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Based on policy review, record review and interview, the hospital failed to have an organized nursing service which provided the services to meet bathing and hygiene needs, and failed to provide ongoing assessments of patients' pain levels, provided interventions for patients experiencing avoidable pain and monitor/assess the effectiveness of the interventions for for 2 of 4 (Patients #1 and #2) sampled patients who were experiencing pain and required assistance with bathing.

The findings included:

1. Review of the hospital's Pain Management Guidelines policy revised "1/21" revealed all patients have the right to have pain assessed and managed and pain reassessed after interventions to determine the effectiveness of the interventions. All nursing staff should document all the above.

Review of the hospital's Patient Assessment policy revised "1/14" revealed the emergency room patient with pain is reassessed every two (2) hours or until the pain level is acceptable to the patient.

Review of the hospital's "Bathing Guidelines for Adult Patients" policy with an effective date of "6/2020" revealed to provide baths or assist patients with baths daily.

2. Patient #1 was admitted to the hospital on 1/4/2021 for a scheduled spinal surgery.

Review of the nursing flowsheets "Hygiene Care" section revealed Patient #1 received 1 bath during his 6 day hospital stay on 1/4/2021. Patient #1 refused a bath offered by staff on 1/7/2021. There was no other documentation the patient was offered a bath, refused a bath, or was too unstable to have a bath noted in the medical record.
Refer to A392.

Medical record review of the nursing flowsheets for Patient #1 revealed the nursing staff failed to follow the hospital's pain policy and ensure patients who had received pain medications were reassessed in order to determine the effectiveness of the pain medications and ensure patient's were relieved of pain. Patient #1 was not assessed for pain every 4 hours
post-operatively and the patient was not reassessed in a timely manner after pain medications were administered repeatedly. Refer to A395.

3. Patient #2 presented to the Emergency Department (ED) on 8/6/2021 at 3:15 PM with complaints of shortness of breath and chest pain.

Medical record review for Patient #2 revealed nursing staff failed to follow the hospital's pain policies and ensure patients were reassessed every two (2) hours for pain and failed to ensure patient's were relieved of pain. There was no documentation Patient #2 received pain medications for a pain level of 10 on a scale of 1 - 10 with 10 being the most severe pain.

Review of the physician's orders for Patient #2 revealed an order for the patient to receive Toradol 15 milligrams (mgs) intravenous (IV) once for pain. Review of the medication Administration Record (MAR) revealed the order for Toradol had been marked through and was not administered to Patient #2. There was no evidence the Toradol order had been discontinued by the physician.

Nursing staff documented that Patient #2 was crying, and shaking and had a blood pressure (BP) of 187/110 and a heart rate of 122. There was no documentation a pain assessment was performed.
Refer to A 395 for additional information regarding the lack of assessments and pain and comfort management for Patient #2.

Based on policy review, record review, and interview, nursing service failed to ensure nursing personnel provided nursing care as needed to patients for patients requiring assistance with hygiene and bathing for 1 of 3 (Patient #1) post-operative patients.

The findings included:


1. Review of the hospital's "Bathing Guidelines for Adult Patients" policy with an effective date of "6/2020" revealed, "...Purpose: To provide guidance for bathing adult patients in the inpatient setting...Provide a daily bath for patients unable to self bathe, unless medically contraindicated, to improve hygiene and promote comfort. More frequent baths may be performed based upon patient request or in response to specific patients needs..."

2. Medical record review revealed Patient #1 was admitted to the hospital on 1/4/2021 for a scheduled spinal surgery. Patient #1 underwent spinal surgery on 1/4/2021 with procedures which included fusion of the lumbar vertebral joint with autologuous tissue substitute, fusions of the lumbar vertebral joint with interbody fusion device, excision of lumbar vertebral disc, and release of the lumbar spinal cord. The surgical procedures were completed at 2:10 PM and Patient #1 was transferred to the post anesthesia care unit (PACU) at 2:15 PM. Patient #1 was transferred to the cardio vascular step down unit (CVSD) on 1/5/2021 at 12:22 AM.

Review of the nursing flowsheets, "functional screen" section dated 1/4/2021 revealed Patient #1 required assistance with bathing.

Review of the nursing flowsheets, dated 1/4/2021 through 1/9/2021 revealed Patient #1 received a chlorhexidine bath prior to his surgery on 1/4/2021 at 6:23 AM, and Patient #1 "refused" a bath on 1/7/2021 at 11:11 AM. There was no other documentation Patient #1 received a bath or was offered a bath during his hospital stay.

