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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13, PATIENT RIGHTS, was out of compliance.

A-0154 USE OF RESTRAINT OR SECLUSION Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. Based on interviews and record review, the facility failed to use restraints in accordance with facility policy and the restraint manufacturer's instructions for use (IFU). This failure included lack of provider orders for restraint use, lack of assessment and monitoring of patients when in restraints, and the use of restraints as a fall precaution. The failure was identified in one of two records reviewed of patients who were restrained (Patient #3).

Based on interviews and record review, the facility failed to use restraints in accordance with facility policy and the restraint manufacturer's instructions for use (IFU). This failure included lack of provider orders for restraint use, lack of assessment and monitoring of patients when in restraints, and the use of restraints as a fall precaution. The failure was identified in one of two records reviewed of patients who were restrained (Patient #3).

Findings include:

Facility Policy:

The facility Restraint/Seclusion policy read, use will be limited to clinically-justified situations, and the least restrictive restraint will be used with the goal of reducing, and ultimately eliminating, the use of restraints. There must be a provider order for restraint with non-violent or non-self-destructive behavior that must specify clinical justification for the restraint, the date and time ordered, the duration of the use, the type of restraint and behavior-based criteria for release. Staff must assess, monitor, and re-evaluate the patient regularly and release the patient from restraint when criteria for release are met.

A physical restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body to include immobilization or reduction of the ability of a patient to move his or her arms, legs, body, or head freely is considered a physical restraint. An object may be a restraint by functional definition, which is when an object restricts the patient's movement or access to his or her body. Under this definition, many commonly used facility devices and practices could meet this definition of a restraint (e.g., tucking in sheets very tightly, use of side rails to prevent a patient from voluntarily getting out of bed, holding a patient to prevent movement, pinning of mitts on infants, arm restraints and other wrappings that prevent infants, children and/or adults from removing invasive lines or reopening surgical sites, etc.)

Reference:

The Posey Self-Releasing Roll Belt instructions for use (IFU) read, the indications for use are for patients needing a reminder to call for assistance before exiting a bed, and are able to follow instructions. Rx (medical prescription) only. The product is designed for self-release. If the patient is not able to easily self-release, it is considered a restraint and must be prescribed by a physician. Contraindications state do not use on a patient who is or becomes highly aggressive, combative, agitated, or suicidal; and do not use on a patient who is unwilling or unable to follow instructions, and is at risk of a fall or re-injury from self-release. Additional warnings include constant monitoring may be required for aggressive or agitated patients. Always monitor patients per facility policy. Improper application or use of any restraint may result in serious injury or death.

1. The facility failed to ensure staff followed facility policies and processes for patients who were restrained.

A. Medical Record Review

i. On 2/26/24, Patient #3 was admitted to the facility with sepsis (a serious condition in which the body responds improperly to an infection) and severe progressive dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life). Medical record review revealed Patient #3 had a suprapubic catheter (a tube used to drain urine from the bladder through a cut in the abdomen) and had been taking antibiotics for a urinary tract infection (UTI). Provider notes stated Patient #3 was not oriented to name, place, or time. Provider notes also stated Patient #3 was agitated with episodes of combative behavior which were refractory (resistant) to medications. The medical record revealed the patient had both neurology and psychiatry consultations which concluded Patient #3's behavior was consistent with dementia.

The nursing flow sheets revealed Patient #3 was placed in a roll belt (a belt used to remind a patient to call for assistance before getting out of bed) on 2/26/24 at 11:52 a.m. The initial provider order for restraint use was written on 2/26/24 at 8:34 p.m., more than eight hours after the roll belt was applied. Additionally, the final order for restraint use for Patient #3 expired on 3/8/24 at 11:59 p.m. However, documentation in the medical record revealed Patient #3 continued to be restrained with a roll belt and at times mitts until discharge from the facility on 3/15/24, which was seven days after the last order for restraints. Nursing staff did not document use of restraints or frequent checks of Patient #3 according to facility policy during this time period.

