HospitalInspections.org

Based on observation, interview, and record review, the facility failed to implement privacy practice for four out of six patients, when one staff (Speech Therapist [ST]) daily assignment sheet (DAS - form that included patients' protected health information, (PHI) - refers to patient's name, age, primary problem) was left unattended on top of a computer in the medical surgical unit (MSU) hallway.

This failure had the potential to unnecessarily expose patient PHI to non-facility personnel such as visitors and/or other patients.

Findings:

A concurrent observation and interview was conducted with the Clinical Nurse Specialist (CNS) 22 on 2/28/25 at 9:10 A.M. in the MSU hallway. A DAS was observed on top of a computer in the MSU hallway. The DAS included patients' PHI. CNE 22 stated that the DAS should have not been left unattended by the staff, to keep patients' confidential information safe from the public view.

An interview was conducted with the ST on 2/28/25 at 11:30 A.M. The ST stated that the DAS found in the MSU belonged to him. The ST further stated that he should have not left the DAS unattended in the hallway, to prevent non-facility personnel to gain access to patients' PHI.

An interview was conducted with the Rehabilitation Supervisor (RS) on 2/28/25 at 11:35 A.M. The RS stated that he expected all patient PHI to be protected from public view. The RS further stated that the ST's DAS should have been kept away, nonvisible, to protect patient's information.

A review of the facility's policy titled, Confidentiality of Information dated 4/29/24 indicated, "III.TEXT...Q. Workforce members are expected to ...3. Maintain safeguards for protection of sensitive information."

Based on interview and record review, the facility failed to ensure care plan (document indicating a patient's needs and goals) documentation (related to being reviewed and noted in the medical record) was completed per the facility's policy, for two of 30 sampled patients (Patient 2 and Patient 3).

This failure had the potential for the patient's (2, 3) needs to be unmet.

Findings:

1. Patient 2 was admitted to the facility on 12/6/24 with a diagnosis that included osteomyelitis (inflammation or swelling of the bone), per Patient 2's history and physical (H&P; assessment and notes written by the physician).

A concurrent interview and review of Patient 2's medical record was conducted on 2/27/25 at 10:19 A.M. with Clinical Nurse Specialist (CNS) 2. Patient 2's care plan indicated that the care plan was not documented (reviewed and noted in the medical record) daily. CNS 2 stated there were no documentation on Patient 2's care plan for 12/16/24, 12/17/24, 12/19/24, 12/24/24, and 12/25/24.

CNS 2 stated care plans needed to be documented every 24 hours. CNS 2 stated care plans were important because it was a documentation of the interdisciplinary (different healthcare professionals working together for a patient) plan of care. CNS 2 stated that anything could change, and goals could change, which was why care plans needed to be documented every 24 hours.

A review of the facility's Adult Nursing Guidelines of Care 2023-2026, updated 5/29/24, indicated "...Person Centered Plan of Care ...plan of care will be reviewed, communicated in the change of shift report, evaluated a minimum every 24 hours ..."

2. Patient 3 was admitted to the facility on 1/6/25 with a diagnosis that included aortic valve stenosis (a heart condition), per Patient 3's history and physical (H&P; assessment and notes written by the physician).

A concurrent interview and review of Patient 3's medical record was conducted on 2/27/25 at 10:49 A.M. with Clinical Nurse Specialist (CNS) 2. Patient 3's care plan indicated the care plan was not documented (reviewed and noted in the medical record) daily. CNS 2 stated there were no care plan documentation for 1/9/24, 1/11/24, 1/12/24, and 1/13/24.

CNS 2 stated care plans needed to be documented every 24 hours. CNS 2 stated care plans were important because it was a documentation of the interdisciplinary (different healthcare professionals working together for a patient) plan of care. CNS 2 stated that anything could change, and goals could change, which was why care plans needed to be documented every 24 hours.

A review of the facility's Adult Nursing Guidelines of Care 2023-2026, updated 5/29/24, indicated "...Person Centered Plan of Care ...plan of care will be reviewed, communicated in the change of shift report, evaluated a minimum every 24 hours ..."

Based on interview and record review the facility failed to ensure hospital policies and procedures were implemented for two of 30 sampled patients (Patient 1, 12) when:

1. Patient 1's STAT (immediate) computed tomography (CT, a type of X-ray imaging) ordered by the physician was not completed timely.

2. a. Patient 12's pain assessments were not completed per policy.
b. Patient 12's physician order for pain medication was not administered per policy.
c. Patient 12's pain assessment and reassessment related to the administration of pain medication were not completed per policy.

These failures had the potential to affect patients' (1, 12) health, care, and well-being.

Findings:

1. Patient 1 was admitted to the facility on 2/16/24 with a diagnosis of back pain, per the history and physical (a physician's assessment and notes), dated 2/16/24.

