HospitalInspections.org

The Condition of Participation for Governing Body has not been met.

Based on review of hospital policies, review of hospital documentation, observations, and staff interviews, the Governing Body failed to ensure the oversight, coordination, and remedial efforts to address staffing shortages throughout the hospital to include intensive/critical care units, emergency department, and housekeeping which led to a finding of Immediate Jeopardy under the Condition of Participation for Patient Rights, care in a safe setting, failed to ensure that the hospital's QAPI program collected and monitored pertinent date related to housekeeping, and failed to ensure oversight of the provision of nursing services in the setting of insufficient staffing.
The findings include:


Based on clinical record reviews, review of staffing plans, review of staffing assignments, observation, interviews, and policy review, the hospital failed to ensure staffing levels were adequate in the intensive/critical care units and the emergency room, failed to ensure patients were assessed/monitoring in accordance with physician orders and hospital policy and failed to ensure a safe and sanitary environment. As a result, Immediate Jeopardy identified.

Please see A115 and A144


Based on observation, review of Quality Assurance documentation, interviews, and policy review, the hospital's quality assurance and performance improvement (QAPI) program failed to collect data to monitor the cleanliness of the environment when a 30% reduction in housekeeping staff was implemented in April, 2022 and failed to ensure concerns related to staffing were tracked and monitored.

Please see A263 and A273


Based on clinical records review, review of staffing plans, review of staffing assignments, review of job descriptions, review of hospital documentation, interviews, observation, and policy review, the hospital failed to ensure staffing levels were adequate in the intensive care units and the emergency room, the hospital failed to ensure adequate pressure relieving measures were implemented to prevent the development of a pressure ulcer, failed to ensure the patient's laboratory tests were completed in a timely manner consistent with the physician's orders, failed to ensure the patient with positive blood cultures had laboratory tests and antibiotic therapy initiated in a timely manner consistent with the physician's orders, failed to ensure patient's pain was addressed consistent with the hospital's policy and practice, and the hospital failed to ensure patients received medications timely.

Please see A392, A395 and A405

The Condition of Participation of Patient Rights has not been met.

Based on clinical record review, review of staffing plans, review of staffing assignments, interviews, policy review and observations, the hospital failed to ensure staffing levels were adequate in the intensive care units and the emergency room, failed to ensure a sanitary environment, and failed to ensure patients were assessed/monitoring in accordance with physician orders and hospital policy. As a result, Immediate Jeopardy identified.


Please see A144

Based on clinical record review, review of staffing plans, review of staffing assignments, interviews, policy review and observations, the hospital failed to ensure staffing levels were adequate in the intensive care units and the emergency room, failed to ensure patients were assessed/monitoring in accordance with physician orders and hospital policy and failed to ensure a safe and sanitary environment. As a result, Immediate Jeopardy identified. The findings include:

a. Patient #54 presented to the hospital on 11/15/22 for unresponsiveness and cardiac arrest. Review of the MSICU admission and physical dated 11/15/22 at 6:46 PM noted the patient was admitted to the MICU for management of acute hypoxic respiratory failure. The note identified the patient would remain on cardiac telemetry and initiate TTM (targeted temperature management). Review of the MSICU acuity protocol noted patients who require TTM are considered critically unstable and are to be one to one care. Review of the hospital's guidelines for 1:1 patient assignment noted hypothermia protocol from initiation through warming. Review of staffing with RN #13 and RN #14 on 11/21/22 at 1:30 PM noted that Patient #54 was not on a one to one as required per hospital protocol due to not enough staff. RN #14 stated that when the unit is full (capacity for 22), the staff to patient ratio is one nurse to 2 patients. RN #14 stated that on 11/16/22 Patient #4 required a one to one for a minimum of 4 hours because the patient required targeted temperature management.


b. Patient #55 was admitted to the hospital on 10/30/22 with aortobifemoral thrombosis. Interview with RN #14 on 11/22/22 at 10:30 AM noted the patient was post t-pa and required one to one nursing for a minimum of 8 to 12 hours until stable. RN #14 stated that the nurse is looking for neuro or vascular changes as well as site checks for bleeding including the right axilla, right flank and right lower leg are to be completed every 15 minutes for the first hour, then every half hour for 2 hours and then hourly until discharge. Review of the assignment sheet dated 10/31/22 and interview with RN #14 on 11/22/22 at 10:30 AM noted that when Patient #55 came to the unit the patient was unable to be on a one to one due to short staffing. RN #14 stated that when the census is full (capacity for 22) there is to be 12 nurse's and on the day the patient was admitted the unit had 10 nurses which meant 3 nurses held an assignment of 3 patients and Patient #55's nurse had an assignment of 2 nurses.


c. Patient # 56's diagnoses included type 2 diabetes, coronary artery disease, hypertension and presented to the hospital on 10/28/22 with abdominal pain and acute kidney injury. Physician orders dated 11/11/22 at 1:08 PM directed to start Continuous Renal Replacement Therapy (CRRT) continuous with a blood flow rate of 300ml/min. Review of the surgical intensive care unit note dated 11/12/22 at 6:16 AM noted worsening acute kidney injury, prompted renal consult and trialysis catheter placement and initiation of CRRT. The note further identified the patient received CRRT from 4:00 PM until 11:00 PM but paused overnight due to staffing constraints. Review of the MSICU acuity protocol noted patients who require CRRT are considered critically unstable and are to be one to one care. Interview with RN #12 on 11/22/22 at 8:28 AM stated that she notified the PA that the CRRT needed to be stopped because of short staffing and had to take an assignment of 3 patients. Review of the clinical record noted the patients CRRT was stopped on 11/11/22 at 11:25 PM. Further review of the clinical record failed to identify that the physician/PA did not see or assess the patient and the clinical record lacked documentation that the nephrologist was made aware of the CRRT was stopped. Interview with RN # 14 on 11/22/22 at 10:30 AM noted that when Patient #56 could not be maintained on a one to one for CRRT due to short staffing, and RN #12 had to pick up a third patient at 11:00 PM and could not monitor Patient #56's CRRT. RN #14 stated that RN #12 notified the PA and the CRRT was stopped for the night.


d. Patient #57 was admitted on 10/30/22 with right flank pain and right lung emphysema. Review of the clinical record noted the patient had a VAT's procedure completed on 11/1/22 and 2 chest tubes placed. Patient #57 was transferred to the MSICU on 11/2/22. Review of the guidelines for 1:1 patient assignments noted unstable patients including patients on vasoactive agents, with rapidly changing hemodynamics or neurological issues, having multiple procedures will be considered on an individual basis and the decision will be made by the charge RN if the patient requires a 1:1. Review of the physician orders dated 11/3/22 noted a do not turn order. Review of staffing for 11/2/22, when Patient #57 was admitted to the MSICU identified the patient a census of 21 patients and 10 nurses. Further review noted that Patient #57 was on a 1:2 or 1:3 staff/patient ratio from 11/2/22 until 11/4/22. Review of the clinical record and interview with RN #14 on 11/22/22 at 9:40AM noted when Patient # 57 was admitted to the MSICU, the patient was highly unstable, paralyzed, had a do not turn order, chest tubes and a recent VAT's procedure. RN #14 stated that the patient met the criteria for 1:1 from the time the patient arrived at the unit (11/2/22) until the patient was stable (11/4/22) but due to short staffing the patient was not on a 1:1.


e. Patient #58 was admitted to the hospital on 10/24/22 for worsening shortness of breath, acute kidney injury, and AML with tumor lysis syndrome. Review of H&P dated 10/28/22 noted Patient #58 was transferred to the MSICU on 10/27/22 for worsening respiratory status and would start on HD/CRRT for AKI on 10/28/22. Review of Patient #58's clinical record with RN #14 on 11/22/22 at 11:00 AM noted the patient was placed on CRRT on 10/29/22 at 2:00 PM and the CRRT was discontinued on 10/31/22 at 1:00 PM. Review of the MSICU acuity protocol noted patients who require CRRT are considered critically unstable and are to be one to one care. Review of the staffing sheets for 10/29/22, 10/30/22 and 10/31/22 identified that during the time the patient was on CRRT, the nurse held a patient assignment of 1:2 or 1:3. RN #14 stated that the patient is to be on a 1:1 while on CRRT due to the increased monitoring of the patient that is required. RN #14 stated that on 10/29/22, 10/30/22 and 10/31/22 they did not have enough nurse's scheduled to allow for the 1:1 for Patient #58. Review of the hospital's guidelines for 1:1 Patient assignments noted patients requiring CRRT are to be a 1:1 nurse/patient ratio.


f. Patient #1 was admitted to the hospital on 9/29/22 with diagnoses that included congestive heart failure, mitral regurgitation, ventricular aneurysm, and chronic renal failure. Physician orders dated 10/12/22 directed continuous renal replacement therapy (CRRT).

CRRT flow sheets identified every four-hour documentation for CRRT from 10/21/22 at 8:00 PM to 8:00 AM on 10/22/22. CRRT was not documented after 6:00 PM on 10/22/22 to 10/23/22 at 11:00 AM (16 hours).

MD #1's progress notes dated 10/23/22 noted P #1's CRRT was held overnight as a result of staffing issues.


g. Patient #5 was admitted to the hospital on 10/12/22 with diagnoses that included significant mitral valve stenosis admitted for optimization prior to mitral valve replacement.

Physician orders dated 10/17/22 directed CRRT. CRRT flow sheets identified every four-hour documentation for CRRT from 10/21/22 at 4:00 AM to 8:00 AM on 10/22/22. CRRT was documented as off from 6:00 PM on 10/22/22 to 10/23/22 at 9:40 AM (9 hours and 40 minutes).

