing the foot dressing of Patient 9. AD 2 will let leadership know to educate the two medical doctors to provide privacy to the patients.

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibility Policy," dated 12/1/2024, the P&P indicated, "Patients' Rights: Considerate and respectful care and to be made comfortable patient has the right to respect for his/her personal values and beliefs. Have personal privacy respected. Privacy curtains will be used."

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

1. Ensure the call light (a device that serves as a means of communication for patients to their care providers that are outside the patients' rooms) was within reach for one of 30 sampled patients (Patient 13), in accordance with the facility's policies and procedures regarding Fall (when someone unintentionally ends up on the ground or a lower level) Prevention (the practice of reducing the risk of falling and injuries from falling).

This deficient practice had the potential to result in a delay in attending to Patient 13's immediate needs as well as may result in a fall with or without injuries.

2. Ensure that a seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking [uncontrolled movement], blank stares, and loss of consciousness [a state where a person is completely unaware of their surroundings and unable to respond to stimuli such as voice or touch]) precaution padding (device to prevent the patient from injuring themselves against the hard frame or side rails of the hospital bed during a seizure episode) was applied to the side rails (safety devices used to prevent patients from falling out of their beds) for one of 30 sampled patients (Patient 12), in accordance with the facility's policy and procedure regarding seizure management.

This deficient practice had the potential for Patient 12 to suffer injuries such as bruising, lacerations (cuts), or broken bones when without padded side rails for protection while having a seizure episode.

3. Ensure one of 30 sampled patient's (Patient 25) pre procedure checklist (a tool that helps ensure patient safety and prepare the patient for surgery. It includes confirming the patient's identity, procedure, and consent, and checking for any allergies or risk factors) was completed prior to surgery, in accordance with the facility's policy and procedure regarding "Admission Protocol for Patients Admitted in the pre-Operative Holding Area..."

This deficient practice had a potential to result in delays in the procedure, increased risk of medical errors, including potential for adverse patient outcomes such as severe reaction to medication due to unidentified allergies.

4. Ensure one of 30 sampled patient's (Patient 19) admission assessment (a process that involves collecting and analyzing a patient's health information to identify their current and future care needs) was completed within 24 hours of inpatient admission, in accordance with the facility's admission process.

This deficient practice had the potential for Patient 19's care needs to not be identified, and appropriate treatment plan not developed which may result in prolonged hospitalization and delayed recovery.


Findings:

1. During a review of Patient 13's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 12/12/2024, the H&P indicated Patient 13 was admitted on 12/12/2024 for falls (when someone unintentionally ends up on the ground or a lower level) and shortness of breath (difficulty breathing). Patient 13 reported multiple falls at home prior to hospital admission.

During a concurrent observation and interview on 1/07/2025 at 2:54 p.m. with Associate Director (AD) 2, in Patient 13's room, the call light cord was observed hanging above the right bottom raised side rail bed of Patient 13 with the call light device on the floor, and not within reach of Patient 13. AD 2 stated the following: Confirmed call light device found on the floor in Patient 13's room. Call light should be within reach for Patient 13 to use in case Patient 13 needs to call the nurse for help. Patient 13 can fall out of bed reaching for the call light. Patient 13 is unable to reach call light on the floor. Will educate staff on making sure call light is within reach and not on the floor.

During a review of the facility's policy and procedure (P&P) titled, "Fall Prevention," dated 2/20/2024, the P&P indicated, "Check the patient for potential dangers hourly during the daytime and evening and every two hours overnight to compile a universal fall precaution, correct potential dangers in the patient's room. Position the call light within the patient's reach out at all times."

2. During a review of Patient 12's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/27/2024, the H&P indicated Patient 12 was admitted on 4/26/2024 for seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking [uncontrolled movement], blank stares, and loss of consciousness [a state where a person is completely unaware of their surroundings and unable to respond to stimuli such as voice or touch]). Patient 12 was admitted to the Intensive Care Unit (ICU, provides critical care and life support for patients who are very sick or injured) due to respiratory failure (a serious condition that makes it difficult to breath on your own) and was intubated (a medical procedure that involves inserting a tube into the windpipe [trachea]).