This was in contrast to the facility Restraint/Seclusion policy which read, there must be a provider order for restraint with non-violent or non-self-destructive behavior that must specify clinical justification for the restraint, the date and time ordered, the duration of the use, the type of restraint and behavior-based criteria for release. Also, the policy read, staff must assess, monitor, and re-evaluate the patient regularly and release the patient from restraint when criteria for release were met.

Physical therapy, occupational therapy, and case management notes reviewed in the medical record revealed Patient #3 continued to be in a roll belt, and at times mitts, days after the last restraint order expired on 3/8/24. On 3/11/24, the provider documented a conversation with the charge nurse about a request for an in-person sitter for Patient #3 to alleviate the need for restraints. The provider was informed there was no staff available to provide a sitter. Case management notes about discharge planning described difficulty finding placement for Patient #3 in a skilled nursing facility due to the use of the roll belt. According to the case management notes, outside facilities required patients to be free from restraint use for 24 hours prior to admission, and due to Patient #3's need for the roll belt facilities would not accept them for admission.

B. Interviews revealed inconsistencies between staff practices, facility policies, facility leadership expectations, and the Posey self-releasing roll belt IFUs.

i. On 3/20/24 at 11:32 a.m., an interview was conducted with patient care technician (PCT) #1. PCT #1 stated a roll belt was used for patients who tried to get out of bed. They explained it was used especially for patients who were disoriented so they would not try to get out of bed alone and hurt themselves. Further, PCT #1 said if a roll belt was used alone it was not considered a restraint, but if the roll belt was used along with mitts then it would be considered a restraint.

This was in contrast to the facility's Restraint/Seclusion policy which read, the definition of a physical restraint was any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient's body that he or she could not easily remove that restricted freedom of movement or normal access to one's body to include immobilization or reduction of the ability of a patient to move his or her arms, legs, body, or head freely was considered a physical restraint. An object may be a restraint by functional definition, which is when an object restricts the patient's movement or access to his or her body. Under this definition, many commonly used facility devices and practices could meet this definition of a restraint.

This was also in contrast to the roll belt IFU which stated the roll belt should have only been used on patients who were able to follow instructions. The product IFU cautioned if the patient was not able to easily self-release, it was considered a restraint and must have been prescribed by a physician. Also, the roll belt contraindications stated not to use it on a patient who was or became highly aggressive, combative, agitated, or suicidal. Furthermore, the contraindications stated not to use the roll belt on a patient who was unwilling or unable to follow instructions and was at risk of a fall.

According to the medical record review, Patient #3, who was disoriented (altered mental state in which the person did not know name, time, date, or location) and had severe dementia, was placed in a roll belt and at times in both a roll belt and mitts. Provider orders for restraints were missing from 3/9/24 through the patient's discharge on 3/15/24.

ii. On 3/20/24 at 12:05 p.m., an interview was conducted with registered nurse (RN) #2. RN #2 stated a roll belt was a belt placed around the patient's waist that could be unclipped by the patient. They said the roll belt was something they used on patients instead of a restraint. They explained the roll belt was a reminder to patients not to get up without help. RN#2 was not sure if a provider order was needed to apply a roll belt to a patient.

iii. On 3/21/24 at 9:13 a.m., an interview was conducted with clinical nurse coordinator (CNC) #3. CNC #3 said a roll belt by itself was not a restraint. They explained a provider order was not needed before they applied the roll belt when it was used alone. CNC #3 said if a roll belt was used with mitts and/or soft wrist restraints then the roll belt would be considered a restraint and a provider order would be needed. Also, they said frequent checks of patients who were restrained were important to ensure the patient got food, water, toileting, and basic needs met. Furthermore, they said patients in roll belts needed frequent checks because they could be at risk of dehydration, pressure injuries, or getting tied up in the roll belt. CNC #3 said they would be difficult if someone tied them to the bed.

iv. On 3/26/24 at 1:02 p.m., an interview was conducted with nurse manager (Manager) #4. Manager #4 stated they had been educated that a roll belt was not a restraint because the patient could remove it. They said if a patient had a roll belt with mitts, the roll belt would be considered a restraint. They said the roll belt would not be considered a restraint if used on a patient with dementia. Manager #4 said staff were educated on how to use roll belts in orientation. Also, they explained the importance of ensuring staff followed IFUs was to be sure they used the product properly. Furthermore, Manager #4 stated incorrect use of any product could harm the patient; for example, if the roll belt were applied too tight, it could harm the skin and any tubes across the patient's midsection.