MD #1's progress notes dated 10/23/22 noted Patient #5's CRRT was held overnight as a result of staffing issues.

The staffing sheet for the cardiac intensive care unit (CICU) identified one RN #38 cared for three patients from 7:00 PM on 10/22/22 to 7:00 AM on 10/23/22 to include Patients #s 1 (CRRT), 5 (CRRT) and 74.

Interview with Assistant Manager #2 on 11/9/22 indicated usual CICU staffing is one RN to two patients unless a patient is unstable. Interview with Manager #3 on 11/17/22 at 10:30 AM stated postoperative open heart surgery patients, patients with extracorporeal membrane oxygenation (ECMO), Impella (medical devices used for temporary ventricular support), and CRRT should have a one patient to one nurse ratio (1:1) per protocol and in accordance with standards of practice. The hospital failed to ensure that Patient #1 and #5 received 1:1 care per protocol.

Interview with MD #1 on 11/10/22 at 1:00 PM identified Patient #1 and Patient #5 had minimal to no effects from withholding the CRRT on 10/22/22. MD #1 further noted the CRRT was held due to staffing issues, and this has happened in the past as well.


h. Patient #63 had a diagnosis of severe aortic stenosis and was admitted to the CICU following cardiac surgery on 10/20/22. Physician orders dated 10/21/22 directed a 2gm sodium diet and Patient #63 was able to participate in room service. Nursing flow records dated 10/22/22 indicated Patient #63 was incontinent of urine at 8:00 AM and could self- reposition. The flow records did not identify food intake for the breakfast and lunch meals.

Interview with RN #18 on 11/9/22 at 10:12 AM noted she was very busy the morning of 10/22/22, took care of Patient #5 who required CRRT and was very unstable. RN#18 stated she was also assigned to care for Patient #63 and was unable to "provide the care she wanted to". RN #18 further indicated Patient #63 had to lie on a "Chucks" (incontinent pad) and against the plastic mattress because there was no linen. She further indicated she was very busy and there was no nurse aide to assist with ordering meals and calling for linen.

Interview with Manager #3 on 11/17/22 at 10:30 AM stated, in part, patients receiving CRRT (Patient #5) should have a one patient to one nurse ratio per protocol.

Review of the staffing sheet dated 10/22/22 identified RN #18 was assigned to care for Patient #63 and Patient #5 who was receiving CRRT from 7:00 AM to 7:00 PM. On 10/22/22, the census was 16 and eight (8) RNs were working the day shift.

The Annual Hospital staffing plan identified the CICU will have 11 RNs and 2 unlicensed assistive personnel (nurse aides) for an average census of 16 patients.

The CICU failed to follow established staffing protocols on 10/22/22 to include 1:1 care of Patient #5 and meet the needs of Patient #63 due to short staffing.


i. Patient #9 was admitted on 10/27/22 with hypothermia and was on ECMO therapy. The staffing sheet dated 10/28/22 identified Patient #9 had been on a 1:1 from 7:00 AM to 7:00 PM and Assistant Manager #1 assumed the care of Patient #9 and Patient #10 from 7:00 PM to 11:00 PM.

Patient #4 was 42 years old, had a diagnosis of right pneumothorax with severe emphysematous changes and was admitted on 10/26/22. The operative note for 10/28/22 indicated Patient #4 had video assisted thoracoscopic surgery (VATS) on 10/28/22, was intubated and sent to the CICU in stable condition.

Interview with Assistant Manager #1 on 11/16/22 at 10:25 PM indicated she had to assume care of Patient #4 at 10:50 AM although she was caring for an ECMO patient, Patient #9 and Patient #10 due to short staffing. Assistant Manager #1 further identified Patient #4 had stable vital signs upon arrival to the unit, went back to care for her other two patients and did not document Patient #4's vital signs upon arrival to the unit. The Assistant Manager identified Patient #4's vital signs became unstable at 11:00 PM.

Interview with Manager #3 on 11/17/22 at 10:30 AM noted, in part, patients with ECMO should have a one patient to one nurse ratio per protocol and standard of care. Therefore, RN had a triple assignment while caring for Patient #9 who was on ECMO and who required 1:1 care.


j. Patient #66 arrived in the ICU on 10/28/22 at 1:04 PM after open heart surgery. Review of the staffing schedule identified that RN #27 was assigned to this patient, and also Patient #6 (3pm-7pm). Interview with Assistant Nurse Manager #1 stated an open-heart patient should be on a 1:1 (one RN to one patient) for at least the first 4 hours postoperatively and RN# 27 had a double assignment due to short staffing.


k. Patient #67 was admitted to the hospital on 10/20/22 following a cardiac arrest. Review of the CICU staffing assignments dated 10/28/22 from 7PM-7AM identified RN #30 was assigned to care for Patient #67 who had an Intra-aortic balloon pump (IAPB). At 7PM, RN #30 assumed the care of Patient #66 from RN #27.

Review of the CICU Acuity Model and interview with Assistant Nurse Manager #1 on 11/21/22 at 2:00 PM stated Patient #67 required 1:1 nursing because the patient had an IABP, however, needed to assign Patient #66 to RN #30 due to short staffing.


l. Patient #5 was admitted to the hospital on 10/12/22 with non-rheumatic mitral valve stenosis. Review of the CICU staffing assignments dated 10/28/22 identified RN #31 was assigned to care for Patient #5 from 7AM-7PM and the patient required CRRT. RN #31 was also assigned to care for Patient #68.

Review of the CICU staffing assignments dated 10/28/22 identified RN #32 was assigned to care for Patient #5 from 7PM-7AM and the patient required CRRT. RN #32 was also assigned to care for Patient #68.

Review of the CICU Acuity Model and interview with Assistant Nurse Manager #1 on 11/21/22 at 2PM stated Patient #5 required 1:1 nursing because the patient's treatment included CRRT, however, RN #31 and RN #32 had double assignments due to short staffing.


m. Patient #1 was admitted to the hospital on 9/29/22 with mitral regurgitation. Review of the CICU staffing assignments dated 10/28/22 identified RN #28 was assigned to care for Patient #1 from 7AM-7PM and the patient required CRRT. RN #28 was also assigned to care for Patient #8 from 7AM-11AM.

Review of the CICU staffing assignments dated 10/28/22 identified RN #33 was assigned to care for Patient #1 from 7PM-7AM and the patient required CRRT. RN #33 was also assigned to care for Patient #69 from 7PM-7AM.

Review of the CICU Acuity Model and interview with Assistant Nurse Manager #1 on 11/21/22 at 2PM stated Patient #1 required 1:1 nursing because the patient's treatment included CRRT and the nurse's had two patients each.


n. Patient #9 was admitted to the CICU on 10/27/22 and was placed on ECMO. The staffing sheet dated 10/31/22 identified RN #20 and an orientee (RN #29) were assigned to care for Patient #9 from 7AM-3PM. During the 3PM-7PM shift, the Nurse Manager was assigned to care for the patient.

Interview with RN #20 on 11/9/22 at 11:15 AM identified she cared for Patient #9 on 10/31/22 and was precepting an orientee, RN #29. RN #20 indicated she had to leave RN #29 alone with Patient #9 to receive Patient #64 (post open heart) because Assistant Manager #2 was busy with Patient #65.

Interview with Nurse Manager #3 on 11/21/22 at 2PM stated she worked until 8:30PM on 10/31/22 and RN #29 (orientee who was with the patient during the day and precepted by RN #20) was monitoring the patient. The Nurse Manager stated she and the Assistant Manager #2, who was also in charge and was assigned two patients' (Patient #39 and #65) rounded every 10 minutes.

Review of personnel files on 11/25/22 identified RN #29 was not signed off to care for a patient receiving ECMO as of 10/31/22. The review further identified Manager #3 was not trained in the management of patients receiving ECMO as of 10/31/22.


o. Patient #5 was admitted to the hospital on 10/12/22 with non-rheumatic mitral valve stenosis. Review of the CICU staffing assignments dated 10/31/22 identified Patient #5 was receiving CRRT, and RN #36 was assigned to care for the patient from 7AM-3PM. RN #36 was also assigned to care for Patient #49 for the same period of time rendering a double assignment.

Review of the staffing sheets with Nurse Manager #3 on 11/21/22 at 2PM stated Patient #5 required a 1:1 ratio as the patient was receiving CRRT.

In addition, further review of the assignment sheet identified Nurse Manager #3 was assigned to Patient #5 from 3PM-7PM and the patient continued to require CRRT. Although the Patient required 1:1 staffing, Nurse Manager was assigned to care for Patient #9 who was receiving ECMO and Patient #49, resulting in a triple assignment.

Interview with Nurse Manager #3 on 11/21/22 at 2:00 PM stated she worked until 8:30 PM on 10/31/22 and RN #36 stayed until 6:00 PM and cared for Patient #5. The Manager stated she turned, repositioned, and suctioned the patient and Assistant Manager did the 7PM charting for the ECMO treatment.

