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Based on interview, record review and policy review, the hospital failed to:
- Provide registered nurse (RN) supervision and evaluation of nursing care for two patients (#32 and #33) of two patients with wounds reviewed; (A-0395)
- Follow the hospital's policy for skin assessment and care for four patients (#5, #14, #32 and #33) of four medical records reviewed; (A-0398)
- Follow the hospital's policy for pain assessment and management for two patients (#36 and, #37) of three Emergency Department (ED) medical records reviewed; (A-0398)
- Follow the hospital's policy for fall prevention for three patients (#42, #43 and #44) of three medical records reviewed; (A-0398)
- Follow the hospital's policy for visitor safety in isolation precautions (techniques used to prevent the spread of highly contagious or high-risk infections) rooms for one patient (#16) of one patient observed; (A-0398);
- Follow the hospital's policy for labeling intravenous (IV, in the vein) dressings and tubing for 11 patients (#1, #3, #4, #5, #6, #9, #10, #11, #17, #18 and #27) of 22 patients observed; (A-0398) and
- Follow the hospital's policy for Standard Precautions (also known as universal precautions, avoiding contact with patients' bodily fluids by means of wearing gloves, goggles and face shields) for 14 patients (#3, #5, #7, #10, #12, #15, #16, #17, #19, #21, #22, #26, #28 and #30) of 18 patients observed.

This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation (CoP): Nursing Services.

Please refer to A-0395 and A-0398.

Based on interview, medical record review and document review, the hospital failed to provide registered nurse (RN) supervision and evaluation of nursing care for two patients (#32 and #33) of two patients with wounds reviewed.

These failures had the potential to lead to poor outcomes for patients with wounds and those at risk for skin breakdown.

Findings include:

Review of the hospital's document titled, "Card Tele Audits," dated 07/15/25 through 08/15/25, showed the audit review included the Braden Scale assessment (an assessment tool for predicting the risk of bed sores or pressure ulcers) completion, two-person skin assessment documentation, door signage for staff awareness, appropriate patient surface, reposition completion and documentation every two hours. On 08/04/25 at 11:27 AM, one audit was performed for Patient #32 and showed within defined limits.

Review of Patient #32's medical record, dated 07/27/25 through 08/04/25 showed:
- On 07/27/25 from 12:00 AM to 6:30 AM, he was not repositioned. His Braden score was 19.
- On 07/28/25 from 10:40 PM to 6:40 AM, he was not repositioned.
- On 07/29/25 at 10:09 AM, Patient #32 complained of bottom pain which was very red. His Braden score was not updated with the new skin condition. No skin/pressure injury (injury to the skin and/or underlying tissue, usually over a bony area) prevention interventions were implemented.
- At 3:00 PM, 6:00 PM and from 10:15 PM to 4:00 AM, he was not repositioned.
- At 5:35 PM, he was transferred to a higher level of care and a skin assessment showed his buttocks had non-blanchable (paling or whitening of the skin when pressed, when skin does not become pale with pressure it is often an indication of injury to the tissue) redness. The skin, wound and ostomy team (SWOT) was consulted, and the patient was placed on an air mattress. His Braden score was 15. Wound pictures showed redness, a large open blister on the left side of the buttocks and several closed blisters on his buttocks.

Although requested the hospital failed to provide leadership skin and wound care audits for the Medical-Stepdown unit, none were completed.

Review of Patient #33's medical record dated 06/15/25, showed he was in the Medical-Stepdown unit from 06/15/25 through 06/29/25.

During a telephone interview on 08/28/25 at 9:00 AM, Staff A, Chief Nursing Officer (CNO), stated the unit managers were expected to perform daily skin and wound care audits to ensure all of the correct processes were in place and provide follow up education to staff who did not meet the expectations.