v. On 3/26/24 at 1:38 p.m., an interview was conducted with the director of acute care (Director) #5. Director #5 stated roll belts were used for patients who were impulsive and at risk of falling. They explained if the patient could demonstrate the ability to remove the roll belt themselves, then it was not considered a restraint. They also said a provider order was not needed. Additionally, Director #5 said in practice they were not considering roll belts a restraint unless the patient had mitts on too. They said the main use for roll belts was for fall prevention. Director #5 stated at some point, they learned a roll belt was a restraint if the patient could not remove it by themselves. Director #5 said other facilities considered a roll belt a restraint because they required the patient to be out of it for 24 hours before they would accept the patient. Furthermore, Director #5 stated it was important for patient safety to follow the IFU. They stated if the roll belt product was not used as intended the risk to patients could be any event up to death.

These interviews were in contrast to the roll belt IFU which stated the device should be used for patients who were able to follow instructions. Additionally, the IFU said if the patient was not able to easily self-release the roll belt it was considered a restraint and must be ordered by a provider. Furthermore, contraindications stated the device should not be used on a patient who was highly aggressive, combative, or agitated; unwilling or unable to follow instructions; and warnings included that constant monitoring would be required for aggressive or agitated patients.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 NURSING SERVICES was out of compliance.

A-0395 - A registered nurse must supervise and evaluate the nursing care for each patient. Based on interviews and document reviews, the facility failed to provide nursing services within recognized standards. Specifically, the facility failed to monitor a tracheostomy patient with continuous pulse oximetry in accordance with facility policy in one of one medical record reviews of patients with a tracheostomy (a curved tube inserted into an opening made in the neck and windpipe to allow air to pass through) (Patient #4). Additionally, the facility failed to ensure staff notified the provider of a change in patient condition in one of six medical records reviewed (Patient #6). In addition, the facility failed to provide assistance with activities of daily living (ADLs) in four of six medical records reviewed (Patients #1, #2, #3, and #4).

Based on interviews and document reviews, the facility failed to provide nursing services within recognized standards. Specifically, the facility failed to monitor a tracheostomy patient with continuous pulse oximetry in accordance with facility policy in one of one medical record reviews of patients with a tracheostomy (a curved tube inserted into an opening made in the neck and windpipe to allow air to pass through) (Patient #4). Additionally, the facility failed to ensure staff notified the provider of a change in patient condition in one of six medical records reviewed (Patient #6). In addition, the facility failed to provide assistance with activities of daily living (ADLs) in four of six medical records reviewed (Patients #1, #2, #3, and #4).

Findings include:

Facility policies:

The Tracheostomy policy read, the purpose was to establish a protocol for the care of tracheostomy patients. The procedure stated continuous pulse oximetry will be used on all trach patients.

The Assessment and Reassessment policy read, the nurse will notify the provider of change in condition.

The Urinary Catheter (Foley) Insertion and Management policy read, its purpose was to define the indication and care of an indwelling urinary catheter, and to provide a guideline for the removal of indwelling urinary catheters when no longer clinically indicated. See the EBSCO Nursing Procedures and Skills for detailed indwelling urinary catheter care and management. Perineal/indwelling urinary catheter care must be performed at least once a shift, during daily bath, and as needed (e.g. after episodes of fecal incontinence).

References:

The Resource Guidebook for New Hire Nurses read, the frequency for patient care routines such as urinary catheter care should be every shift and as needed, a full bath should be daily and as needed, oral care should be every shift and as needed, and for pressure ulcer prevention turning should be every two hours. The owner for each of these interventions is listed as the RN. The documentation checklist read, routine care should be documented every shift, Activities of Daily Living (ADL) should be documented at the end of the shift, and CHG baths should be documented twice each day for patients with central lines or a foley.