The personnel files reflected that Nurse Manager #3 was not fully trained in the management of patients receiving ECMO or CRRT as of 10/31/22.


p. Patient #5 was admitted to the hospital on 10/12/22 with non-rheumatic mitral valve stenosis. Review of the CICU staffing assignments dated 10/31/22 identified Patient #5 was receiving CRRT, and RN #37 was assigned to care for the patient from 7PM-11PM. RN #37 was also assigned to Patient #49 and #65 resulting in a triple assignment. At 11PM, RN #37 had a double assignment (#5 and #65) until 7:00 AM.


q. Patient #65 was directly admitted to the CICU following open heart surgery on 10/31/22 at 10:19 AM. The staffing sheet dated 10/31/22 indicated Assistant Manager #2 was assigned to care for Patient #65 from 10:19AM until 3:00 PM.

The staffing sheet identified that Patient #64 was admitted to the CICU following open heart surgery on 10/31/22 at 1:38 PM and was assigned to Assistant Manager #2.

Interview with Assistant Nurse Manager #2 on 11/9/22 at 12:45 PM noted she received the two open heart patients in approximately 2 hours of each other and RN #20 left Patient #9 for a short time to help her settle Patient #64 because she was busy caring for Patient #65. Assistant Manager #2 identified one RN should not care for more than one fresh open-heart patient for the first four hours of receiving that patient. Assistant Manager #2 indicated that while she was busy with her two open heart patients, she had to help Manager #3 with Patient #5 and #49 with taking a glucose finger stick, drawing blood from an A-line and calculating the numbers for the CRRT.


r. Patient #70 was admitted on 10/26/22 following a cardiac arrest. Review of the assignment sheet dated 10/31/22 identified RN #34 was assigned to Patient #70 (had an Impella device) from 7AM-7PM and was also assigned to care for Patient #71. At 7PM, RN #35 assumed the care of Patient #70 and #71 until 7AM (12-hour shift).

Interview with the Nurse Manager on 11/21/22 at 11:30AM stated this was a double assignment due to staffing shortage. Although nurses are called for availability it is sometimes difficult to fill the shifts.


s. Patient #67 was admitted on 10/20/22 following a cardiac arrest. Review of the assignment sheet dated 10/31/22 identified RN #25 was assigned to Patient #67 (required ECMO and CRRT) from 7PM-11PM and was also assigned to care for Patient #10 who transferred out of the unit at 11:07PM.

Interview with the Nurse Manager on 11/21/22 at 11:30AM stated this was a double assignment due to staffing shortage.


t. Patient #73 arrived in the ICU on 10/31/22 at 1:36PM following a cardiac catheterization. Review of the assignment sheet identified that RN #27 was assigned to care for Patient #73 who had an IABP until 7PM. RN #27 was also assigned to care for Patient #72 from 7AM-7PM resulting in a double assignment.

Interview with the Nurse Manager on 11/21/22 at 11:30 AM stated this was a double assignment due to short staffing.

Interview with staff on 11/21/22 and 11/22/22, who wished to remain anonymous, stated staffing has been an ongoing concern and although Leadership is notified, short staffing remains a concern including one RN with multiple devices and double and triple assignments. One staff member stated s/he is unable to provide basic care, such as mouth care, due to short staffing.

Interview with the Chief Nursing Officer on 11/22/22 at 4:30 PM stated she was aware there were instances of staffing issues and multiple interventions are in place including in part; daily bed meetings, First Choice program (organization float pool), vendor management system (agency contracts for staffing), onboarding new staff and recruitment of staff are ongoing.

The Hospital Criteria, Nurse Manager Job Description identified the Nurse Manager is responsible and accountable for providing clinical and administrative leadership to an assigned patient care unit or department. The nurse manager obtains and allocates available resources to assure efficient, effective, and safe patient care.

Review of the Plan for Provision of Care, last revised 10/2015, identified the CICU is a 20-bed critical care unit that focuses on the care of patients requiring intensive cardiac monitoring. The delivery of care is achieved via a modified approach with the emphasis on quality and safety. The RN is the leader of the team, coordinating care, and focusing on quality outcomes. Patients are assigned based on level of acuity and staff competency. The Charge Nurse is responsible for making the patient assignments and staffing is adjusted on a every 4 hour basis based on activity and acuity of the unit. The staffing plan is reviewed on an annual basis and adjusted accordingly.


u. Patient #14 was admitted to the facility's Emergency Department (ED) on 8/29/22 at 3:51 PM with diagnoses to include alcohol intoxication and request for detoxification from ethyl alcohol (EtOH).

Review of Patient #14's history and physical dated 8/29/22 at 5:02 PM identified that the patient had a very unsteady gait, strong alcohol odor, poor coordination, and was aggressive with RN #5. The note identified that Patient #14 was brought to the behavioral health area of the ED for evaluation and was placed in a SOMA (net) bed for safety.

An Emergency Department (ED) provider note dated 8/29/22 at 5:45 PM identified the Physician was informed by RN #5 that Patient #14 cut his/her wrist and neck with a razor blade that the patient indicated was in his/her underwear and Patient #14 later identified that he/she swallowed the razor. The ED provider note identified Patient #14 was noted to have a laceration on the left side of the neck measuring 4 centimeters long by 2 millimeters deep and a laceration to right wrist measuring 4 centimeters long by 2 millimeters deep. The Provider note further identified direction to cover the wounds because Patient #14 was not cooperating for any sort of laceration repair, and to obtain radiographs to exclude ingestion of foreign body.

The RN ED note dated 8/29/22 at 6:40 PM identified that after the initial cutting RN #5 checked on Patient #14 and found additional bleeding from the wrist with a razor next to the patient on the bed. The RN note identified that Patient #14 reported having the razor the entire time. The RN note identified that the razor was not found when Patient #14 was searched between incidents.

The clinical record identified that after the second incident of cutting Patient #14 was placed on strict constant 1:1 observation.

Tour of the ED West Wing (Behavioral Health) and interview with RN #4 on 11/10/22 at 11:29 AM identified that it was not uncommon for the hospital to staff the area with only 1 RN which made it difficult to provide care to patients in a timely manner.

In an interview with RN #5 on 11/16/22 at 1:20 PM, RN #5 identified that on the day of the incident the Behavioral health wing may have had the maximum patient census (12 patients). RN #5 indicated that at times the area was staffed by 2 RNs but on the day of the incident RN #5 was the only RN assigned to the behavioral health wing. RN #5 indicated that it was the practice to remove a patient's clothing and perform a comprehensive body search when patients were admitted to the behavioral health area of the ED. RN #5 identified that there were issues with other patients and identified that when the safety checks were performed for Patient #14, she did not check under the underwear and may have missed the razor on 2 searches as there were many issues with other assigned patients. RN #5 indicated that having 2 RNs assigned to the behavioral health area would have been ideal to provide care to the patients.

A review of ED staffing for 8/29/22 against the Hospital's staffing plan with Manager #1 and Director #1 on 11/18/22 identified that the department was short staffed by 4 nurses for the 3:00 PM to 7:00 PM shift and 6 nurses for the 7:00 PM to 11:00 PM shift.

Review of the Behavioral Health Patient Search Process policy directed, a comprehensive body search would be conducted when the patient's clinical behavior indicates the need for a comprehensive search.


v. Patient #11 was admitted to the Emergency Department at 1:05 PM with a diagnosis of positive blood culture and triaged as Emergency severity Index (ESI) level 2 (Requiring reassessment every 2 hours or more frequently).

Review of the Emergency Department provider note dated 7/23/22 at 4:48 PM identified Patient #11 was recalled to the ED for abnormal blood cultures gram + Cocci with concerns for Methicillin resistant staphylococcus aureus (MRSA) identified in blood cultures of 7/21/22. The provider note identified repeat laboratory tests and intravenous antibiotics including Vancomycin and ceftriaxone were ordered.

The Physician's order dated 7/23/22 at 2:08 PM directed blood cultures, send prior dose of antibiotics. (Blood cultures sent prior to antibiotics treatment ensure the specific organism to target in treatment decisions are identified).

Review of Patient #11's laboratory results identified two blood cultures for Patient #11 were completed on 7/23/22 at 7:21 PM and a second at 8:16 PM (5 hours after physician's order).

Patient #11's clinical record identified the first dose of Vancomycin was administered at 2:14 AM on 7/24/22 (6 hours after the blood cultures were obtained).

An interview with RN #22 on 11/16/22 at 1:15 PM identified the delay with Patient #11's laboratory test, and initiation of antibiotics may have been lack of resource or human error. RN #22 indicated she was unable to recall Patient #11 but stated it may have been a very busy day as the department had nurses who were floated to the ED from other areas.

An interview with Director #1 on 11/16/22 at 10:24 AM indicated if a phlebotomist was not available it was the responsibility of the RN to obtain laboratory specimens in the Emergency room. Director #1 indicated all specimen draws were considered STAT (at once).

A review of the Emergency room staffing for 7/23/22 - 7/24/22 3:00 PM to 3:00 AM time period with Manager #1 and Director #1 on 11/18/22 identified the department was short by 4- 6 nurses.

The Hospital's laboratory call and panic values Policy directed Emergency/STAT specimens from receipt to test completion is 1 hour.

The medication ordering and Administration Policy directed medications need to be administered no later than one hour after the scheduled time.

The Hospital's RN job description directed the RN should execute the medical regimen under the direction of a licensed physician.


w. Patient #12 was admitted to the Emergency Department from another facility on 8/8/22 with a chief complaint of COVID Pneumonia.

Review of Patient #12's clinical record with Manager #1 on 11/10/22 at 1:08 PM identified that Patient #12 was admitted to the ED on 8/8/22 and remained in the ED until transferred to an inpatient unit on 8/9/22 (36 hours).