51292

Based on observation, interview and policy review; the hospital failed to follow the hospital's policy for:
- Skin assessment and care for four patients (#5, #14, #32 and #33) of four medical records reviewed;
- Pain assessment and management for two patients (#36 and, #37) of three Emergency Department (ED) medical records reviewed;
- Fall prevention for three patients (#42, #43 and #44) of three medical records reviewed;
- Visitor safety in isolation precautions (techniques used to prevent the spread of highly contagious or high-risk infections) rooms for one patient (#16) of one patient observed;
- Labeling intravenous (IV, in the vein) dressings and tubing for 11 patients (#1, #3, #4, #5, #6, #9, #10, #11, #17, #18 and #27) of 22 patients observed; and
- Standard Precautions (also known as universal precautions, avoiding contact with patients' bodily fluids by means of wearing gloves, goggles and face shields) for 14 patients (#3, #5, #7, #10, #12, #15, #16, #17, #19, #21, #22, #26, #28 and #30) of 18 patients observed.

These failures could place all patients at risk for their safety.

Findings included:

Review of the hospital's policy titled, "Nursing Standards and Documentation Guidelines," approved 01/24/25, showed a comprehensive and systematic head-to-toe assessment is performed and documented at the beginning of each shift, when assuming care of the patient, upon transfer to a new unit, with any major or minor change in patient condition and more often, as necessary by patient condition. A Braden Scale (an assessment tool for predicting the risk of bed sores or pressure injury [injury to the skin and/or underlying tissue, usually over a bony area]) score of 18 or less will prompt further interventions.

Review of Patient #5's medical record dated 08/18/25, showed:
- He was a 60-year-old who was admitted through the ED with congestive heart failure (CHF, a weakness of the heart that causes it to not pump blood like it should leading to a buildup of fluid in the lungs and surrounding body tissues.).
- He had a history of high blood pressure, right toe osteomyelitis (infection of the bone), chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing), diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing) and peripheral artery disease (PAD, blood circulation disorder that causes arteries to narrow, block or spasm and cause pain and tiredness in the legs, arms, or other body parts).
- At 10:19 AM, a wound care order for his right foot was written for every eight hours. There were no specific wound care directions and there was no attempt to clarify the order.
- From 08/18/25 at 11:05 AM through 08/19/25 at 8:11 AM, he was not turned.
- At 11:15 AM, his Braden Scale was 18.
- At 11:00 AM, skin assessment pictures showed he had buttock and penis irritation, his right foot had peeled skin and discoloration and his right first toe had a black wound.
- No wound care was provided.

Review of Patient #14 medical record, dated 07/31/25 showed:
- He was a 62-year-old admitted for a planned tracheostomy (an opening created in the neck in order to place a tube into a person's windpipe that allows air to enter the lungs) and percutaneous endoscopic gastrostomy (PEG, a tube inserted through a person's abdomen directly into the stomach to provide a means of feeding when oral intake is not possible) placement following a heart attack that left him with an anoxic brain injury (harm to the brain due to a lack of oxygen).
- His initial skin assessment showed he had no skin abnormalities. His Braden Scale score was eight, which initiated the hospital protocol for a pressure relieving mattress, heel elevation, repositioning wedges, turning every two hours and foam dressings to protect bony prominences (parts of the body where a bone is close to the skin's surface).
- On 08/01/25, he was not turned from 4:00 PM to 8:00 PM.
- On 08/02/25, he was not turned from 3:00 PM to 6:47 PM.
- On 08/03/25, he was not turned from 9:00 AM to 1:00 PM.
- On 08/04/25, he was not turned from 11:00 AM to 3:00 PM and 5:00 PM to 8:00 PM.
- On 08/05/25, he was not turned from 9:00 AM to 6:00 PM.