The EBSCO Pressure Injury Prevention guidelines read, relieve/redistribute pressure with frequent position changes. Avoid positioning on erythemic areas.

The EBSCO Oral Care guidelines read, providing oral hygiene improves oral health, overall health, and comfort. Consistent oral hygiene prevents the proliferation and spread of oral microbes which cause oral disease and other complications. Educate the patient about the need for brushing at least twice per day and flossing once per day.

The EBSCO Bathing guidelines read, bathing on a regular basis is a necessary part of personal hygiene and is a method of preventing body odor and infection.

The EBSCO Urinary Catheter Care guidelines read, providing urinary catheter care involves regular cleaning. Encourage patient to clean their established urinary catheter using clean technique with warm soapy water, usually twice daily.

1. The facility failed to ensure a patient with a tracheostomy (trach) was monitored in accordance with the facility's expectations.

A. Medical Record Review

i. On 12/15/23, Patient #4 was admitted to the facility with a history of agitation and a tracheostomy and they remained hospitalized until 2/18/24 when they died after a cardiorespiratory arrest (the cessation of effective ventilation and circulation).

Provider notes read on 2/18/24 the patient was found with an oxygen saturation level (the amount of oxygen circulating in the blood) of 4% (normal range is above 94%) and the tracheostomy tube (a tube inserted into the windpipe to allow ventilation) was dislodged. A code blue was called at 6:52 a.m. All pulse checks showed asystole. After 20 minutes of asystole and attempts to revive the patient, resuscitative efforts were stopped and the patient died at 7:12 a.m.

Patient #4's past medical history was significant for a stroke (occurred when the blood supply to part of the brain was blocked or when a blood vessel in the brain burst) with left-sided weakness. On their previous admission, Patient #4 had also had a tracheostomy placed, had increased oxygen needs, and struggled with mucus plugging in their airway. After prolonged hospitalization Patient #4 was discharged to a skilled nursing facility but returned to the hospital due to agitation which required a right-hand mitt to decrease the risk of removing the tracheostomy tube.

Medical record review revealed when Patient #4 was readmitted for agitation there was an initial telemetry order placed by the provider on 12/15/23. This provider order was from the tracheostomy protocol and specified the patient may not be off telemetry monitoring. This order was stopped on 2/13/24. No order was written for continuous pulse oximetry throughout Patient #4's admission.

This was in contrast to the facility's tracheostomy policy which read, continuous pulse oximetry would be used on all tracheostomy patients.

According to the medical record, trach care had been provided by respiratory therapy (RT) on 2/17/24 at 7:45 a.m., 2:38 p.m., 8:07 p.m., and on 2/18/24 at 3:12 a.m. At 3:12 a.m. the RT documented the patient was combative but tolerated the trach care and the trach was secure. Further documentation revealed Patient #4 was found by nursing staff at 6:52 a.m. in complete cardiorespiratory arrest with the trach tube dislodged and a code blue was called.

B. Interviews

i. On 3/27/24 at 12:15 p.m., an interview was conducted with the clinical coordinator of respiratory care (CCRC) #10. CCRC #10 stated all patients with a tracheostomy should have been placed on continuous pulse oximetry. They said the risk to the tracheostomy patient of no continuous pulse oximetry monitoring would be delayed notification to staff if oxygen levels and heart rate were out of normal range.

ii. On 3/27/24 at 12:15 p.m., an interview was conducted with registered nurse (RN) #11. RN #11 stated a patient with a tracheostomy would be continuously monitored with pulse oximetry. Also, they said they would ensure there was another trach tube, a cleaning kit, and suctioning equipment at the patient's bedside. They said they would contact respiratory therapy (RT) if deep suctioning was needed. They stated VS were checked every four hours and patients would be monitored either by the VS machine in the patient's room or remotely by centralized telemetry monitoring. RN #11 explained if an alarm sounded they would go straight to the patient's room to check on the patient first. If the monitor was being remotely monitored and it alarmed the monitor technicians would call the RN first. RN #11 said it was important to continuously monitor trach patients because they were on continuous oxygen and their airway was compromised. They said they would need to know if the trach had been removed or dislodged. Further, they said the risk to the patient of not continuously monitoring with pulse oximetry and the airway was dislodged the patient could code or or die.