A review of Patient 1's medical record was conducted from 2/25/25 through 2/28/25. The physician's orders indicated a CT angiography (CTA, a medical imaging procedure that uses X-rays and dye to create detailed images of blood vessels) of the chest on 3/3/24 at 10:12 P.M. due to Patient 1's complaint of new chest pain. The CTA of the chest was ordered "STAT". A review of Patient 1's CTA timeline indicated the CTA was started on 3/4/24 at 10:44 A.M. The STAT CTA was completed 12 hours after it was ordered.

A review of the facility's policies using the facility's policy portal was conducted on 2/26/25 at 10:54 A.M. with Regulatory Affairs (RA) 2. There were no policies that defined "STAT". There were no policies or procedures that defined the timeline of a STAT order. There were no policies that guided staff to determine which STAT CT orders should be completed first.

An interview was conducted with CT tech (CTT) 1 on 2/26/25 at 1:46 P.M. CTT 1 stated that a STAT CTA order for an admitted patient such as Patient 1 was uncommon, so they (CT staff) knew it was supposed to be completed "right away." CTT 1 stated there was no documentation on why there was a delay in completing Patient 1's STAT CT.

An interview was conducted with Clinical Nurse Specialist (CNS, nurse educator) 1 on 2/26/25 at 2:31 P.M. CNS 1 stated that Patient 1's CT should had been completed sooner than 12 hours because it was ordered to be completed STAT.

An interview was conducted on 2/27/25 at 7:41 A.M. with Licensed Nurse (LN) 1. LN 1 stated that Patient 1 had complained of chest pain and needed oxygen. LN 1 stated the physician ordered a STAT CTA because Patient 1 had a high heart rate and needed oxygen. LN 1 stated that "STAT" meant immediately. LN 1 stated the STAT CT was not completed by the end of the shift, 8 hours after the STAT CT was ordered.

An interview was conducted on 2/28/25 at 8:20 A.M. with Medical Doctor (MD) 1. MD 1 stated the expectation was for a STAT order to be completed within one hour. MD 1 stated that when there was a STAT order, it needed to be done immediately or there was no point of ordering (to be completed) STAT.

A review of the facility's Adult Nursing Guidelines of Care, update 5/29/24, indicated " ...ANA [American Nurses Association] Standards of Practice ...Standard 5: Implementation. The RN [Registered Nurse] implements the identified plan ...Coordination of Care. The RN coordinates care delivery ..."



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2. Patient 12 was admitted to the facility on 2/24/25 with diagnoses which included Deep Vein Thrombosis (DVT - clot in the vein) of the right lower extremity, per Patient 12's undated admission record.

a. A concurrent interview and record review was conducted on 2/26/25 at 2:57 P.M. with Clinical Nurse Specialist (CNS) 11. Patient 12's pain assessments dated 2/24/25 through 2/27/25 did not include complete pain assessments and documentation that provided information on the patient's pain location, acceptable pain level and other components of pain assessment. CNS 11 acknowledged that pain assessment and documentation should include the pain level, location, acceptable pain level, type and characteristic of pain, onset and duration, interventions provided, and response to intervention.

A review of the hospital policy and procedure titled Patient Screening, Assessment and Management of Pain, last revised 5/2/24 indicated " ...IV: Procedure ...B. Perform a Pain Assessment if pain present in screening. Pain Assessment must include. 1. Pain intensity level and function ... 2. Location 3. Acceptable pain intensity rating 4. Note: Additional assessment components may include: Onset, Duration, Quality, Radiation characteristics, Associated Factors, Associated Symptoms ... C. Perform pain assessment with any new report of pain and as determined by individual patient clinical condition/need ..."


b. A review of Patient 12's physician orders indicated "Hydromorphone PF (Dilaudid) Injection 0.5 milligrams (mg) intravenous (IV) every 4 hours PRN (pro re nata - as needed) for severe 7-10 pain" and Oxycodone (Roxicodone) immediate release tablet 5 mg oral (PO; oral route) every 4 hours PRN for severe 7-10 pain."

A concurrent interview and review of Patient 12's medication administration records dated 2/25/25 through 2/26/25 was conducted on 2/26/25 at 2:57 P.M. with Clinical Nurse Specialist (CNS) 11. Hydromorphone IV and Oxycodone PO were administered without an indicated pain severity. CNS 11 acknowledged that pain severity and indication should have been consistently documented when the Hydromorphone IV and Oxycodone PO were administered to Patient 12.

A review of the hospital's policy and procedure titled Medication Administration last revised 8/9/24 indicated, " ...III. Text ... B. The 6 Rights of medication administration will be followed: ...6. Right Rationale: Validate the medication is being given for the prescribed reason. ...J. For PRN medications: 1. Document reason medication was given.


c. A review of Patient 12's physician orders indicated "Hydromorphone PF (Dilaudid) Injection 0.5 milligrams (mg) intravenous (IV) every 4 hours PRN (pro re nata - as needed) for severe 7-10 pain" and Oxycodone (Roxicodone) immediate release tablet 5 mg oral (PO; oral route) every 4 hours PRN for severe 7-10 pain."