Review of Patient #32's medical record, dated 07/27/25, showed:
- He was an 89-year-old admitted through the ED with bradycardia (slow heart rate) and lower leg swelling.
- He had a history of atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow), CHF, high blood pressure, prediabetes (higher than normal blood sugar levels but not high enough for a diabetes diagnosis), neuropathy (nerve damage that causes numbness, tingling, burning pain and muscle weakness in the hands and feet) and a stroke (a medical emergency that occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients) with paralysis. The patient was weak, lightheaded, dizzy and incontinent (unable to control urination).
- At 9:46 PM, his Braden Scale score was 19. No pressure injury prevention interventions were implemented. He was not turned from 12:00 AM through 6:30 AM.
- On 07/28/25, he was not turned from 10:40 PM through 6:40 AM. There was no skin assessment documented on the night shift.
- On 07/29/25 at 10:09 AM, the physical therapist (a healthcare professional who focus on range or motion and decreasing pain after an injury or illness) documented that was the first time he was out of bed, he complained of bottom pain and his bottom was very red. She notified the patient's nurse. The nurse applied lotion to his bottom. No pressure injury prevention interventions were implemented. His Braden Scale score was not updated with the new skin concerns.
- At 3:30 PM, a different nurse took over care of the patient within the dayshift without completing a skin assessment. His Braden Scale score was 19. The patient was not turned at 3:00 PM, 6:00 PM and from 10:15 PM through 4:00 AM.
- At 5:35 PM, he was transferred to a higher level of care, and a skin assessment was completed. His buttocks had non-blanchable (paling or whitening of the skin when pressed, when skin does not become pale with pressure it is often an indication of injury to the tissue) redness. The Skin, Wound and Ostomy Team (SWOT) was consulted, and the patient was placed on an air mattress. His Braden Scale score was 15. Wound pictures showed redness, a large open blister on the left side of the buttocks and several closed blisters on his buttocks. Prevention injury interventions were implemented. There was no skin assessment documented on the night shift.
- 07/31/25 at 9:10 AM, a skin/wound care nurse assessment was completed. The buttock wound was a deep tissue pressure injury (DTI, intact or non-intact skin that has red, maroon or purple discoloration that does not go away if pressure is applied) measured 13 by 15 centimeters (cm). The wound base was purple, non-blanchable with serous (water-like fluid) filled blisters and a small amount of drainage.

During an interview on 08/19/25 at 10:45 AM, Staff JJ, Registered Nurse (RN), stated that patients with a Braden Scale score of 16 to 18 should have a specialty mattress and those with a score of less than 16 should have an air mattress. In addition, for a score of 18 or less, the patient should be turned every two hours with the use of wedges/pillows, have heel boots and should be educated on why turning was important.

Review of Patient #33's medical record, dated 06/15/25, showed:
- On 06/15/25, he was a 74-year-old admitted through the ED for altered mental status (AMS, mental functioning ranging from slight confusion to coma), inability to use his left arm and pain in his buttocks.
- He had a history of stroke with right sided weakness, paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease) and he resided at a rehabilitation unit (an inpatient area staffed and medically supervised in the care and treatment of the physical restorative needs of patients).
- On 06/15/25 at 7:02 PM, a pressure injury to his tailbone area caused pain. Pillows were placed under the patient for comfort and the provider was notified. The provider documented the wound appearance as a stage one pressure injury (intact skin with an area of redness that does not go away when pressure is applied) to a Stage two pressure injury (a shallow opening in the skin with red or pink tissue, or may present as a fluid filled blister) on his tailbone, both heels and several more wounds present on both feet. No measurements were documented, and a consult for SWOT was ordered.
- On 06/16/25 at 4:56 PM, pictures were taken to document the wounds. No description of the wounds was documented. Two-hour turning was initiated.
- On 06/17/25 at 1:57 PM, Staff CCC, SWOT RN, documented pressure injuries to his tailbone measuring 2.7 by 2.5 cm with pink thin skin surrounding the wound on both sides, a left heel wound measuring 2 by 3.2 cm with a closed blister without drainage and several closed wounds to both feet including the great toe, seven wounds in total. Wound care orders included to clean the wounds gently with soap and water, pat dry, apply barrier cream to the tailbone area, keep uncovered, turn every two hours and notify SWOT if the wounds deteriorated.
- On 06/27/25 at 2:28 PM, the SWOT RN reassessed the wounds and found the wound on the left heel was 7 by 10 cm, open and draining. The wound to the tailbone area was 6 by 5 cm, sloughing (layer of dead tissue separated from surrounding living tissue, as in a wound, sore or inflammation), beefy red and draining. SWOT was not notified of the wound deterioration.