iii. On 3/27/24 at 12:34 p.m., an interview was conducted with RN #8. They said for trach patients there was supposed to be a black box with emergency supplies that RT set up at the bedside. Also, they said continuous pulse oximetry would be in place on all trach patients remotely and at the nursing stations. RN #8 explained if the monitor alarmed, the techs would call the RN and then they would page overhead if there was no response from the call. They said nurses needed a provider order for continuously monitoring pulse oximetry. They also said there were capnography (monitoring of the carbon dioxide levels in respiratory gasses) machines that could be used until the nurse obtained a provider order. RN #8 said patients were not monitored if their trach was capped. They said it was important to monitor trach patients because they need to be suctioned frequently. They said if the trach patient's airway were blocked or would decannulate (removal of the trach tube), they would need to know immediately because the risk to the patient would be that their oxygen level would drop too low and could cause brain damage or death.

iv. On 3/27/24 at 12:53 p.m., an interview was conducted with RN #12. They said trach care was not done very often in the medical acute care unit. They said continuous pulse oximetry monitoring would be used for all trached patients. RN #12 stated the staff was supposed to respond to alarms within two minutes. They said the risk of not monitoring a trach patient would be a rapid decline in the patient's condition that could go unnoticed.

v. On 3/27/24 at 1:41 p.m., an interview was conducted with patient safety manager (Manager) #13. Manager #13 stated there had been a review of Patient #4's unexpected death. They said the review of this incident had determined the code blue response was appropriate and the patient monitoring had been appropriate for a medical-surgical level of care. Manager #15 explained there was no specific provider order for continuous pulse oximetry so by default the nurses would follow unit standards for tracheostomy care. For the nursing unit where Patient #4 was located, they said it would have been nursing protocol for the patient to have continuous pulse oximetry in place. They said for Patient #4 the staff was following the trach policy. They said the policy did not differentiate between a new trach or one that was in place for a while. Manager #13 said they were unsure what determined whether a trach patient would have continuous pulse oximetry in the patient's room or remote monitoring. They said they would defer to the nursing unit for that decision.

This interview was in contrast with the Tracheostomy policy which instructed that continuous pulse oximetry would be used on all trach patients.

vi. On 3/28/24 at 8:52 a.m., an interview was conducted with the interim hospitalist medical director (MD #14). When asked about Patient #4, MD #14 said they had been waiting for skilled nursing facility (SNF) placement for several days and that Patient #4 was medically stable. They said the trach was pre-established and secured and the patient had no respiratory distress. They said RT was doing daily suctioning. MD #14 said when Patient #4 was first admitted, at least the first 48 hours, was when they would have needed monitoring. They said the decision to place patients on continuous pulse oximetry came down to provider practice. They said when the intensivist went to the code it was unclear whether the trach came out prior to the code or during resuscitation efforts. They said Patient #4 was a very sick patient and a number of things could have caused their cardiopulmonary arrest. MD #14 stated since Patient #4 was going to a SNF, they would have taken care of the immediate needs and then taken her off monitoring to get her ready for discharge to the SNF which would not have had continuous monitoring capability.

This was in contrast to facility policy which stated continuous pulse oximetry will be used on all trach patients.

2. The facility failed to ensure staff notified the provider of a change in condition.

A. Medical Record Review

i. On 2/8/24, Patient #6 was admitted to the facility with sepsis (a serious condition in which the body responded improperly to infection) and pneumonia (an infection in the lungs). Medical record review revealed on the evening of 2/14/24 Patient #6 experienced a marked increase in oxygen needs. They were emergently transferred to the ICU for bedside bronchoscopy (a procedure to look directly at the airways in the lungs using a thin, lighted tube) and intubation (a tube inserted through the nose or mouth into the trachea so air can get through) to clear an obstruction of the lung.