Tour of the ED on 11/10/22 at 9:45 AM with Manager #1 and Director #1 identified that floors within patient care rooms and hallways were discolored, scuffed and with debris. Observation of exam room S-43 with Manager #1 and Director #1 identified an unmade stretcher bed with a ripped mattress rendering the mattress unable to be sanitized between patients. An interview with Manager #1 indicated the room was cleaned and ready for a patient.

Tour and observation of an unoccupied trauma room (identified as clean and ready to accept a patient) noted scuffed and stained floors with dried, red, blood-like spills over the equipment. Throughout the department, floors under the wall mounted hand sanitizers were stained with gray to blackened sticky build up.

Review of ED Patient satisfaction surveys for the months of September and October 2022 identified that patients described the environment as 'very dirty', 'nasty', 'disgusting', 'old fluid bag from previous patient still hanging', 'blood on the floors', 'visible blood in the trash can', 'chaotic environment', and 'cleanliness not acceptable.'

An interview with RN #1 on 11/10/22 at 10:03 AM identified there was an inadequate number of housekeepers in the Department and nurses were expected to clean the rooms between patients. RN #1 indicated that the trash cans were sometimes full and not emptied before other patients were admitted to the rooms.

An interview with Manager #2 (Environmental Services) on 11/10/22 at 11:15 AM identified that in May of 2022 the Hospital reduced the Environmental service staff by 30%. Manager #2 indicated that there has been an increased number of patient complaints related to the environment since the reduction in the number of housekeeping staff. Manager #2 identified that there were two housekeepers assigned to the Emergency Department from 11:00 PM to 7:00 AM which meant that there was one staff member in the department when the second staff member was on a break. Manager #2 stated that he would float staff from the inpatient units to cover vacation hours within the Emergency Department.

In an interview with Director #3 (Facilities) on 11/21/22 at 3:33 PM, Director #3 identified that Environmental care rounds were conducted in clinical areas two times/year which entailed review of environmental cleanliness. Director #1 indicated that on the most recent rounds cleanliness issues were brought up for the 5-9 and 9-9 units and for the Emergency Department. The Director stated that work orders were made out and presented to the environmental service department.

An interview with Person #4 on 11/28/22 at 2:23 PM identified that as a patient in the Emergency Department Patient #12's room was filthy, the beside tables had dried spills, and used bandages were seen over the floor of the patient's room.

Review of the Cleaning Patient Care and Environment policy directed Environmental Services to perform terminal cleaning of patient rooms between patient occupancy and at discharge and directed to terminally clean all equipment and room after patient discharge.

Subsequent to the surveyor's observations the environmental service department provided a plan to improve cleanliness in the Emergency Department.


x. Patient #37 presented to the emergency department (ED) on 11/21/22 with family members with suicidal ideation and a history of self-harm including cutting of wrists. Patient #37 has diagnoses that include Bipolar one disorder, outbursts of explosive behavior, PTSD (Post traumatic stress disorder, and schizophrenia. A nursing note dated 11/21/22 at 4:27 A.M. identified that Patient #37 was brought back to the ED's West Wing (locked psychiatric unit) but due to very aggressive initial behavior and recent suicide attempt at home, confirmation with Charge RN (Registered Nurse) confirmed that patient will remain on a one-to-one observation until evaluation by the psychiatry/crisis team. A physician's note dated 11/21/22 at 6:09 A.M. identified Patient #37 admitted to suicidal ideation but without a clear plan. Hospital documentation identified Patient #37 was on constant observation and monitoring.

During a tour of the ED's west wing unit with the Director of Nursing, and Quality Specialist, on 11/21/22 at 10:10 A.M. an observation was made of Patient #37 asleep in bed, with hands, neck, and face covered by a blanket and Patient Care Technician (PCT) #1 sitting at a computer next to Patient #37's bed.

Interview with PCT #1 on 11/21/22 at 10:10 A.M. identified that she was assigned to continuously observe Patient #37. PCT#1 further identified that she was not able to visualize Patient #37's hands, neck, or face. PCT#1 identified that she has received hospital education on constant observation role and responsibilities within the past year.

Observation was made on 11/21/22 at 10:15 identified that PCT #1 had not made any attempt t

The Condition of QAPI has not been met.

Based on observation, review of Quality Assurance documentation, interviews, and policy review, the hospital's quality assurance and performance improvement (QAPI) program failed to collect data to monitor the cleanliness of the environment when a 30% reduction in housekeeping staff was implemented on _____ and failed to ensure concerns related to staffing were tracked and monitored.


Refer to A 273

Cross reference A115 and A385

Based on observation, review of Quality Assurance documentation and meeting minutes, interviews, and policy review, the hospital's quality assurance and performance improvement (QAPI) program failed to collect data to monitor the cleanliness of the environment when a 30% reduction in housekeeping staff was implemented in May 2022 and failed to track and monitor concerns related to staffing. The findings include:

Cross reference A144

a. Review of hospital documentation identified that in May of 2022 the Hospital reduced the Environmental Service staff by 30%. This included housekeeping services.

Review of the monthly tool utilized by the Housekeeping Manager from August 10, 2022 through October 20, 2022 identified that the Nurse Managers of multiple units noted the following concerns on their units: rated cleanliness of patient care areas as poor, identified more resources are required, more frequent cleaning is required, numerous patient complaints, laundry hampers frequently appear overfilled and would benefit from frequent emptying, concerns voiced over cleaning patient bathrooms and emptying the trash, and the loss of EVS personnel has made a big difference in the visual and personal cleanliness of the ICU causing nurses to clean more frequently.

Review of complaints submitted to the Patient Relations Department of the hospital from June 16, 2022 through October 25, 2022 identified dirty chairs in the Radiology Department, patient placed in a dirty room in the emergency department (ED), the ED room was dirty with supplies on the floor, floors dirty (inpatient unit), bed linen never changed, floors filthy, ED room filthy, triage area of the ED dirty, patient placed in a filthy ED room (table was covered with bloody gauze, half eaten food, dirty paper towels), no paper or soap in the ED bathroom, and an IV bag hanging in the room for the patient prior.


Review of the Infection Prevention and Control Meeting Minutes identified the following concerns on clinical units:

4/28/22 - Soiled vents, dusty & soiled areas, floors, and walls soiled, dust on high surfaces, vents, air intake and return soiled, dirty or tears on furniture.
5/26/22- Dust in high surfaces.
6/23/22- Floors and walls were not clean in multiple units, dust in high surfaces, soiled bathroom.
7/28/22- Dust on high surfaces in multiple units i.e., hanging pictures in hallway, family room, dusty areas, floors, and walls soiled.
8/25/22- Overflowing debris in multiple units, waste containers overfilled.
9/22/22- Dusty areas in multiple units, overflowing debris, debris on floor in multiple units.
10/5/22- High touch areas dusty, soiled, and torn furniture.
10/13/22- High touch areas dusty.
10/12/22- Soiled linen hamper overflowing.
10/27/22- Debris on the floor, dusty areas, high touch items in hallway, dirty toilet.
11/10/22- Dietary areas- soiled floors, refrigerator soiled, empty soap dispenser, storage areas with soiled floors, high dust throughout.

The action/recommendation for all these concerns identified "all items corrected". A date in which this should occur was lacking.

Interview with the Manager of Infection Prevention on 11/21/22 at 2:45PM stated on 11/10/22 she toured the CICU and shared the ongoing concerns with the Facilities Director. This included soiled floors, refrigerator soiled, and empty soap dispenser in the dietary areas, storage areas with soiled floors, and high dust throughout the unit.

Although concerns were identified by the Infection Control Manager on 11/10/22, the issues were not addressed as evidenced by the surveyor's observations as follows:

Tour of the CICU on 11/21/22 at 9:55 AM with Nurse Manager #3 and the Quality Assurance Specialist identified,

i. the equipment storage room (5934) that contained equipment and supplies had dusty floors and supplies were on the floor. Documentation could not be provided as to when the room was last cleaned.

ii. the dirty utility room floor was stained and dusty.

iii. the storage room that contained oxygen cylinders was dusty, had thick dirt in the corners of the room, walls were marred and had stained, an outlet had wires without a covering, and the oxygen storage cabinet was dust laden with debris on the floor.

iv. the clean utility room, where patient care items were stored, was dust laden and suction canisters were stored in the sink (remember to wash hands sign noted above the sink).

v. the nourishment room floor was heavily soiled, sticky, and dusty. The plastic sheets beneath stored items was heavily soiled, and the refrigerator contained outdated food. A thick black substance was noted under the edges of the refrigerator.


On 11/22/2022 at 10:00 AM and various times throughout the day, tours of the building 5 CICU unit with the Director Facilities identified the following:

i. mold and mildew under nourishment refrigerators, melted ice cream on the bottom of the freezer portion of the refrigerator and debris laden interior of the refrigerator portion for the two (2) patient nourishment rooms for the CICU.

ii. debris laden floors in the medication room west nurse station CICU and medications on floors behind the pyxis
iii. storage room 4 debris laden floors and oxygen storage cabinets that were debris laden and contained oxygen for use on patients.

Interview with the Director of Facilities stated Environmental Services Department was short staffed by twenty-four (24).

Although these concerns were identified the day prior, they were not corrected.

Review of the Environment of Care Committee meeting minutes from May 2022 through November 21, 2022, with the Manager of Housekeeping on 11/21/22 at 11AM failed to identify data/metrics were analyzed based on patient and staff concerns regarding the cleanliness of the environment subsequent to services being reduced. Further interview identified that although he rounds monthly with the Managers of the units, he addresses issues in real time, however, does not document or track these issues to monitor improvement.