Review of Patient #33's medical record, dated 07/04/25, showed:
- On 07/04/25, he was admitted through the ED for AMS. A skin assessment showed wounds were photographed, and a SWOT consult was ordered. The provider ordered all wounds except the buttock wound to be cleansed with Chlorhexidine Gluconate (CHG, an antiseptic solution used to reduce the bacteria on a patient's skin) wipes, allowed to dry and apply a thin layer of Venelex (an ointment to help skin wounds heal) ointment twice daily. No orders were written for the buttock wound.
- On 07/04/25, 07/05/25, 07/06/25 and 07/07/25 wound care was provided once daily.
- On 07/08/25 at 2:21 PM, a skin assessment of seven wounds with pictures was performed by a SWOT RN. Wound care for the buttocks/tailbone wounds was to be provided twice daily, with specific instructions for cleaning and dressing. Wound care for the left heel and remaining wounds was to be performed three times daily with specific instructions for cleaning and dressing.
- On 07/09/25 at 1:58 AM and 5:16 PM, although provided, wound care was not performed as ordered. Wound care was not provided a third time.
- On 07/10/25 at 7:59 AM, 07/11/25 at 5:45 PM and 07/13/25 at 7:45 AM, although provided, wound care was not performed as ordered. Wound care was not provided a second and third time.
- 07/12/25 at 2:11 AM and 12:36 PM, although provided, wound care was not performed as ordered. Wound care was not provided a third time.
- On 07/14/25, no wound care was provided, he was discharged to a rehabilitation unit.

During a telephone interview on 08/28/25 at 9:00 AM, Staff A, Chief Nursing Officer (CNO), stated that he expected staff to follow the hospital's policy for skin care and wound management. He expected patients were repositioned every two hours with a Braden Scale score of 18 or less. He expected nursing to follow orders. He expected the patient's position and refusals were documented in the medical record. Braden scale assessment education was provided to staff upon hire and at the unit level during orientation. He was aware the SWOT team identified inconsistencies in the Braden Scale Assessments. A yearly summit was developed in an effort to improve consistency. The SWOT team adjusted the Braden score as needed.

Review of the hospital's policy titled, "Pain Assessment and Reassessment Policy," dated 04/22/25, showed pain assessment and documentation occurs upon admission assessment or triage (process of determining the priority of a patient's treatment based on the severity of their condition) assessment and at regular intervals in accordance with the patient's status.

Review of the hospital's untitled document, dated 02/18/25 to 08/18/25, showed eight patient grievances (a formal written or verbal complaint related to care or service that cannot be resolved immediately at the bedside) were filed with the hospital in regard to poor pain management in the ED between 05/27/25 to 08/18/25.

Review of the hospital's document titled, "Resolution Manager Form ID 77120," dated 08/05/25, showed:
- Patient #36's daughter commented on the patient's survey and stated, "your triage system is terrible. My mom had two broken arms, and it took hours to get at least just something for pain. X-rays (test that creates pictures of the structures inside the body-particularly bones) were attempted in triage, when she was unable to tolerate the pain, they received nothing but attitude."
- The findings included a statement that Patient #36 received the standard of care, but there were systems in place where a nurse could ask a provider for pain medication, or the charge nurse could place protocol orders.
- The plan was to follow up with the team to ensure they had the resources they needed to help future patients.

Review of Patient #36's medical record dated 07/26/25, showed:
- At 2:59 PM, she was a 70-year-old who presented to the ED for a fall and stated she had pain in both arms.
- At 3:01 PM, her triage assessment began.
- At 3:06 PM, her triage assessment was completed. No pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) was completed during triage.
- At 3:58 PM, a pain scale assessment showed she rated her pain at a 10. Her pain was assessed 52 minutes after her triage assessment was completed. She stated she was unable to tolerate the pain for x-rays.
- At 4:38 PM, a right arm x-ray showed a fracture (break in a bone) to both bones in her lower right arm.
- At 4:40 PM, a left arm x-ray showed a fracture to her left upper arm bone.
- At 4:44 PM, she received morphine (an opioid pain medication) intramuscularly (IM, within the muscle), one hour and 38 minutes after her triage assessment was completed.