A review of Patient #6's medical record revealed in the hours leading up to the respiratory crisis on 2/14/24 the patient had diminished lung sounds on the morning of 2/13/24 and at 9:24 a.m. the provider ordered a chest CT (diagnostic imaging technique used to get internal images of the body). The chest CT was not completed until 2/14/24 at 9:21 p.m., which was 36 hours after the order was written. There was no evidence in the medical record to explain why there was a delay in completing the provider order.

On 2/14/24 at 10:34 a.m., nursing documentation reported Patient #6's lung sounds were clear. At 3:54 p.m. that afternoon, Patient #6 had a respiratory rate of 18 on one liter of oxygen and had an oxygen saturation of 92%. At 8:15 p.m., the medical record revealed Patient #6 had increased respiratory effort with the use of accessory muscles. The documentation stated lung sounds were absent in the left upper and lower lobes of the lung and diminished on the right side. Patient #6's oxygen had been increased to five liters via nasal cannula. There was no evidence in the medical record the provider had been notified of the patient's change in condition.

On 2/14/24 at 9:21 p.m., the chest CT which had been ordered 36 hours prior on 2/13/24 at 9:24 a.m. was completed on Patient #6. At 9:42 p.m. the report read, complete collapse of the left lung, likely secondary to mucus plugging. There was no evidence in the medical record this imaging result had been called to the care team in accordance with facility policy.

On 2/14/24 at 11:47 p.m., two hours after the chest CT was completed, medical record documentation revealed respiratory therapy (RT) placed Patient #6 on 45 liters of heated high-flow oxygen at 65% and notified the nurse and provider. On 2/15/24 at 1:00 a.m., Patient #6 was transferred to ICU for intubation and bronchoscopy. At 2:10 a.m. bedside bronchoscopy was completed and at 2:15 a.m. Patient #6 was intubated.

B. Interviews

i. On 3/27/24 at 12:15 p.m., an interview was conducted with the clinical coordinator of respiratory care (CCRC) #10. CCRC #10 explained a respiratory therapist (RT) would notify the nurse and provider of a patient's change in condition. They stated if the patient's condition were emergent the RT would hit the rapid response button. If the patient had increased oxygen needs, RT would communicate directly with the bedside nurse and when appropriate let the rapid response nurse know too. CCRC #10 stated depending on the situation either RT or the nurse would contact the provider about an acute change in condition.

ii. On 3/27/24 at 2:34 p.m., an interview was conducted with the manager of medical imaging (Manager) #15. Manager #15 stated there were a variety of reasons why a delay in completing a routine CT test could occur. They said the healthcare standard most hospitals abided by was usually within 12 to 24 hours of the provider order being placed for inpatient care. They said the timeframe to report a critical test result was 30 minutes. Manager #15 explained a critical result was anything seen on imaging that the provider deemed critical. They said a new collapsed lung finding would be considered a critical result.

Manager #15 reviewed the PACS (computerized system for imaging communications) notes for Patient #6's chest CT procedure to understand why there was a 36-hour delay in completing the chest CT. Manager #15 explained on 2/13/24, the date of the chest CT order, there were texts exchanged between imaging and the primary nurse at 6:48 p.m., 8:26 p.m. and 11:00 p.m. At 11:00 p.m. a note was made in PACS which stated the test would be done in the morning per the charge nurse. Manager #15 said on 2/14/24, there were texts exchanged between imaging and nursing at 6:14 p.m., 7:31 p.m., and 8:19 p.m. The 8:19 p.m. text was when transport was requested to bring Patient #6 to radiology for the chest CT. Manager #15 said there were no notes in PACS that indicated there was a critical finding. They also said there was no documentation the radiologist had notified the ordering provider or care team.

iii. On 3/27/24 at 12:31 p.m., an interview was conducted with nurse manager (Manager) #16. Manager #16 said they were involved with the review of the incident regarding Patient #6's collapsed lung. Manager #16 reviewed the incident follow-up documentation which read, the critical results list was reviewed, the exam was read promptly by the care team, and the care was appropriate. Manager #16 said they debriefed Patient #6's collapsed lung incident the morning after it occurred with the charge nurse who had been working at the time of the incident.