Interview with the Director of Quality on 11/22/22 at 11:10AM stated the minutes did not reflect a mechanism to ensure these concerns were corrected and this would be addressed moving forward. I

n addition, the EOC Committee should meet at least nine (9) times annually, however, will have only met seven (7) times for 2022.


Review of the System Wide Management Plans for the Environment of Care (EOC) policy identified a safe environment for employees, physicians, students, patients, visitors, and contractors will be maintained. The System Safety Officer is responsible to communicate at least quarterly safety management issues and summaries of the Environment of Care activities to the Healthcare Quality and Value Committee which in turn, reports the information to the Board of Directors. Standing and appointed subcommittees, including Infection Control Activities, are responsible for tracking a variety of safety functions which underpin the Safety Management Program.


b. Review of Hospital Staffing during the period of 10/21/22 through 11/22/22 identified periods of inadequate staffing in the CICU, MMSICU, and the ED. Cross reference A144.

Review of the QA meeting minutes for July 2022 noted a grievance was filed for being "understaffed". The November 2022 meeting minutes reflected concern with dialysis treatment due to staffing.

Interview with the Director of Quality on 11/22/22 at 11:15AM identified that staffing is discussed at many levels throughout the day, however, was unable to provide data that staffing concerns were correlated with Midas reports and/or complaints.

The Condition of Participation of Nursing has not been met.

Based on observation, review of clinical records, review of staffing plans, review of staffing assignments, review of job descriptions, review of hospital documentation, interviews, and policy review, the hospital failed to ensure staffing levels were adequate in the intensive care units and the emergency room, the hospital failed to ensure adequate pressure relieving measures were implemented to prevent the development of a pressure ulcer, failed to ensure the patient's laboratory tests were completed in a timely manner consistent with the physician's orders, failed to ensure the patient with positive blood cultures had laboratory tests and antibiotic therapy initiated in a timely manner consistent with the physician's orders, failed to ensure patient's pain was addressed consistent with the hospital's policy and practice, and the hospital failed to ensure patients received medications timely.

Please see A392, A395, and A405

Based on review of clinical records, review of staffing plans, review of staffing assignments, review of job descriptions, review of hospital documentation, interviews, and policy review, the hospital failed to ensure staffing levels were adequate in the intensive care units and the emergency room in accordance with the hospitals' staffing plan and the acuity levels of the patients. The findings include:

a. Patient #54 presented to the hospital on 11/15/22 for unresponsiveness and cardiac arrest. Review of the MSICU admission and physical dated 11/15/22 at 6:46 PM noted the patient was admitted to the MICU for management of acute hypoxic respiratory failure. The note identified the patient would remain on cardiac telemetry and initiate TTM (targeted temperature management). Review of the MSICU acuity protocol noted patients who require TTM are considered critically unstable and are to be one to one care. Review of the hospital's guidelines for 1:1 patient assignment noted hypothermia protocol from initiation through warming. Review of staffing with RN #13 and RN #14 on 11/21/22 at 1:30 PM noted that Patient #54 was not on a one to one as required per hospital protocol due to not enough staff. RN #14 stated that when the unit is full (capacity for 22), the staff to patient ratio is one nurse to 2 patients. RN #14 stated that on 11/16/22 Patient #4 required a one to one for a minimum of 4 hours because the patient required targeted temperature management.


b. Patient #55 was admitted to the hospital on 10/30/22 with aortobifemoral thrombosis. Interview with RN #14 on 11/22/22 at 10:30 AM noted the patient was post t-pa and required one to one nursing for a minimum of 8 to 12 hours until stable. RN #14 stated that the nurse is looking for neuro or vascular changes as well as site checks for bleeding including the right axilla, right flank and right lower leg are to be completed every 15 minutes for the first hour, then every half hour for 2 hours and then hourly until discharge. Review of the assignment sheet dated 10/31/22 and interview with RN #14 on 11/22/22 at 10:30 AM noted that when Patient #55 came to the unit the patient was unable to be on a one to one due to short staffing. RN #14 stated that when the census is full (capacity for 22) there is to be 12 nurse's and on the day the patient was admitted the unit had 10 nurses which meant 3 nurses held an assignment of 3 patients and Patient #55's nurse had an assignment of 2 nurses.


c. Patient # 56's diagnoses included type 2 diabetes, coronary artery disease, hypertension and presented to the hospital on 10/28/22 with abdominal pain and acute kidney injury. Physician orders dated 11/11/22 at 1:08 PM directed to start Continuous Renal Replacement Therapy (CRRT) continuous with a blood flow rate of 300ml/min. Review of the surgical intensive care unit note dated 11/12/22 at 6:16 AM noted worsening acute kidney injury, prompted renal consult and trialysis catheter placement and initiation of CRRT. The note further identified the patient received CRRT from 4:00 PM until 11:00 PM but paused overnight due to staffing constraints. Review of the MSICU acuity protocol noted patients who require CRRT are considered critically unstable and are to be one to one care. Interview with RN #12 on 11/22/22 at 8:28 AM stated that she notified the PA that the CRRT needed to be stopped because of short staffing and had to take an assignment of 3 patients. Review of the clinical record noted the patients CRRT was stopped on 11/11/22 at 11:25 PM. Further review of the clinical record failed to identify that the physician/PA did not see or assess the patient and the clinical record lacked documentation that the nephrologist was made aware of the CRRT was stopped. Interview with RN # 14 on 11/22/22 at 10:30 AM noted that when Patient #56 could not be maintained on a one to one for CRRT due to short staffing, and RN #12 had to pick up a third patient at 11:00 PM and could not monitor Patient #56's CRRT. RN #14 stated that RN #12 notified the PA and the CRRT was stopped for the night.


d. Patient #57 was admitted on 10/30/22 with right flank pain and right lung emphysema. Review of the clinical record noted the patient had a Video Assisted Thoracoscopic Surgery (VAT's) procedure completed on 11/1/22 and 2 chest tubes placed. Patient #57 was transferred to the MSICU on 11/2/22. Review of the guidelines for 1:1 patient assignments noted unstable patients including patients on vasoactive agents, with rapidly changing hemodynamics or neurological issues, having multiple procedures will be considered on an individual basis and the decision will be made by the charge RN if the patient requires a 1:1. Review of the physician orders dated 11/3/22 noted a do not turn order. Review of staffing for 11/2/22, when Patient #57 was admitted to the MSICU identified the patient a census of 21 patients and 10 nurses. Further review noted that Patient #57 was on a 1:2 or 1:3 staff/patient ratio from 11/2/22 until 11/4/22. Review of the clinical record and interview with RN #14 on 11/22/22 at 9:40AM noted when Patient # 57 was admitted to the MSICU, the patient was highly unstable, paralyzed, had a do not turn order, chest tubes and a recent VAT's procedure. RN #14 stated that the patient met the criteria for 1:1 from the time the patient arrived at the unit (11/2/22) until the patient was stable (11/4/22) but due to short staffing the patient was not on a 1:1.


e. Patient #58 was admitted to the hospital on 10/24/22 for worsening shortness of breath, acute kidney injury, and AML with tumor lysis syndrome. Review of H&P dated 10/28/22 noted Patient #58 was transferred to the MSICU on 10/27/22 for worsening respiratory status and would start on HD/CRRT for AKI on 10/28/22. Review of Patient #58's clinical record with RN #14 on 11/22/22 at 11:00 AM noted the patient was placed on CRRT on 10/29/22 at 2:00 PM and the CRRT was discontinued on 10/31/22 at 1:00 PM. Review of the MSICU acuity protocol noted patients who require CRRT are considered critically unstable and are to be one to one care. Review of the staffing sheets for 10/29/22, 10/30/22 and 10/31/22 identified that during the time the patient was on CRRT, the nurse held a patient assignment of 1:2 or 1:3. RN #14 stated that the patient is to be on a 1:1 while on CRRT due to the increased monitoring of the patient that is required. RN #14 stated that on 10/29/22, 10/30/22 and 10/31/22 they did not have enough nurse's scheduled to allow for the 1:1 for Patient #58. Review of the hospital's guidelines for 1:1 Patient assignments noted patients requiring CRRT are to be a 1:1 nurse/patient ratio.


f. Patient #1 was admitted to the hospital on 9/29/22 with diagnoses that included congestive heart failure, mitral regurgitation, ventricular aneurysm, and chronic renal failure. Physician orders dated 10/12/22 directed continuous renal replacement therapy (CRRT).

CRRT flow sheets identified every four-hour documentation for CRRT from 10/21/22 at 8:00 PM to 8:00 AM on 10/22/22. CRRT was not documented after 6:00 PM on 10/22/22 to 10/23/22 at 11:00 AM (16 hours).

MD #1's progress notes dated 10/23/22 noted Patient #1's CRRT was held overnight as a result of staffing issues.


g. Patient #5 was admitted to the hospital on 10/12/22 with diagnoses that included significant mitral valve stenosis admitted for optimization prior to mitral valve replacement.

Physician orders dated 10/17/22 directed CRRT. CRRT flow sheets identified every four-hour documentation for CRRT from 10/21/22 at 4:00 AM to 8:00 AM on 10/22/22. CRRT was documented as off from 6:00 PM on 10/22/22 to 10/23/22 at 9:40 AM (9 hours and 40 minutes).

MD #1's progress notes dated 10/23/22 noted Patient #5's CRRT was held overnight as a result of staffing issues.