Review of the hospital's document titled, "Resolution Manager Form ID 77387," dated 08/18/25, showed:
- Patient #37 filed a formal complaint regarding her treatment in the ED.
- At approximately 12:00 AM, she arrived at the ED via an ambulance with severe flank pain (discomfort felt in the area between the ribs and the hip, can indicate infection in the kidney).
- While in the waiting room she requested a blanket and was denied because of a low-grade fever of 99o Fahrenheit (F).
- She explained to a nurse that sitting upright in a wheelchair made her pain worse and she requested to lie down. She was ignored. No attempt was made to address her pain, assess her worsening condition or provide basic accommodations.
- When a computed tomography (CT, a combination of x-rays and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) was completed she was informed she required emergency surgery.

Review of Patient #37's medical record dated 08/15/25, showed:
- At 11:55 PM, she was a 37-year-old who presented to the ED with back pain and urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra) symptoms.
- At 11:58 PM, her triage assessment began.
- At 11:59 PM, her triage assessment was completed. No pain scale assessment was completed during triage.
- At 5:53 AM, a CT scan showed an obstructing stone to her right ureter (tube that carries urine from the kidneys to the bladder) with hydronephrosis (a condition characterized by excess fluid in a kidney due to a backup of urine and inflammation). Possible obstructive uropathy (a condition where urine flow is blocked in the urinary tract, causing urine to back up into the kidney and potentially leading to kidney damage) or pyelonephritis (a life-threatening bacterial infection in the kidneys and urinary tract) with concern for a possible abscess (collection or pocket of thick fluid caused by an infection).
- At 3:06 AM, Morphine intravenous push (IVP, to manually administer a dose of medication through a tube into a vein) was ordered.
- At 4:54 AM, Morphine IVP was administered, four hours and 55 minutes after her triage assessment was completed.
- On 08/16/25 at 6:40 AM, the first pain assessment showed she complained of pain. No pain scale assessment was completed.

During an interview on 08/20/25 at 1:10 PM, Staff PP, ED Director, stated that he expected staff to follow the hospital's pain assessment and management policy. A pain assessment was to be completed during the triage assessment and with vital signs (VS, measurements of the body's most basic functions) every two hours. He was not aware of the increase in patient grievances related to pain management in the ED. He did not perform audits in regard to pain management. He expected the ED staff to provide comfort within the capability of the ED. A blanket warmer was moved closer to the waiting room, and he expected a patient to be given a blanket upon request even with a fever.

During a telephone interview on 08/28/25 at 9:00 AM, Staff A, CNO, stated that he expected patients were rounded on in the ED every hour. The ED Director recently brought the increase in patient grievances related to pain management to his attention, in response to the survey. He expected staff to follow the hospital's policy for pain assessment and management. He expected patients to receive pain management while in the waiting room based on their pain scale assessment score.

Review of the hospital's untitled document, dated 02/18/25 to 08/18/25, showed 595 patient falls occurred within the hospital.

Review of the hospital's policy titled, "Nursing Standards and Documentation Guidelines," dated 01/24/25, showed:
- Hourly safety rounding is a standard component of Mercy practice.
- Hourly safety rounding is to be completed and consist of:
- Checking the environment for safety;
- Addressing the 5 P's (pain, personal needs, positioning, personal items, pick up the
environment);
- Communicating a review of the plan of care/address questions or concerns;
- Current predicted fall risk; and
- Safety precautions to be documented if applicable.
- Documentation will be performed in electronic heath record (EHR) in the Daily Care flowsheet.