During an interview on 8/5/2021 at 12:41 AM, the Director of Nursing Professional Development (DONPD) was asked how often patients should be offered a bath or assisted with bathing. The DONPD stated, "A bath should be offered daily; that's what staff are advised to do." The DONPD then stated staff were to document when a patient refused, or if a bath was not provided and the reason why it was not done. The DONPD reviewed the documentation in Patient #1's medical record and verified there was no further documentation the patient received a bath, refused a bath, or gave himself a bath during his hospital stay.

Based on policy review, record review and interview, nursing services failed to adhere to the hospital's policy and procedures for pain assessments, provide interventions for patients' pain, provide ongoing assessments of patients pain and comfort levels and monitor the effectiveness of pain interventions for 2 of 4 (Patients #1 and #2) patients reviewed.

The findings included:

1. Review of the facility's "Pain Management Guidelines" policy revised "1/21" revealed, "...The entity establishes procedures for managing and preventing pain including: Patients have the right to have pain assessed and managed or referred for treatment, including managing pain aggressively and effectively according to the needs of the patients at the end of life. A comprehensive pain assessment is conducted as appropriate to the patient's condition and the scope of care, treatment and services provided. The pain assessment considers psychological, cultural, spiritual and or ethnic beliefs...Patients are screened for pain at the point of entry to the facility (inpatient, outpatient Emergency Department etc.). The patient's pain status is assessed, but is not limited to: Each complete patient assessment per patient care area policy; Each complaint of pain; When pain medication or dosage is changed; When pain interventions are provided...Pain assessment includes: A pain intensity rating scale appropriate for the patient, Location, Quality, Onset, Duration, Aggravating/relieving factors, Relieving medications...When pain interventions are provided...When medication orders for pain management included levels of pain...the following categories may be used 1-3 Mild Pain 4-6 Moderate Pain 7-10 Severe Pain The nurse continues to intervene until an acceptable level of pain is obtained as determined collaboratively by the patient, family and caregiver...Document pain assessment, interventions, and reassessment in the medical record".

Review of the facilities "Patient Assessment" policy revised "1/14" revealed, "...the initial assessment includes an assessment of pain and a focus exam involving the patient's chief complaint...The emergency room patient with pain is reassessed every two hours or until the pain level is acceptable by the patient..."

2. Medical record review revealed Patient #1 was admitted to the hospital on 1/4/2021 for a scheduled spinal surgery. Patient #1 underwent spinal surgery on 1/4/2021 with procedures which included fusion of the lumbar vertebral joint with autologuous tissue substitute, fusions of the lumbar vertebral joint with interbody fusion device, excision of lumbar vertebral disc, and release of the lumbar spinal cord. The surgical procedures were completed at 2:10 PM and Patient #1 was transferred to the post anesthesia care unit (PACU) at 2:15 PM. Patient #1 was transferred to the cardio vascular step down unit (CVSD) on 1/5/2021 at 12:22 AM.

A physician's order dated 1/5/2021 at 12:56 PM revealed Patient #1 was to be given 1 to 2 tablets of Oxycodone-acetaminophen (Percocet) 7.5 milligram (mg) - 325 mg by mouth every 4 hours as needed for pain.
On 1/6/2021 at 3:15 PM, a pain assessment was performed on Patient #1 at which time Patient #1 rated his pain at a level of 8 or severe pain.

Review of Patient #1's Medication Administration Record (MAR) revealed 2 tablets of Percocet were administered by mouth to Patient #1 at 3:18 PM.

There was no documentation Patient #1 was reassessed for the effectiveness of the medication until 7:41 PM, a total of 4 hours and 23 minutes later, at which time Patient #1 rated his pain at a level 9 or severe pain.

Review of Patient #1's MAR revealed 2 tablets of Percocet were administered by mouth to Patient #1 at 7:53 PM.

There was no documentation the patient's pain was re-assessed for the effectiveness of the pain medication until
11:09 PM, a total of 3 hours and 16 minutes later.

Review of Patient #1's MAR revealed 2 tablets of Percocet were administered by mouth to Patient #1 on 1/7/2021 at at 1:31 AM; however, there was no documentation a pain assessment had been performed and no documentation of the patient's pain level.

Review of Patient #1's MAR revealed 2 tablets of Percocet were administered by mouth to Patient #1 on 1/7/2021 at at 9:28 AM; however, there was no documentation a pain assessment had been performed and no documentation of the patient's pain level. The patient's pain level was not reassessed until 1:00 PM, a total of 3 hours and 32 minutes later.

On 1/8/2021 at 1:12 AM, a pain assessment was performed on Patient #1 at which time Patient #1 rated his pain at a level of 7 or severe pain. Review of Patient #1's MAR revealed 2 tablets of Percocet were administered by mouth to Patient #1 on 1/8/2021 at 1:12 AM. There was no documentation Patient #1 was reassessed for the effectiveness of the medication.