The staffing sheet for the cardiac intensive care unit (CICU) identified one RN #38 cared for three patients from 7:00 PM on 10/22/22 to 7:00 AM on 10/23/22 to include Patients #s 1 (CRRT), 5 (CRRT) and 74.

Interview with Assistant Manager #2 on 11/9/22 indicated usual CICU staffing is one RN to two patients unless a patient is unstable. Interview with Manager #3 on 11/17/22 at 10:30 AM stated postoperative open heart surgery patients, patients with extracorporeal membrane oxygenation (ECMO), Impella (medical devices used for temporary ventricular support), and CRRT should have a one patient to one nurse ratio (1:1) per protocol and in accordance with standards of practice. The hospital failed to ensure that Patient #1 and #5 received 1:1 care per protocol.

Interview with MD #1 on 11/10/22 at 1:00 PM identified Patient #1 and Patient #5 had minimal to no effects from withholding the CRRT on 10/22/22. MD #1 further noted the CRRT was held due to staffing issues, and this has happened in the past as well.


h. Patient #63 had a diagnosis of severe aortic stenosis and was admitted to the CICU following cardiac surgery on 10/20/22. Physician orders dated 10/21/22 directed a 2gm sodium diet and Patient #63 was able to participate in room service. Nursing flow records dated 10/22/22 indicated Patient #63 was incontinent of urine at 8:00 AM and could self- reposition. The flow records did not identify food intake for the breakfast and lunch meals.

Interview with RN #18 on 11/9/22 at 10:12 AM noted she was very busy the morning of 10/22/22, took care of Patient #5 who required CRRT and was very unstable. RN#18 stated she was also assigned to care for Patient #63 and was unable to "provide the care she wanted to". RN #18 further indicated Patient #63 had to lie on a "Chucks" (incontinent pad) and against the plastic mattress because there was no linen. She further indicated she was very busy and there was no nurse aide to assist with ordering meals and calling for linen.

Interview with Manager #3 on 11/17/22 at 10:30 AM stated, in part, patients receiving CRRT (Patient #5) should have a one patient to one nurse ratio per protocol.

Review of the staffing sheet dated 10/22/22 identified RN #18 was assigned to care for Patient #63 and Patient #5 who was receiving CRRT from 7:00 AM to 7:00 PM. On 10/22/22, the census was 16 and eight (8) RNs were working the day shift.

The Annual Hospital staffing plan identified the CICU will have 11 RNs and 2 unlicensed assistive personnel (nurse aides) for an average census of 16 patients.

The CICU failed to follow established staffing protocols on 10/22/22 to include 1:1 care of Patient #5 and meet the needs of Patient #63 due to short staffing.


i. Patient #9 was admitted on 10/27/22 with hypothermia and was on ECMO therapy. The staffing sheet dated 10/28/22 identified Patient #9 had been on a 1:1 from 7:00 AM to 7:00 PM and Assistant Manager #1 assumed the care of Patient #9 and Patient #10 from 7:00 PM to 11:00 PM.

Patient #4 was 42 years old, had a diagnosis of right pneumothorax with severe emphysematous changes and was admitted on 10/26/22. The operative note for 10/28/22 indicated Patient #4 had video assisted thoracoscopic surgery (VATS) on 10/28/22, was intubated and sent to the CICU in stable condition.

Interview with Assistant Manager #1 on 11/16/22 at 10:25 PM indicated she had to assume care of Patient #4 at 10:50 AM although she was caring for an ECMO patient, Patient #9 and Patient #10 due to short staffing. Assistant Manager #1 further identified Patient #4 had stable vital signs upon arrival to the unit, went back to care for her other two patients and did not document Patient #4's vital signs upon arrival to the unit. The Assistant Manager identified Patient #4's vital signs became unstable at 11:00 PM.

Interview with Manager #3 on 11/17/22 at 10:30 AM noted, in part, patients with ECMO should have a one patient to one nurse ratio per protocol and standard of care. Therefore, RN had a triple assignment while caring for Patient #9 who was on ECMO and who required 1:1 care.


j. Patient #66 arrived in the ICU on 10/28/22 at 1:04 PM after open heart surgery. Review of the staffing schedule identified that RN #27 was assigned to this patient, and also Patient #6 (3pm-7pm). Interview with Assistant Nurse Manager #1 stated an open-heart patient should be on a 1:1 (one RN to one patient) for at least the first 4 hours postoperatively and RN# 27 had a double assignment due to short staffing.


k. Patient #67 was admitted to the hospital on 10/20/22 following a cardiac arrest. Review of the CICU staffing assignments dated 10/28/22 from 7PM-7AM identified RN #30 was assigned to care for Patient #67 who had an Intra-aortic balloon pump (IAPB). At 7PM, RN #30 assumed the care of Patient #66 from RN #27.

Review of the CICU Acuity Model and interview with Assistant Nurse Manager #1 on 11/21/22 at 2:00 PM stated Patient #67 required 1:1 nursing because the patient had an IABP, however, needed to assign Patient #66 to RN #30 due to short staffing.


l. Patient #5 was admitted to the hospital on 10/12/22 with non-rheumatic mitral valve stenosis. Review of the CICU staffing assignments dated 10/28/22 identified RN #31 was assigned to care for Patient #5 from 7AM-7PM and the patient required CRRT. RN #31 was also assigned to care for Patient #68.

Review of the CICU staffing assignments dated 10/28/22 identified RN #32 was assigned to care for Patient #5 from 7PM-7AM and the patient required CRRT. RN #32 was also assigned to care for Patient #68.

Review of the CICU Acuity Model and interview with Assistant Nurse Manager #1 on 11/21/22 at 2PM stated Patient #5 required 1:1 nursing because the patient's treatment included CRRT, however, RN #31 and RN #32 had double assignments due to short staffing.


m. Patient #1 was admitted to the hospital on 9/29/22 with mitral regurgitation. Review of the CICU staffing assignments dated 10/28/22 identified RN #28 was assigned to care for Patient #1 from 7AM-7PM and the patient required CRRT. RN #28 was also assigned to care for Patient #8 from 7AM-11AM.

Review of the CICU staffing assignments dated 10/28/22 identified RN #33 was assigned to care for Patient #1 from 7PM-7AM and the patient required CRRT. RN #33 was also assigned to care for Patient #69 from 7PM-7AM.

Review of the CICU Acuity Model and interview with Assistant Nurse Manager #1 on 11/21/22 at 2PM stated Patient #1 required 1:1 nursing because the patient's treatment included CRRT, and the nurse's had two patients each.


n. Patient #9 was admitted to the CICU on 10/27/22 and was placed on ECMO. The staffing sheet dated 10/31/22 identified RN #20 and an orientee (RN #29) were assigned to care for Patient #9 from 7AM-3PM. During the 3PM-7PM shift, the Nurse Manager was assigned to care for the patient.

Interview with RN #20 on 11/9/22 at 11:15 AM identified she cared for Patient #9 on 10/31/22 and was precepting an orientee, RN #29. RN #20 indicated she had to leave RN #29 alone with Patient #9 to receive Patient #64 (post open heart) because Assistant Manager #2 was busy with Patient #65.

Interview with Nurse Manager #3 on 11/21/22 at 2PM stated she worked until 8:30 PM on 10/31/22 and RN #29 (orientee who was with the patient during the day and precepted by RN #20) was monitoring the patient. The Nurse Manager stated she and the Assistant Manager #2, who was also in charge and was assigned two patients' (Patient #39 and #65) rounded every 10 minutes.

Review of personnel files on 11/25/22 identified RN #29 was not signed off to care for a patient receiving ECMO as of 10/31/22. The review further identified Manager #3 was not trained in the management of patients receiving ECMO as of 10/31/22.


o. Patient #5 was admitted to the hospital on 10/12/22 with non-rheumatic mitral valve stenosis. Review of the CICU staffing assignments dated 10/31/22 identified Patient #5 was receiving CRRT, and RN #36 was assigned to care for the patient from 7AM-3PM. RN #36 was also assigned to care for Patient #49 for the same period of time rendering a double assignment.

Review of the staffing sheets with Nurse Manager #3 on 11/21/22 at 2PM stated Patient #5 required a 1:1 ratio as the patient was receiving CRRT.

In addition, further review of the assignment sheet identified Nurse Manager #3 was assigned to Patient #5 from 3PM-7PM and the patient continued to require CRRT. Although the Patient required 1:1 staffing, Nurse Manager was assigned to care for Patient #9 who was receiving ECMO and Patient #49, resulting in a triple assignment.

Interview with Nurse Manager #3 on 11/21/22 at 2:00 PM stated she worked until 8:30 PM on 10/31/22 and RN #36 stayed until 6:00 PM and cared for Patient #5. The Manager stated she turned, repositioned, and suctioned the patient and Assistant Manager did the 7PM charting for the ECMO treatment.

The personnel files reflected that Nurse Manager #3 was not fully trained in the management of patients receiving ECMO or CRRT as of 10/31/22.


p. Patient #5 was admitted to the hospital on 10/12/22 with non-rheumatic mitral valve stenosis. Review of the CICU staffing assignments dated 10/31/22 identified Patient #5 was receiving CRRT, and RN #37 was assigned to care for the patient from 7PM-11PM. RN #37 was also assigned to Patient #49 and #65 resulting in a triple assignment. At 11:00 PM, RN #37 had a double assignment (#5 and #65) until 7:00 AM.


q. Patient #65 was directly admitted to the CICU following open heart surgery on 10/31/22 at 10:19 AM. The staffing sheet dated 10/31/22 indicated Assistant Manager #2 was assigned to care for Patient #65 from 10:19AM until 3:00 PM.