Review of the hospital's policy titled, "Patient Falls Policy," dated 03/05/24, showed post fall documentation in the medical record included a fall risk assessment, actual time and event description, name and time of provider notification and name of leadership notified.

Review of the hospital's document titled, "SAFE 435033 Factual Event Summary," dated 03/15/25, showed:
- At 6:45 PM, a safety rounding was performed, Patient #42 was in bed, all four side rails were up, the bed was locked and in the low position, her call light was within reach and her daughter was at the bedside.
- At 6:50 PM, the daughter informed the nurse she was leaving.
- At 7:15 PM, the patient was found face down on the floor next to the bed. No bed alarm sounded, and the patient was unresponsive and breathing.
- Opportunities identified included nurse awareness that four side rails qualified as a non-violent restraint (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head), shift report was not completed at the bedside, the physician informed the patient it was okay to sit on the edge of the bed as long as family was present which did not align with patient safety guidelines and a bed alarm refusal was not documented.

Review of Patient #42's medical record, dated 03/06/25, showed:
- At 2:31 PM, she was admitted with a pulmonary embolism (PE, blood clot in the lung).
- On 03/15/25 at 9:15 AM, a safety check was completed.
- At 6:45 PM, patient rounding was completed and showed her pain was addressed and the call light was within reach.
- At 7:48 PM, a rapid response (a changing situation that requires more staff to address the current needs of the patient) team note showed the patient was lying in bed after being lifted to bed after an unwitnessed fall. The patient did not have a pulse (normal pulse/heartbeats for adults range from 60 to 100 per minute) and was a Do Not Resuscitate (DNR, written instructions from a physician telling health care providers not to perform cardiopulmonary resuscitation [CPR, emergency life-saving procedure performed when a person's breathing or heartbeat has stopped]). The provider and house supervisor were at the bedside. The patient died and the family was notified.
- The last safety check was completed 10 hours 33 minutes prior to Patient #42's fall.

Review of the hospital's untitled document dated 3/07/25, showed:
- At 5:38 PM, Patient #43 was admitted with COVID-19 (highly contagious, and sometimes fatal, virus) and dehydration (a condition caused by excessive loss of water from the body).
- She was confused.
- Staff stated that during bedside shift report she was in bed and the bed alarm was on.
- At 6:50 PM, Patient #43 was found in a sitting position on the ground, her back was against the wall.
- The bed alarm did not sound.
- The patient denied pain.
- There was no documented toileting from the time of admission to the time of the fall.
- The nurse reported that she tried to use the bed alarm, but it was not working. She notified the charge nurse.
- On 03/08/25, the patient stated she had pain in her right hip and an x-ray showed a fracture.

Review of Patient #43's medical record dated 03/07/25, showed:
- On 03/07/25 at 6:15 PM, a safety check was completed.
- At 6:30 PM, a safety check showed she was a predicted high fall risk. The safety check did not include the 5 P's, a review of the plan of care/address questions or concerns or safety precautions.
- At 7:24 PM, the patient was found on the ground against the wall, she was assisted to bed. No injuries were noted, VS were stable, the provider, family and charge nurse were notified.
- There was no documented post fall patient assessment.
- At 10:06 PM, a safety check was completed, three hours and 51 minutes after the previous safety check.
- On 03/08/25 at 3:47 PM, a right hip x-ray, showed a fracture.

Review of the hospital's untitled document, dated 04/24/25, showed:
- On 04/24/25 at 10:46 AM, Patient #44 fell resulting in a fracture of his right thumb.
- He had a history of alcohol abuse. Clinical Institute Withdrawal Assessments (CIWA, a 10-item scale used in the assessment and management of alcohol withdrawal) were ordered but discontinued because he was sober for eight months. The patient was confused and agitated during the admission which was later attributed to acute (sudden onset) metabolic encephalopathy (a disease in which the functioning of the brain is affected by an illness or organs that are not working as well as they should, such as with a viral infection or toxins in the blood).
- He had a fall on 04/23/25 and 04/24/25, he got out of bed unattended and fell hitting his hand against the wall.
- A safety sitter (person assigned to continuously observe a patient within close proximity, to ensure their safety) and psychiatric (relating to mental illness) consult were ordered.
- Opportunities identified included an early psychiatry consult and medications for agitation.