Review of a nurse's note written by Nurse #1 dated 1/8/2021 at 4:02 AM revealed, "...extremely agitated and angry throughout the night with intermittent episodes of being apologetic. At 0400 [4:00 AM] pt [patient] requested Robaxin. I explained to the patient that the medicine was not given as needed but was in fact a scheduled medicine with the next dose being scheduled for 0900 [9:00 AM]. Pt right away became extremely angry with my response and began to curse extremely loud and state, "you do anything not to give me my medicine." I explained that was not the case and let him know I would return..." There was no documentation the patient was assessed for pain at this time.

There was no documentation the Nurse reassessed or evaluated Patient #1 until 7:15 AM, a total 3 hours and 15 minutes after informing Patient #1 that she would return and check on his pain. The total hours from the last administration of the Percocet at 1:12 AM and the reassessment of Patient #1's pain was 6 hours and 3 minutes.

From 7:15 AM until 8:40 PM on 1/8/2021 there was no documentation Patient #1 was assessed for pain; a total of 12 hours and 25 minutes.

On 1/8/2021 at 9:06 PM, a pain assessment was performed on Patient #1 at which time Patient #1 rated his pain at a level of 6 or moderate pain. Review of Patient #1's MAR revealed 2 tablets of Percocet were administered by mouth to Patient #1 on 1/8/2021 at 9:06 PM. There was no documentation Patient #1 was reassessed for effectiveness of the medication until 12:00 AM, a total of 3 hours and 6 minutes later.

On 1/9/2021 at 4:26 AM, a pain assessment was performed on Patient #1 at which time Patient #1 rated his pain at a level of 6 or moderate pain. Review of Patient #1's MAR revealed 2 tablets of Percocet were administered by mouth to Patient #1 on 1/9/2021 at 4:26 AM. There was no documentation Patient #1 was reassessed for effectiveness of the medication until 8:00 AM, a total of 3 hours and 34 minutes later.

Review of Patient #1's MAR revealed 2 tablets of Percocet were administered by mouth to Patient #1 on 1/9/2021 at 1:49 PM; however, there was no documentation a pain assessment had been performed and no documentation of the patient's pain level.

Patient #1 was discharged from the hospital with home health services on 1/9/2021 at 4:17 PM.

During a telephone interview on 8/2/2021 at 4:05 PM, Patient #1 informed this surveyor he was in a lot of pain and asked Nurse #1 for some muscle relaxers (Robaxin). Patient #1 then stated, "She [Nurse #1] didn't give me any and she didn't explain how my medicines were supposed to be given." The patient continued and stated, "I did blow up at her. All she had to do was explain to me how my meds were to be given."

During a telephone interview on 8/4/2021 at 9:12 AM, Nurse #1 was asked how often patients should be assessed for pain and Nurse #1 stated every 2 hours and if a pain medication is given, they should be reassessed within a hour. Nurse #1 stated she remembered caring for Patient #1. She stated a patient pain level should be assessed every 2 hours and if a pain medication is given, they should be reassessed within an hour. Nurse #1 stated Patient #1 called her to his room and was complaining of pain, but it was too early for him to get anything. Nurse #1 stated when she tried to explain to the patient it was too early for him to get medication, the patient became very agitated, so she left the room and "sent another nurse" into Patient #1's room. Nurse #1 did not recall who the other nurse was that went into the room. Nurse #1 stated that she informed the House Supervisor about the incident. Lastly, Nurse #1 stated, that she was unsure of any follow up with the patient after their encounter. stating, "Not that I'm aware of."

During an interview on 8/5/2021 at 12:41 PM, the Director of Nursing Professional Development
(DONPD) stated, a pain assessment should be done with every full physical assessment and a full physical assessment was completed "every 4 hours". The DONPD clarified her statement and stated a full assessment was completed at the beginning of each shift and then a focused assessment is completed to address any patient's problems and this is performed every 4 hours thereafter. A pain assessment is part of the focused assessments for post-operative patients. When asked when patients should be reassessed for pain following administration of pain medications, the DONPD stated, "Our policy doesn't give a time frame, but it's based on the patient...we wouldn't wake a sleeping patient to assess for pain..."

3. Patient (Pt.) #2 presented to the Emergency Department (ED) on 8/6/2021 at 3:14 PM with a chief complaints of Intermittent Shortness of Breath and Chest Pain after having an asthma attack at home.

Review of Pt. #2's Triage Assessment dated 8/6/2021 at 3:21 PM revealed the Registered Nurse documented Pt.#2's Blood Pressure (B/P) was 159/80, pulse/heart rate was 117, and the patient complained of a pain level of 10, on a scale of 1 - 10 with 10 being the most severe pain. There was no documentation of an assessment of the quality, onset, duration, or aggravating/relieving factors of the patient's pain. There was no documentation Pt. #2 received any pain medication or interventions.