The staffing sheet identified that Patient #64 was admitted to the CICU following open heart surgery on 10/31/22 at 1:38 PM and was assigned to Assistant Manager #2.

Interview with Assistant Nurse Manager #2 on 11/9/22 at 12:45 PM noted she received the two open heart patients in approximately 2 hours of each other and RN #20 left Patient #9 for a short time to help her settle Patient #64 because she was busy caring for Patient #65. Assistant Manager #2 identified one RN should not care for more than one fresh open-heart patient for the first four hours of receiving that patient. Assistant Manager #2 indicated that while she was busy with her two open heart patients, she had to help Manager #3 with Patient #5 and #49 with taking a glucose finger stick, drawing blood from an A-line and calculating the numbers for the CRRT.


r. Patient #70 was admitted on 10/26/22 following a cardiac arrest. Review of the assignment sheet dated 10/31/22 identified RN #34 was assigned to Patient #70 (had an Impella device) from 7AM-7PM and was also assigned to care for Patient #71. At 7PM, RN #35 assumed the care of Patients #70 and #71 until 7:00 AM (12-hour shift).

Interview with the Nurse Manager on 11/21/22 at 11:30AM stated this was a double assignment due to staffing shortage. Although nurses are called for availability it is sometimes difficult to fill the shifts.


s. Patient #67 was admitted on 10/20/22 following a cardiac arrest. Review of the assignment sheet dated 10/31/22 identified RN #25 was assigned to Patient #67 (required ECMO and CRRT) from 7PM-11PM and was also assigned to care for Patient #10 who transferred out of the unit at 11:07 PM.

Interview with the Nurse Manager on 11/21/22 at 11:30AM stated this was a double assignment due to staffing shortage.


t. Patient #73 arrived in the ICU on 10/31/22 at 1:36PM following a cardiac catheterization. Review of the assignment sheet identified that RN #27 was assigned to care for Patient #73 who had an IABP until 7PM. RN #27 was also assigned to care for Patient #72 from 7AM-7PM resulting in a double assignment.

Interview with the Nurse Manager on 11/21/22 at 11:30 AM stated this was a double assignment due to short staffing.

Interview with staff on 11/21/22 and 11/22/22, who wished to remain anonymous, stated staffing has been an ongoing concern and although Leadership is notified, short staffing remains a concern including one RN with multiple devices and double and triple assignments. One staff member stated s/he is unable to provide basic care, such as mouth care, due to short staffing.

Interview with the Chief Nursing Officer on 11/22/22 at 4:30 PM stated she was aware there were instances of staffing issues and multiple interventions are in place including in part; daily bed meetings, First Choice program (organization float pool), vendor management system (agency contracts for staffing), onboarding new staff and recruitment of staff are ongoing.

The Hospital Criteria, Nurse Manager Job Description identified the Nurse Manager is responsible and accountable for providing clinical and administrative leadership to an assigned patient care unit or department. The nurse manager obtains and allocates available resources to assure efficient, effective, and safe patient care.

Review of the Plan for Provision of Care, last revised 10/2015, identified the CICU is a 20-bed critical care unit that focuses on the care of patients requiring intensive cardiac monitoring. The delivery of care is achieved via a modified approach with the emphasis on quality and safety. The RN is the leader of the team, coordinating care, and focusing on quality outcomes. Patients are assigned based on level of acuity and staff competency. The Charge Nurse is responsible for making the patient assignments and staffing is adjusted on a every 4 hour basis based on activity and acuity of the unit. The staffing plan is reviewed on an annual basis and adjusted accordingly.


u. Patient #14 was admitted to the facility's Emergency Department (ED) on 8/29/22 at 3:51 PM with diagnoses to include alcohol intoxication and request for detoxification from ethyl alcohol (EtOH).

Review of Patient #14's history and physical dated 8/29/22 at 5:02 PM identified that the patient had a very unsteady gait, strong alcohol odor, poor coordination, and was aggressive with RN #5. The note identified that Patient #14 was brought to the behavioral health area of the ED for evaluation and was placed in a SOMA (net) bed for safety.

An Emergency Department (ED) provider note dated 8/29/22 at 5:45 PM identified the Physician was informed by RN #5 that Patient #14 cut his/her wrist and neck with a razor blade that the patient indicated was in his/her underwear and Patient #14 later identified that he/she swallowed the razor. The ED provider note identified Patient #14 was noted to have a laceration on the left side of the neck measuring 4 centimeters long by 2 millimeters deep and a laceration to right wrist measuring 4 centimeters long by 2 millimeters deep. The Provider note further identified direction to cover the wounds because Patient #14 was not cooperating for any sort of laceration repair, and to obtain radiographs to exclude ingestion of foreign body.

The RN ED note dated 8/29/22 at 6:40 PM identified that after the initial cutting RN #5 checked on Patient #14 and found additional bleeding from the wrist with a razor next to the patient on the bed. The RN note identified that Patient #14 reported having the razor the entire time. The RN note identified that the razor was not found when Patient #14 was searched between incidents.

The clinical record identified that after the second incident of cutting Patient #14 was placed on strict constant 1:1 observation.

Tour of the ED West Wing (Behavioral Health) and interview with RN #4 on 11/10/22 at 11:29 AM identified that it was not uncommon for the hospital to staff the area with only 1 RN which made it difficult to provide care to patients in a timely manner.

In an interview with RN #5 on 11/16/22 at 1:20 PM, RN #5 identified that on the day of the incident the Behavioral health wing may have had the maximum patient census (12 patients). RN #5 indicated that at times the area was staffed by 2 RNs but on the day of the incident RN #5 was the only RN assigned to the behavioral health wing. RN #5 indicated that it was the practice to remove a patient's clothing and perform a comprehensive body search when patients were admitted to the behavioral health area of the ED. RN #5 identified that there were issues with other patients and identified that when the safety checks were performed for Patient #14, she did not check under the underwear and may have missed the razor on 2 searches as there were many issues with other assigned patients. RN #5 indicated that having 2 RNs assigned to the behavioral health area would have been ideal to provide care to the patients.

A review of ED staffing for 8/29/22 against the Hospital's staffing plan with Manager #1 and Director #1 on 11/18/22 identified that the department was short staffed by 4 nurses for the 3:00 PM to 7:00 PM shift and 6 nurses for the 7:00 PM to 11:00 PM shift.

Review of the Behavioral Health Patient Search Process policy directed, a comprehensive body search would be conducted when the patient's clinical behavior indicates the need for a comprehensive search.


v. Patient #11 was admitted to the Emergency Department at 1:05 PM with a diagnosis of positive blood culture and triaged as Emergency severity Index (ESI) level 2 (Requiring reassessment every 2 hours or more frequently).

Review of the Emergency Department provider note dated 7/23/22 at 4:48 PM identified Patient #11 was recalled to the ED for abnormal blood cultures gram + Cocci with concerns for Methicillin resistant staphylococcus aureus (MRSA) identified in blood cultures of 7/21/22. The provider note identified repeat laboratory tests and intravenous antibiotics including Vancomycin and ceftriaxone were ordered.

The Physician's order dated 7/23/22 at 2:08 PM directed blood cultures, send prior dose of antibiotics. (Blood cultures sent prior to antibiotics treatment ensure the specific organism to target in treatment decisions are identified).

Review of Patient #11's laboratory results identified two blood cultures for Patient #11 were completed on 7/23/22 at 7:21 PM and a second at 8:16 PM (5 hours after physician's order).

Patient #11's clinical record identified the first dose of Vancomycin was administered at 2:14 AM on 7/24/22 (6 hours after the blood cultures were obtained).

An interview with RN #22 on 11/16/22 at 1:15 PM identified the delay with Patient #11's laboratory test, and initiation of antibiotics may have been lack of resource or human error. RN #22 indicated she was unable to recall Patient #11 but stated it may have been a very busy day as the department had nurses who were floated to the ED from other areas.

An interview with Director #1 on 11/16/22 at 10:24 AM indicated if a phlebotomist was not available it was the responsibility of the RN to obtain laboratory specimens in the Emergency room. Director #1 indicated all specimen draws were considered STAT (at once).

A review of the Emergency room staffing for 7/23/22 - 7/24/22 3:00 PM to 3:00 AM time period with Manager #1 and Director #1 on 11/18/22 identified the department was short by 4- 6 nurses.

The Hospital's laboratory call and panic values Policy directed Emergency/STAT specimens from receipt to test completion is 1 hour.

The medication ordering and Administration Policy directed medications need to be administered no later than one hour after the scheduled time.

The Hospital's RN job description directed the RN should execute the medical regimen under the direction of a licensed physician.


w. Patient #12 was admitted to the Emergency Department from another facility on 8/8/22 with a chief complaint of COVID Pneumonia.

Review of Patient #12's clinical record with Manager #1 on 11/10/22 at 1:08 PM identified that Patient #12 was admitted to the ED on 8/8/22 and remained in the ED until transferred to an inpatient unit on 8/9/22 (36 hours).


x. Patient # 18 presented to the Emergency Department (ED) at 10:48 AM with history of Crohns' disease, nephrolithiasis and with complaints of abdominal pain and vomiting.

The ED Provider History and physical dated 10/12/22 at 10:59 AM identified that upon presentation to the ED P #18 reported pain of 12 out of 10 and improved to 9 out of 10 with temporary relief provided by pain medications. The physical exam identified P #18 had generalized abdominal tenderness.