Manager #16 stated the expectation for notifying a provider of a change in patient condition was based on nursing critical thinking and best judgment. They said any time there was a change in the patient's condition the nurse would have been expected to notify the provider. They said the nursing staff used their best judgment on what would have been the best way to do that. For example, if a change in patient condition occurred in the middle of the night, the nurse would have needed to use their best judgment whether to text or call the provider.

Manager #16 stated they were unsure why the chest CT that had been ordered on 2/13/24 had not been completed until 36 hours later. They said some causes for the delay could have been CT equipment out of service or the imaging team had prioritized other imaging tests ahead of Patient #6. Manager #16 said nurse staffing would have been reviewed as part of the incident follow-up and they were unaware if nurse staffing was a causative factor in the delayed chest CT.

Nursing assignment sheets for 2/13/24, the day the chest CT was ordered, were reviewed and revealed, the nursing unit was short an RN and the charge nurse had a five-patient assignment on that day shift. On 2/13/24, the night shift assignment sheet was not available and the daily roster revealed the unit was short two RNs for that shift. On 2/14/24, the night of Patient #6's collapsed lung, the night shift assignment sheet was not available and the daily roster revealed the unit was short one RN.

3. The facility failed to ensure patients received assistance with activities of daily living (ADLs) in accordance with the facility's expectations.

A. Record review

i. Review of Patient #1's medical record revealed the patient was admitted to the facility 12/19/23 for sepsis and anemia. Patient #1 had a stage 4 sacral decubitus ulcer on admission. A Plastic surgery consultation on 2/20/24 recommended wound care evaluation and treatment, antibiotics, a specialty offloading mattress, a dietitian consult for nutritional optimization, and routine nursing care.

A review of the nursing documentation for turning Patient #1 every two hours throughout this hospital admission revealed turning and repositioning every two hours was not performed in nine of the nineteen shifts (47%) shifts reviewed.

This was in contrast to the Resource Guidebook for New Hire Nurses which read, for pressure ulcer prevention turning should have occurred every two hours.

ii. Review of Patient #2's medical record revealed the patient was admitted to the facility on 1/11/24 for treatment of a subdural hematoma (bleeding between the brain and its outermost covering). A review of the nursing documentation for Patient #2's ADLs revealed oral care was not provided in 49 of 149 (33%) of shifts reviewed.

This was in contrast to the Resource Guidebook for New Hire Nurses and the EBSCO Oral Care guideline which read, the frequency of oral care should have occurred every shift or twice daily and as needed.

iii. Review of Patient #3's medical record revealed the patient was admitted to the facility on 2/26/24 for sepsis (a serious condition in which the body responded improperly to an infection) and dementia (loss of memory, language, problem-solving, and other thinking abilities that were severe enough to interfere with daily life). A review of the nursing documentation for Patient #3's ADLs revealed oral care was not provided in 13 of 38 (34%) shifts during hospital admission.

This was in contrast to the Resource Guidebook for New Hire Nurses and the EBSCO Oral Care guideline which read, the frequency of oral care should have occurred every shift or twice daily and as needed.

iv. Review of Patient #4's medical record revealed the patient was admitted to the facility 12/15/23 for agitation with recent past medical history of stroke (loss of blood flow to part of the brain which damaged brain tissue) and a tracheostomy (incision in the throat for placement of a breathing tube). A review of the nursing documentation for Patient #4's ADLs revealed oral care was not provided on 20 of 34 (59%) shifts reviewed and CHG urinary catheter care was not provided on 18 of 34 (53%) shifts reviewed.

This was in contrast to the Resource Guidebook for New Hire Nurses and the EBSCO Oral Care guideline which read, the frequency of oral care should have occurred every shift or twice daily and as needed. Also, this was in contrast to the facility's Urinary Catheter (Foley) Insertion and Management policy which read, perineal/indwelling urinary catheter care must be performed at least once a shift, during daily bath and as needed (e.g. after episodes of fecal incontinence). Additionally, the facility Resource Guidebook for New Hire Nurses read, urinary catheter/CHG care/Foley Care should have been completed every shift and as needed. Further, the EBSCO Urinary Catheter Care guidelines read, providing urinary catheter care involved regular cleaning using clean technique, usually twice daily.