On 8/6/2021 at 8:53 PM, the physician ordered Toradol 15 mg Intravenous (IV) once for Patient #2's inflammation and pain.

Review of Medication Administration Record (MAR) dated 8/6/2021 at 9:00 PM revealed the RN documented Toradol 15 mg IV once for inflammation and pain was a canceled entry. There was no documentation why the medication order was canceled. There was no documentation Pt.#2 received the pain medication. There were no other orders for pain medication.

Review of the flowsheet dated 8/6/2021 at 9:49 PM revealed the RN documented Pt. #2 was crying and shaking, and the patient's BP had increased to 187/110 and the patient's pulse/heart rate had increased to 122. There was no documentation a pain assessment was performed by the RN. There was no documentation of any interventions related to Pt #2's increased BP and pulse/heart rate.

On 8/6/2021 at 10:06 PM the physician ordered Ativan 1 mg intramuscular (IM) for Patient #2 due to anxiety.

On 8/7/2021 at 2:20 AM the nurse documented Pt. #2's BP was 184/103, and the pulse/heart rate was 111. The nurse documented the patient's pain level was "0".

On 8/7/2021 at 2:34 AM the nurse documented Pt. #2 was administered the Ativan 1 mg IM. This was over 4 hours after the order had been written by the physician.

There was no documentation from 8/6/2021 at 3:22 PM - 8/7/2021 at 6:35 AM that Pt. #2 was assessed every 2 hours for pain.

On 8/7/2021 at 6:35 AM the physician documented that Patient #2 had received Albuterol and blood pressure medications and was now chest pain free with no shortness of breath. Pt. #2 was discharged home on 8/7/2021 at 6:50 AM in stable condition.

In a telephone interview on 8/10/2021 at 1:42 PM, Pt #2 stated she had taken a breathing treatment at home for an asthma attack but the treatment did not help. Patient #2 stated she started having severe chest pain and tightness and decided to go to the ED. Pt. #2 stated she was hurting "real bad" when she got there and ask for pain medicine. Pt.
#2 stated she told the nurse she was still hurting when the nurse came around about 6:00 PM and around 2:00 AM. Pt. #2 stated her blood pressure was going up from the pain. When Pt. #2 was asked to describe her pain on a scale of 1 - 10 with 10 being the most severe, Pt. #2 stated, "...It was a 10 when I got there [ to the hospital's ED] and never did go lower than 5-6...my blood pressure finally started coming down when they gave me a blood pressure medicine after 2:00 AM...the nurse gave me a shot of Ativan around 2:30 AM, cause I was still hurting and was shaking...around 3:00 AM they sent me back out to the waiting area...back to a [ED] room around 6:00 AM and they gave me a breathing treatment...the doctor came in and talked to me, told me all my test were good and I could go home...".

In a telephone interview on 8/13/2021 at 10:10 AM, the Risk Manager verified there was no documentation pain assessments were done every 2 hours.

Based on policy review, record review, and interview, the hospital failed to ensure measures to prevent the potential spread of infectious pathogens were followed when 1 of 2 (Nurse #2) Emergency Department nurses cut off the tip of his glove prior to inserting an intravenous catheter into Patient #3's hand.

The findings included:

1. Review of the hospital's "Hand Hygiene Program Guidelines" policy revealed, "...Gloves are worn when exposure to blood or body fluids is likely..."

2. Medical record review revealed Patient #3 presented to the hospital's Emergency Department (ED) on 9/29/2020 with complaints of headaches, dizziness, tightness in the head and face and knee pain.

Nurse #2 inserted an intravenous (IV) catheter into the patient's right hand in order to administer IV fluids, Acetaminophen, Pepcid, and Benadryl. The patient was also treated with 2 tablets of Fioricet by mouth.

Patient #3's condition improved, the IV access was discontinued and the patient was discharged home in stable condition.

Patient #3 alleged via the state complaint hotline, that Nurse #2 cut the finger tip off of his glove covering his index finger prior to inserting the IV catheter.

During an interview on 8/4/2021 at 11:17 AM, Nurse #2 was asked if he ever cut the index finger tip off of his gloves when performing venipuncture or IV catheterization. Nurse #2 stated, "Yes, if it's a hard stick, I'll tear off the tip of the pointer [gloved] finger [in order to feel the vein and insert the needle]."

During an interview on 8/4/2021 at 1:10 PM, the Director of Infection Prevention (DIP) stated that staff should wear gloves when there is a "reasonable indication they will be handling something that could be infectious; usually every time they enter a room to do care." The DIP stated it is not acceptable for a nurse to remove the finger tip off of the gloves prior to performing venipuncture or inserting an IV catheter. "No, you [staff] have a reasonable expectation of exposure to a blood borne pathogen if you do that."