During a concurrent interview and record review on 1/09/2025 at 3:47 p.m. with the Associate Director (AD) 2, Patient 12's "Order Review," was reviewed. The Order Review indicated active Seizure Precaution (safety measures to help prevent injuries and ensure the well-being of people experiencing seizures) order starting on 4/26/2024 for Patient 12. AD 2 stated the following: Confirmed seizure precaution for Patient 12 is still active and Patient 12 should have padding on the side rails to protect patient (Patient 12).

During a concurrent observation and interview on 1/09/2025 at 3:58 p.m. with Associate Director (AD) 2, in Patient 12's room, side rails for Patient 12 were observed not padded. AD 2 stated the following: AD 2 confirmed the side rails were not padded for Patient 12. AD 2 will educate staff to pad side rails for Patient 12. It is important to provide seizure precaution for Patient 12 which includes padded side rails in case patient (Patient 12) has a seizure and will not injure self.

During a review of the facility's policy and procedure (P&P) titled, "Seizure Management Policy," dated 11/18/2024, the P&P indicated "Patients at risk for seizures need precautionary measures to help prevent injury if a seizure occurs. Equipment: Padding for side rails."

3. During a review of Patient 25's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 1/2/2025, the H&P indicated Patient 25 was a 79 year old male with history of Type 2 diabetes (or DM2, a chronic disease that occurs when the body doesn't produce enough insulin [a hormone that helps regulate blood sugar levels] or doesn't use it properly), hypertension (high blood pressure), and Hyperlipidemia (high levels of fats or lipids in the blood), and was being admitted to the emergency room (Emergency Department, an area of the hospital designed to provide immediate medical care to patients with serious or life-threatening illnesses or injuries) for weakness.

During a concurrent interview and record review on 1/7/2025 at 3:10 p.m. with the Assistant Nurse Manager 6 (ANM 6), Patient 25's electronic medical record (EMR), was reviewed. The EMR indicated that on 1/6/2025, Patient 25 had a bilateral (both) lower extremity wound debridement (a surgical procedure that removes infected or dead tissue from both lower extremities). There was no record that a pre procedure checklist (a tool that helps ensure patient safety and prepare the patient for surgery. It includes confirming the patient's identity, procedure, and consent, and checking for any allergies or risk factors) was completed prior to Patient 25's debridement surgery. ANM 6 stated that a pre procedure checklist was not completed prior to Patient 25's debridement surgery. ANM 6 said that it was important that a pre procedure checklist be completed because the pre-procedure list ensured that all necessary steps and information before a surgical procedure were carried out and completed, thus minimizing the risk of errors.

During a review of the facility's policy and procedure (P&P) titled, "Admission Protocol for Patients Admitted in the pre-Operative Holding Area: OR/ Anesthesia," with effective date of 12/04/2024, the P&P indicated the following:

"Documentation Requirements

The following shall be on the patient's medical record prior to the patient being moved into the OR. The nurse shall verify that the documentation is complete prior to patient transfer to the OR, including but not limited to:
1. A history and physical examination that is completed by a Medical Staff Member with appropriate privileges.:
"Prior to starting the procedure, but no more than thirty days prior to the procedure.
2. Pre-op tests, documentation of waivers, based on the [Name of Facility] pre-op testing guidelines, and on the needs of the patient.
3. MD Documentation of informed consent, specifically stating that the risks, benefits and alternatives of the procedure have been discussed with the patient or their legal representative.
4. Additional special consents required for the procedure (i.e., Hysterectomy consent, Sterilization consent, etc.)
5. Ensure that consent for blood transfusion is signed when there is an order for type and cross/ type and screen for blood transfusion.
6. MD documentation of Interval H&P: to attest that the patient has been re-evaluated immediately prior to the procedure. For AM admits and outpatients, an Interval H&P needs to be done After admission, right before surgery/procedure. For inpatients, an Interval H&P needs to be done within 24 hours."

4. During a review of Patient 19's electronic medical record (EMR), the EMR indicated that Patient 19 was a 40 years old female with history of seizure (a sudden change in behavior, movement or consciousness due to abnormal electrical activity in the brain) and substance abuse (the harmful or hazardous use of psychoactive substances [drugs that affect the mood, awareness, thoughts, feelings, etc.], including alcohol and illicit [illegal] drugs). Patient 19 was originally at a different facility (General Acute Care Hospital 1) for seizure and was intubated (patient inserted with a breathing tube through the mouth and down the throat into the lungs). Patient was transferred and admitted to the current facility (General Acute Care Hospital 2) on 1/5/2025 for higher level of care (a more intensive or specialized level of medical treatment or support, usually provided when a patient's condition requires greater monitoring, intervention, or specialized expertise compared to standard care).