B. Interviews revealed inconsistencies between staff practices, facility policy and guidelines, and facility leadership expectations.

i. On 3/18/24 at 10:25 a.m., an interview was conducted with patient care technician (PCT) #6. When asked about the frequency of ADLs on their unit, PCT #6 stated they offered patients a bath or shower and oral care daily.

ii. On 3/18/24 at 10:41 a.m., an interview was conducted with licensed practical nurse (LPN) #7. When asked about ADLs in their unit, LPN #7 stated they offered patients at least one shower in 48 hours. They stated the frequency of showering and bathing patients had just been discussed in a recent staff meeting.

This was in contrast to the Resource Guidebook for New Hire Nurses which read, the frequency for a full bath should have occurred daily and as needed.

iii. On 3/20/24 at 12:05 p.m., an interview was conducted with registered nurse (RN) #2. When asked about ADLs on their unit, RN #2 stated they offered a daily bath. For any patient with a central line, foley catheter, or any tubes in the body, they said those patients were to get a daily chlorhexidine (CHG) (wipes with antiseptic antibacterial agent used to clean the skin after an injury, before surgery, or before an injection) bath. They said personal hygiene care was important to prevent infection because over time skin and the bed sheets would get dirty and feel sticky. RN #2 said it was basic human decency to provide daily hygiene care to patients.

iv. On 3/26/24 at 11:32 a.m., an interview was conducted with registered nurse (RN) #8. When asked about ADLs, RN #8 stated CHG baths were done daily or more often. They also said they did not know what the expected frequency for hygiene, perineal care, or oral care was and these were the PCT's responsibilities. RN #8 said the nurses did not check up on the LPNs and PCTs on their team to ensure ADLs were completed. Furthermore, she stated they always had some PCTs but when they were short staffed and had so many patients to provide care, it could be very overwhelming for the PCTs, and, depending on the acuity of the patient assignment, ADLs would get missed.

v. On 3/21/24 at 9:13 a.m., an interview was conducted with clinical nurse coordinator (CNC) #3. When asked about ADLs on their unit, CNC #3 stated the expectation was to offer daily bed bath or shower and to offer oral care once each shift. They also said it was important to have enough staff, and if the ratios were too high, the staff would not have the time to check on their patients as often as needed. Further, CNC #3 said if staffing ratios were too high, things like 1:1 feedings were rushed, baths would be rushed or not done, and patients were only getting the bare minimum to keep them alive. They said this made it hard for the dependent patients or the patients with no family to receive the ADL care needed. CNC #3 said the risk to patients if there was not enough staff was patients not getting turned, skin breakdown, not getting showers, and the PCTs would not have enough time to feed full meals to patients.

vi. On 3/26/24 at 1:02 p.m., an interview was conducted with nurse manager (Manager) #4. When asked about the expectations for ADLs on the Medical Acute Care unit, Manager #4 stated their unit expectation was a CHG bath to be done every shift but the hospital policy was a CHG bath every 24 hours. Manager #4 said, ideally, oral care, showers, and baths would be done daily, but they tried for a goal of bathing every 2-3 days. They also said the expectation for perineal care would be done each time the patient was dirty. Further, Manager #4 stated the risks to patients of not getting ADLs completed could be skin breakdown, pressure injury, pneumonia, and weakness if not moving around enough.

This was in contrast to the Resource Guidebook for New Hire Nurses which read, the frequency for a full bath should have occurred daily and as needed, and oral care should have occurred every shift and as needed.

vii. On 3/21/24 at 9;38 a.m., an interview was conducted with director of acute care (Director) #9. When asked about the facility's expectations for ADLs, Director #9 stated staff RNs partnered with PCTs to ensure all ADLs were completed for a given patient assignment. They said ADLs included daily bathing, oral care, linen changes, ordering meals, and feeding. Director #9 said RNs, LPNs, and PCTs were each given access to the fields in the EMR so they could document ADLs after they were completed.

This was in contrast to the interview with RN#8 who stated the RNs did not check with LPNs and PCTs to ensure ADLs were completed.