Review of Patient #44's medical record dated 04/18/25, showed:
- He was a 66-year-old admitted with seizures (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness).
- His history included alcohol withdrawal, arthritis (inflammation that causes pain, stiffness and swelling in and around the tissues that connect bones), back pain and chronic (long-term, ongoing) hypoxic respiratory failure (a condition where there is not enough oxygen reaching the tissues of the body caused by a failure of the respiratory system).
- On 04/22/25 at 11:17 PM, a safety check was completed.
- On 04/23/25 at 8:00 AM, Patient #44's bed alarm sounded, he was found in the bathroom, he lost his balance and fell to a seated position. A safety check showed he was a predicted high fall risk. The safety check did not include the 5 P's, a review of the plan of care/address questions or concerns or safety precautions. There was no documented leadership notification.
- At 8:18 PM, a safety check was completed, 12 hours and 18 minutes after the previous safety check.
- On 04/24/25 at 12:00 PM, a safety check was completed.
- There was no documented post fall patient assessment, post fall risk assessment, actual time and event description, name and time of provider notification or leadership notification.
- At 12:22 PM, a right wrist x-ray showed a fractured right thumb.
- At 2:00 PM, a safety check was completed, two hours after the previous safety check.

During a telephone interview on 08/20/25 at 9:00 AM, Staff A, CNO, stated that he expected staff to follow the hospital's policy for fall prevention and management. He was aware of the frequency of falls in the hospital. The hospital worked to reduce falls by performing weekly audits and white board updates for staff review. The audits were to ensure precautions were in place and "just in time" education was provided to staff as indicated. He was not surprised by the inconsistencies of the hourly rounding. He expected patients were rounded on every hour by either a nurse or a patient care technician (PCT). The rounding was a shared responsibility. He expected rounding to be documented in the medical record.

Review of the hospital's policy titled, "MP IP Enhanced Contact Precautions Policy," dated 09/10/24, directed staff to provide patient and family/visitor education to explain precautions and document in the EHR upon the initiation of isolation.

Observation with concurrent interview on 08/19/25 at 9:20 AM, showed Patient #16 was on contact precautions (precautions used to minimize the risk of infection spreading through touching an infected person or contaminated object) for Methicillin-Resistant Staphylococcus aureus (MRSA, highly contagious bacteria, that causes infections in different parts of the body and is resistant to many common antibiotics). Visitors were in the patient's room without personal protective equipment (PPE, such as gloves, gowns, goggles and masks). Patient #16's visitor stated that she was not educated on PPE, hand hygiene or safety related to the precautions.

During an interview on 08/19/25 at 9:25 AM, Staff T, Supervisor, stated that staff were expected to have a conversation with a demonstration of proper safety techniques with visitors of patients on isolation precautions upon initiation of the precautions.

Review of the hospital's policy titled, "Intravascular and Intraosseous (IO, the insertion of a needle through the skin directly into the bone marrow in order to inject medications and fluids when IV access is not available) Therapy - Adult Policy," approved 05/07/25, showed IV dressing should be labeled with date, time, and initials. The nurse who initiates IV tubing affixes a label to the tubing with the date and time of initiation, the date and time to be discarded and the nurse's initials.

Observation on 08/18/25 at 2:00 PM, on the Neurology (a branch of medicine concerned with the study and treatment of disorders of the nervous system) floor, showed Patient #1's IV dressing was not labeled with date, time or initials.

Observation on 08/18/25 at 2:40 PM, on Seven West, showed Patient #3's IV dressing and tubing were not labeled with the date, time or initials.

Observation on 08/18/25 at 2:45 PM, on Seven East, showed Patient #4's IV dressing was not labeled with date, time or initials.

Observation on 08/18/25 at 2:50 PM, on Seven East, showed Patient #5's IV dressing and tubing were not labeled with date, time or initials.