During a concurrent interview and record review on 1/9/2025 at 10:45 a.m. with the Nurse Educator (NE) 1, Patient 19's medical record titled, "Admission Navigator," was reviewed. The record indicated that the nursing admission assessment was not completed. NE1 stated that there was no admitting assessment completed on admission for Patient 19 and that it was the admitting nurse's responsibility to complete the admission assessment. NE1 added that the importance of completing an admission assessment was for the nurse to gather comprehensive information about a patient upon arrival at the facility, allowing the nurse to create a care plan (a process through which nurse identifies, documents, and keeps track of a parent's state or condition, needs, and risks) that will enable the delivery of appropriate and safe care.

During a review of the facility's policy and procedure (P&P) titled, "Admission," with last revised date of 5/20/2024, the P&P indicated the following:

"The Joint Commission and DNV GL-Healthcare (accreditation bodies that evaluate the quality of patient care services provided) require that each patient undergo an admission assessment by a registered nurse within 24 hours of inpatient admission. The Healthcare Facilities Accreditation Program requires that a registered nurse perform an initial assessment within the time frame established by the individual facility. During this assessment, the nurse should prioritize the patient's needs, always be conscious of the patient's levels of fatigue and comfort and maintain the patient's privacy while obtaining the health history. According to the American Hospital Association's Patient Care Partnership (which replaced the Patient's Bill of Rights), patients have the right to expect that all examinations, consultations, and treatments will be conducted in a manner that protects their privacy.

-Obtain a complete patient history. Include all previous hospitalizations, illnesses, surgeries, and food and medication allergies.
-Screen the patient for influenza immunization and for tobacco and unhealthy alcohol use.
-Ensure that a complete list of the medications that the patient was taking at home (including over-the-counter medications, supplements, and herbal preparations) is documented in the patient's medical record. Include doses, routes of administration, and frequencies for all medications. Compare this list with the patient's current medications. Reconcile and document any discrepancies (omissions, duplications, adjustments, deletions, and additions) in the patient's medical record to reduce the risk of transition-related adverse drug events.
-Determine whether the patient has an advance directive and, if so, ask for a copy to place in the patient's medical record. If the patient doesn't have one, provide the necessary advance directive information to the patient.
-Review patient rights with the patient and family (if appropriate).
-Perform an admission assessment. Ask the patient to explain the reason for coming to the facility. Record the answer (in the patient's own words) as the chief complaint. Follow up with a physical assessment, focusing on the patient's complaints. Record any noted marks, bruises, or discolorations on the nursing assessment form.
-Screen the patient for suicide ideation (thoughts of killing one's self) using a brief, standardized, evidence-based screening too. If the patient is at risk for suicide, address immediate safety needs and collaborate with the multidisciplinary health care team to determine the most appropriate setting for treatment."

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

1. Initiate and implement a Peripheral Inserted Central Catheter (PICC, a long, flexible tube that's inserted into a vein in the arm and threaded into a vein near the heart) line care plan (a written document that details the specific nursing care a patient needs, outlining their individual health needs, goals, and the interventions required to achieve them) for one of 30 sampled patients (Patient 14), who was diagnosed with Mediastinal Mass (a growth in the chest that can be benign [noncancerous] or malignant [cancerous]) and had a PICC line to receive medication, in accordance with the facility's policy and procedure regarding care plan preparation.

This deficient practice had the potential for Patient 14's needs and risks to remain unidentified which may result in complications such as infection, bleeding, blood clots, etc.

2. Ensure one of 30 sampled patient's (Patient 24) care plan for infection (the invasion and growth of germs in the body) was initiated on admission, in accordance with the facility's policy and procedure regarding care plan preparation. Patient 24 was placed on contact isolation (a medical practice used to prevent the spread of infectious diseases by isolating a patient who has germs that can be transmitted through direct or indirect contact with their body or contaminated surfaces in their room) upon being admitted to the hospital on 1/1/2025 for previously testing positive for Extended-Spectrum Beta-Lactamase (ESBL, is an enzyme that makes some bacteria resistant to antibiotics) in the urine on 12/8/2024.