A concurrent interview and review of Patient 12's medication administration record dated February 2025 was conducted on 2/26/25 at 2:57 P.M. with Clinical Nurse Specialist (CNS) 11. Per this record, Hydromorphone IV and Oxycodone PO were administered to Patient 12 multiple times. The record did not include consistent documentation of pain assessment and reassessment of the medication's effectiveness. CNS 11 acknowledged that pain assessments prior to medication administration, and pain reassessments of the medication effectiveness were not consistently completed, and should have been.

A review of the hospital's policy and procedure titled Medication Administration last revised 8/9/24 indicated, " ...III. Text ...J. For PRN medications: 1. Document reason medication was given. 2. Assess/Reassess medication effect and patient response ..."

A review of hospital policy and procedure titled Patient Screening, Assessment and Management of Pain last revised 5/2/24 indicated " ...IV: Procedure ...C. Perform pain assessment with any new report of pain and as determined by individual patient clinical condition/need ... F. Perform reassessment of pain and sedation level to evaluate the safety and effectiveness of pain management interventions... 1. NOTE: Reassessment timing is based upon analgesic, route, dose and risk factors... General guidelines... IV... within 10-30 min... PO... within 45-60 min..."

Based on interview and record review, the facility failed to follow its policy and procedure related to medication administration when:

1. Patient 21's Lasix (medication that helps to reduce the amount of excess fluid in the body; also used to treat high blood pressure) was given when the order was to hold (not give) Lasix if systolic blood pressure (SBP - top number of blood pressure reading) was below 110.

2. Patient 22 did not receive hydralazine (HYD- medication to lower blood pressure) for SBP more than 140.

These failures had the potential to affect the patients' (21, 22) health and well-being.

Findings:

1. A review of Patient 21's clinical record indicated Patient 21 was admitted to the facility on 2/8/25 with medical diagnoses of acute kidney failure and high blood pressure.

A review of Patient 21's physician order dated 2/9/25 indicated, 'Give Lasix 40 milligrams (mg - unit of measurement), oral, daily. Hold for SBP less than 110."

A concurrent interview and review of Patient 21's blood pressure flow sheet and medication administration record dated February 2025, was conducted with CNS 11 on 2/27/25 at 2 P.M. Per this record, Patient 21's SBP was 107 on 2/25/25 at 9:05 A.M., and on 2/26/25 at 7:37 A.M. Patient 21's SBP on 2/27/25 at 7:40 A.M. was 108. The record indicated that Patient 21 was administered Lasix on the three occasions.

CNS 11 stated that Patient 21's SBP was already low on 2/25/25 at 9:05 A.M., 2/26/25 at 7:37 A.M., and 2/27/25 at 7:40 A.M., and that Lasix should have been held per physician order.

An interview was conducted with Unit Manager (UM) 21 on 2/28/25 at 10:08 A.M. UM 21 acknowledged that the Lasix should not have been administered to Patient 21 per physician order, on 2/25/25 at 9:05 A.M., 2/26/25 at 7:37 A.M. and 2/27/25 at 7:40 A.M. to prevent Patient 21's blood pressure from dropping further.

The facility's policy titled Medication Administration, dated 8/9/24, indicated, " ...III. Text:..B. The "6 Rights" of medication administration will be followed ...6. Right Rationale: Validate the medication is being given for the prescribed reason."

2. A review of Patient 22's clinical record indicated that Patient 22 was admitted to the facility on 1/30/25 with medical diagnoses of cerebral infarction (brain blockage) and high blood pressure.

A review of Patient 22's physician order dated 1/30/25 indicated, "Give Hydralazine (HYD) 10 milligrams (mg - unit of measurement) every four hours as needed for SBP above 140.

A concurrent interview and record review was conducted with Clinical Nurse Specialist (CNS) 22 on 2/28/25 at 10:30 A.M. Patient 22's blood pressure flow sheet and medication administration record dated February 2025 indicated:

On 2/26/25 at 8:44 A.M., the SBP was 159. HYD was not given.
On 2/27/25 at 7:55 A.M., the SBP was 149. HYD was not given.
On 2/28/25 at 7:20 A.M., the SBP was 151. HYD was not given.

CNS 22 stated that the licensed nurses should have given the HYD medication per physician order, to keep Patient 22's SBP below 140.

An interview was conducted with Unit Manager (UM) 21 on 2/28/25 at 11 A.M. UM 21 stated that the HYD medication should have been given to Patient 22 per physician order (as needed for SBP above 140), to prevent Patient 22's blood pressure from further increasing.

The facility's policy titled Medication Administration dated 8/9/24, indicated, " ...III. Text. b. The "6 Rights" of medication administration will be followed ...6. Right Rationale: Validate the medication is being given for the prescribed reason."