Observation on 08/18/25 at 3:00 PM, on Seven West, showed Patient #6's IV dressing was not labeled with date, time or initials.

Observation on 08/18/25 at 2:00 PM, on Five West, showed Patient #9's IV dressing and tubing were not labeled with date, time or initials.

Observation on 08/18/25 at 2:15 PM, on Five West, showed Patient #10's IV tubing was not labeled with date, time or initials.

Observation on 08/18/25 at 3:00 PM, on Five East, showed Patient #11's IV tubing was not labeled with date, time or initials.

Observation on 08/19/25 at 9:50 AM, on Seven East, showed Patient #17's IV dressing was not labeled with date, time or initials.

Observation on 08/19/25 at 10:05 AM, on Three East, showed Patient #18's IV dressing was not labeled with date, time or initials.

Observation on 08/19/25 at 10:20 AM, on Surgical Intensive Care Unit (ICU, a unit where critically ill patients are cared for), showed Patient #27's IV dressing and tubing were not labeled with date, time or initials.

During a telephone interview on 08/28/25 at 9:00 AM, Staff A, CNO, stated that he expected staff to follow the "IV and IO Therapy - Adult Policy," for labeling IV dressings and tubing. The labels were to include the nurse's initials, date and time.

Review of the hospital's policy titled, "Standard Precautions and Use of Protective Barriers Policy," dated 09/11/2023, showed:
- Hand hygiene must be performed immediately prior to donning, and immediately after removal of gloves.
- Gloves should be changed between tasks and procedures on the same patient after contact with potentially infectious material, when moving from a contaminated site to a clean site.
- Staff must practice safe handling of potentially contaminated equipment, linen or surfaces in the patient environment and any patient contact that might result in bleeding or exposure to potentially infectious material.

Observation on 08/18/25 at 2:40 PM, in Seven West, showed Staff E, Licensed Practical Nurse (LPN), failed to perform hand hygiene and glove changes when she retrieved and returned her mobile device to her pocket. Staff E placed medications on the dirty linen hamper and workstation on wheels (WOW, a computer or supply and medication storage on a wheeled stand, that can be moved from patient to patient) and failed to provide a clean barrier. Staff E removed a blunt needle from a syringe with the open package that was placed on the WOW prior to administration to Patient #3.

Observation on 08/18/25 at 2:50 PM, on Seven East, showed Staff F, RN, failed to perform hand hygiene and glove changes when she retrieved and returned her mobile device to her pocket and between touching a dirty and clean area while she administered medications to Patient #5.

Observation on 08/18/25 at 3:30 PM, on the Labor and Delivery Unit, showed Staff H, RN, failed to perform hand hygiene between glove changes when she started an intravenous catheter (IVC, small flexible tube inserted into a vein through the skin to deliver medications or fluids into the bloodstream). Staff H placed IVC insertion supplies on the blanket and failed to provide a clean barrier while she provided care to patient #7.

Observation on 08/18/25 at 2:15 PM, on Five West, showed Staff K, RN, placed medications on the bedside table and failed to provide a clean barrier prior to administration to Patient #10.

Observation on 08/18/25 at 2:35 PM, on Five West, showed Staff J, RN, failed to perform hand hygiene and glove changes when she retrieved and returned her mobile device to her pocket when she provided care to Patient #12, who was on isolation precautions.

Observation on 08/19/25 at 9:00 AM, on Seven West, showed Staff I, RN, failed to perform hand hygiene between glove changes when she started an IVC. Staff I placed IVC insertion supplies on the bedside table and failed to provide a clean barrier for Patient #15.

Observation on 08/19/25 at 9:20 AM, on Seven West, showed Staff V, RN failed to perform hand hygiene with glove changes. Staff V placed medications on the WOW and failed to provide a clean barrier while she provided care to Patient #16.

Observation on 08/19/25 at 9:50 AM, on Seven East, showed Staff W, LPN failed to perform hand hygiene with glove changes while she administered medications to Patient #17.