This deficient practice had the potential for Patient 24's needs and risks to remain unidentified and may also result to the spread of infection to other patients, staff, and visitors.

Findings:

1. During a review of Patient 14's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 12/22/2024, the H&P indicated Patient 14 was transferred from outside facility for further work up due to a mediastinal mass (a growth in the chest that can be benign [noncancerous] or malignant [cancerous]).

During a review of Patient 14's PICC (Peripheral Inserted Central Catheter, a long, flexible tube that's inserted into a vein in the arm and threaded into a vein near the heart) Insertion Note, dated 1/04/2025, the PICC Insertion Note indicated Patient 14 had a PICC line placed on 1/04/2025 to the right arm.

During a concurrent interview and record review on 1/09/2025 at 3:47 p.m. with the Nurse Professional Development Practitioner (NPDP) 6, Patient 14's Care Plan (a written document that details the specific nursing care a patient needs, outlining their individual health needs, goals, and the interventions required to achieve them), was reviewed. There was no care plan initiated or implemented regarding Patient 14's PICC line. NPDP 6 stated the following: Confirmed no care plan for PICC line was initiated or implemented for Patient 14. The assigned nurse for Patient 14 should and need to select the care plan Risk for central line associated blood stream infection.

During an interview on 1/09/2025 at 2:40 p.m. with the Assistant Nurse Manager (ANM) 6, ANM stated the following: Assigned nurse is responsible for selecting the right care plan for Patient 14. Confirmed the care plan, Risk for central line associated blood stream infection should be selected for patient with a PICC line. Patients with PICC line are at risk for infection whenever they have PICC line placed, and therefore, should have right care plan selected. "I will follow up to educate staff and remind staff to select care plan risk of central lines associated blood stream infection."

During a review of the facility's policy and procedure (P&P) titled, "Care Plan Preparation," with last revised date of 5/20/2024, the P&P indicated the following:

"A care plan directs a patient's nursing care from admission to discharge. This written action plan is based on nursing diagnoses that have been formulated after reviewing assessment findings, and it embodies the components of the nursing process: assessment, diagnosis, planning, implementation, and evaluation. A care plan consists of three parts: goals or expected outcomes (which describe behaviors or results to be achieved within a specified time), appropriate nursing actions or interventions necessary to achieve these goals, and evaluations of the established goals."

"A nursing care plan should be written for each patient, preferably within 24 hours of admission. It's usually started by the patient's primary nurse or the nurse who admits the patient. If the care plan contains more than one nursing diagnosis, the nurse must assign priorities to each one and implement those with the highest priority first. The nurse must update and revise the plan throughout the patient's stay based on the patient's response."

"A nursing care plan serves as a database for planning assignments, giving change-of-shift reports, conferring with the practitioner and other members of the health care team, planning patient discharge, and documenting patient care. In addition, the care plan can be a management tool for use in determining staffing needs and assignments."

2. During a concurrent interview and record review on 1/7/2025 at 2:37 p.m. with the Assistant Director 5 (AD5), Patient 24's medical record titled, "History and Physical," dated 1/1/2025, was reviewed. The H&P indicated that Patient 24 was a 67 year old male with Human immunodeficiency virus (HIV, is a virus that attacks the body's immune system [A complex network of cells, tissues, organs, and the substances they make that helps the body fight infections and other diseases]), hypertension (high blood pressure) and anxiety (a feeling of fear, dread, and uneasiness), and presented on 1/1/2025 with agitation (a feeling of intense distress, irritability, or restlessness that can make it hard to relax). The H&P also indicated that Patient 24 was previously admitted for pneumonia (a lung infection that causes inflammation and fluid buildup in the air sacs of the lungs), altered mental status (a change in mental function), as well as ESBL (Extended-Spectrum Beta-Lactamase, an enzyme that makes some bacteria resistant to antibiotics) bacteremia (a serious bacterial infection in the blood caused by ESBL-producing bacteria). AD5 stated that Patient 24 was on contact isolation (a set of precautions that healthcare workers take to prevent the spread of germs from a patient to others) for previously testing positive of ESBL urine last 12/8/2024.

During a concurrent interview and record review on 1/7/2025 at 2:54 p.m. with the Assistant Nurse Manager 6 (ANM6), Patient 24's electronic medical record titled, "Care Plans Report," was reviewed. The report indicated that there was no nursing care plan for infection. ANM6 said that nursing staff should have initiated a care plan for infection because Patient 24 was placed on isolation for contact precaution (a medical practice used to prevent the spread of infectious diseases by isolating a patient who has germs that can be transmitted through direct or indirect contact with their body or contaminated surfaces in their room) and was previously identified ESBL positive of urine. ANM 6 also stated that it was important that nursing staff identify the infection problem in the care plan because it will outline the patient's care needs, goals, and interventions. ANM 6 further said, it also ensured that all healthcare providers involved were on the same page and consistent in providing care for Patient 24.

During a review of the facility's policy and procedure titled, "Care Plan Preparation," with last revised date of 5/20/2024, the P&P indicated the following:

"A care plan directs a patient's nursing care from admission to discharge. This written action plan is based on nursing diagnoses that have been formulated after reviewing assessment findings, and it embodies the components of the nursing process: assessment, diagnosis, planning, implementation, and evaluation. A care plan consists of three parts: goals or expected outcomes (which describe behaviors or results to be achieved within a specified time), appropriate nursing actions or interventions necessary to achieve these goals, and evaluations of the established goals."

"A nursing care plan should be written for each patient, preferably within 24 hours of admission. It's usually started by the patient's primary nurse or the nurse who admits the patient. If the care plan contains more than one nursing diagnosis, the nurse must assign priorities to each one and implement those with the highest priority first. The nurse must update and revise the plan throughout the patient's stay based on the patient's response."

"A nursing care plan serves as a database for planning assignments, giving change-of-shift reports, conferring with the practitioner and other members of the health care team, planning patient discharge, and documenting patient care. In addition, the care plan can be a management tool for use in determining staffing needs and assignments."

Based on interview and record review, the facility failed to ensure one of six (6) sampled nursing personnel (Registered Nurse 9), completed an annual health screening (a screening process for identifying potential health issues that could compromise nursing staff ability to practice safe infection control measures, protecting both staff and patients by ensuring they are up-to-date on necessary vaccinations) in accordance with the facility's policy and procedure regarding health screening. Registered Nurse (RN) 9's last annual health screening was on 12/7/2023.

The deficient practice had the potential of failing to monitor for staff exposure to infectious diseases and identifying any health concerns that might increase the risk of transmitting infections to patients, visitors, or other staff.

Findings:

During a concurrent interview and record review on 1/9/2025 at 3:38 p.m. with the Manager of Clinical Operation (MCO), Registered Nurse 9's (RN9) personnel health records titled, "Annual Health Evaluation," was reviewed. The record indicated that RN9's last annual health evaluation was completed on 12/7/2023. MCO stated that all staff were expected to complete a health evaluation annually. RN 9 failed to complete her annual health evaluation last 12/7/2024. The MCO said RN9 had been previously out for medical leave but had been back working since November 2024. RN9 failed to schedule an appointment with employee health. MCO further stated Staff were expected to complete an annual health evaluation because it ensured nurses were physically and mentally capable of providing safe patient care, it ensured that nurses were up-to-date on necessary vaccinations, monitoring for potential exposure to infectious diseases, and identifying any personal health concerns that might increase their risk of transmitting infections to patients, visitors, or other staff.

During a review of the facility's policy and procedure (P&P) titled, "Health Screening Procedures for Employees and Non-Employee Groups", with effective fate of 2/28/2024, indicates the following:

Employee Annual Clearance
-All employees must receive annual clearance to continue working.
-When all laboratory and data have been reviewed and the individual is determined safe to work, EHS will "clear" the employee to work. If the employee is not cleared, he or she will receive a form indicating that he or she is not cleared. The employee's department and/or Human Resources representative will be notified by the EHS provider that the person has not been cleared to work.
-Individuals will be notified of any borderline abnormal laboratory test by letter requesting that they return to EHS to discuss the results of their evaluation. Individuals with abnormal labs may be contacted by phone by an EHS RN, NP, or MD in addition to receiving a letter.
-For those individuals that work in areas that require Respiratory Fit Testing, the process will be incorporated into their annual clearance timeframes.