The ED Provider note dated 10/12/22 at 4:35 PM identified P #18's CBC were notable for leukocytosis with CT scan of the pelvis notable for 4 mm obstructing right side stone with hydronephrosis and peri-renal fluid suggestive of formiceal rupture.

The urology consult note dated 10/12/22 at 6:03 PM identified Leucocytes may be consistent with ureteral stone. The urology consult recommended that if symptoms were unable to be controlled with conservative measures urology would return to discuss possible right ureteral stent placement.

A physician's order dated 10/12/22 at 8:26 PM for P #18 directed CBC without differential STAT once, Unit to collect.

Review of P #18's laboratory orders and results identified CBC without differential ordered on 10/12/22 at 8:26 PM was collected on 10/13/22 at 2:10 AM ( 5 hours and 16 minutes after the physician's order was placed) and resulted at 3:46 AM.

A Physician's order dated 10/12/22 at 8:06 PM for P #18 directed Blood culture, bacterial STAT once, Unit to collect. Review of P #18's laboratory orders and results identified Blood culture ordered on 10/12/22 at 8:06 PM was collected on 10/13/22 at 2:10 AM (6 hours after the physician's order was placed)

Review of the Complete blood count (CBC) laboratory results from the 12:18 PM on 10/12/22 to 10/13/22 at 2:10 AM identified white blood cell count increase from 16.5 on 10.12/22 at 12:18 PM to 21.5 on 10/13 at 2:10 AM (normal range 4-10.5).

An operative note dated 10/13/22 at 8:27 PM identified P #18 underwent surgical procedures to include Cystoscopy, retrograde pyelogram, and right stent placement for hydronephrosis with obstructing stone.

An interview with RN # 9 ( P #18's nurse)on 11/18/22 at 11:13 AM identified that during the shift the department was chaotic. RN #9 identified she was busy, had other patients needing her attention. RN #9 stated she did not get the opportunity to check to ensure the labs were completed in a timely manner.

Review of the ED staffing for the period 7:00 PM to 3:00 AM on 10/12/22 to 10/13/22 with Manager #1 on 11/18/22 identified the department was short 6 nurses from 7 PM to 11:00 PM and 4 nurses 11:00 PM to 3:00 AM.

The Hospital's Critical tests and Critical Results policy directed that in- patient STAT requests will be drawn within 30 minutes of request and resulted within 1 hour.



16649





41683

Based on clinical record review, review of job descriptions, interviews, and review of hospital policies, for 5 of 32 patients reviewed for care and services, (Patient #3, #11, #13, #17, #18) the hospital failed to ensure adequate pressure relieving measures were implemented to prevent the development of a pressure ulcer, failed to ensure the patient's laboratory tests were completed in a timely manner consistent with the physician's orders, failed to ensure the patient with positive blood cultures had laboratory tests and antibiotic therapy initiated in a timely manner consistent with the physician's orders, and failed to ensure patient's pain was addressed consistent with the hospital's policy and practice. The findings include:


a. Patient #3 was admitted to the hospital on 10/14/22 for an elective left heart catheterization surgical procedure. The procedure notes dated 10/14 22 identified an emergent intra-aortic balloon pump (IABP) and Impella were placed during the cardiac catheterization procedure and Patient #3 was taken to the operating room (OR) for emergent surgical revascularization.

Patient #3's electronic record review on 11/17/22 at 12:30 PM noted Patient #3 had operative procedures performed in the OR on 10/17/22, 10/19/22 (ECMO placed), and 10/27/22.

The anesthesia note dated 11/4/22 indicated was called to bedside for an endotracheal tube change. The note further identified Patient #3 had an edematous posterior scalp from where the foam donut was used below the occiput.

The wound consult note dated 11/4/22 identified a deep tissue injury posterior head from the donut pillow.

Interview with the Patient Safety Coordinator on 11/16/22 at 9:05 AM indicated the head donuts are used for positioning in the OR. Interview with CICU Quality and Safety personnel on 11/16/22 at 9:30 AM noted the patient arrives from the OR with a head donut and the RN on the CICU should remove the head donut upon admission and replace it with a heart pillow (Z- Flo cushion).

The hospital policy entitled Extracoprporeal Membrane Oxygenation identified use a Z-Flo cushion as needed for occipital protection.


b. Patient #18 presented to the Emergency Department (ED) at 10:48 AM with history of Crohn's' disease, nephrolithiasis and with complaints of abdominal pain and vomiting.

The ED provider History and physical dated 10/12/22 at 10:59 AM identified that upon presentation to the ED Patient #18 reported pain of 12 out of 10 and improved to 9 out of 10 with temporary relief provided by pain medications. The physical exam identified Patient #18 had generalized abdominal tenderness.

The ED provider note dated 10/12/22 at 4:35 PM identified Patient #18's CBC were notable for leukocytosis with CT scan of the pelvis notable for 4 mm obstructing right side stone with hydronephrosis and peri-renal fluid suggestive of formiceal rupture.

The urology consult note dated 10/12/22 at 6:03 PM identified Leucocytes may be consistent with ureteral stone. The urology consult recommended that if symptoms were unable to be controlled with conservative measures urology would return to discuss possible right ureteral stent placement.

A physician's order dated 10/12/22 at 8:26 PM for P #18 directed CBC without differential STAT once, Unit to collect.

Review of Patient #18's laboratory orders and results identified CBC without differential ordered on 10/12/22 at 8:26 PM was collected on 10/13/22 at 2:10 AM (5 hours and 16 minutes after the physician's order was placed) and resulted at 3:46 AM.

A Physician's order dated 10/12/22 at 8:06 PM for Patient #18 directed Blood culture, bacterial STAT once, Unit to collect. Review of Patient #18's laboratory orders and results identified Blood culture ordered on 10/12/22 at 8:06 PM was collected on 10/13/22 at 2:10 AM (6 hours after the physician's order was placed)

Review of the Complete blood count (CBC) laboratory results from the 12:18 PM on 10/12/22 to 10/13/22 at 2:10 AM identified white blood cell count increase from 16.5 on 10.12/22 at 12:18 PM to 21.5 on 10/13 at 2:10 AM (normal range 4-10.5).

An operative note dated 10/13/22 at 8:27 PM identified Patient #18 underwent surgical procedures to include Cystoscopy, retrograde pyelogram, and right stent placement for hydronephrosis with obstructing stone.

An interview with RN #9 (Patient #18's nurse) on 11/18/22 at 11:13 AM identified that during the shift the department was chaotic. RN #9 identified she was busy, had other patients needing her attention, and did not get the opportunity to ensure the labs were completed in a timely manner.

Review of the ED staffing for the period 7:00 PM to 3:00 AM on 10/12/22 to 10/13/22 with Manager #1 on 11/18/22 identified the department was short 6 nurses from 7 PM to 11:00 PM and 4 nurses 11:00 PM to 3:00 AM.

The Hospital's Critical tests and Critical Results policy directed that in- patient STAT requests will be drawn within 30 minutes of request and resulted within 1 hour.


c. Patient #11 was admitted to the Emergency Department at 1:05 PM with a diagnosis of positive blood culture and triaged as Emergency severity Index (ESI) level 2 (Requiring reassessment every 2 hours or more frequently).

Review of the Emergency Department provider note dated 7/23/22 at 4:48 PM identified Patient #11 was recalled to the ED for abnormal blood cultures gram + Cocci with concerns for Methicillin resistant staphylococcus aureus (MRSA) identified in blood cultures of 7/21/22. The provider note identified repeat laboratory tests and intravenous antibiotics including Vancomycin and ceftriaxone were ordered.

The Physician's order dated 7/23/22 at 2:08 PM directed blood cultures, send prior dose of antibiotics. (Blood cultures sent prior to antibiotics treatment ensure the specific organism to target in treatment decisions are identified).

Review of Patient #11's laboratory results identified two blood cultures for Patient #11 were completed on 7/23/22 at 7:21 PM and a second at 8:16 PM (5 hours after physician's order).

Patient #11's clinical record identified the first dose of Vancomycin was administered at 2:14 AM on 7/24/22 (6 hours after the blood cultures were obtained).

An interview with RN#22 on 11/16/22 at 1:15 PM identified the delay with Patient #11's laboratory test, and initiation of antibiotics may have been lack of resource or human error. RN #22 indicated she was unable to recall Patient #11 but stated it may have been a very busy day as the department had nurses who were floated to the ED from other areas.

An interview with Director #1 on 11/16/22 at 10:24 AM indicated if a phlebotomist was not available it was the responsibility of the RN to obtain laboratory specimens in the Emergency room. Director #1 indicated all specimen draws were considered STAT (at once).

The Hospital's laboratory call and panic values Policy directed Emergency/STAT specimens from receipt to test completion is 1 hour.

The medication ordering and Administration Policy directed medications need to be administered no later than one hour after the scheduled time.

The Hospital's RN job description directed the RN should execute the medical regimen under the direction of a licensed physician.

A review of the Emergency room staffing for 7/23/22 - 7/24/22 3:00 PM to 3:00 AM time period with Manager #1 and Director #1 on 11/18/22 identified the department was short by 4- 6 nurses.


d. Patient #13 was admitted to the Hospital's Emergency room at 10:00 AM with complaint of vaginal bleeding and a pain score of 10 of 10.

Review of the ED provider note dated 9/18/22 at 10:08 AM identified Patient #13 presented with vaginal bleeding and presumed she was pregnant. The Provider note indicated Patient #13 reported suprapubic cramping, nausea, and vaginal bleeding x 1 day and stated she did not take any analgesics due to a question of pregnancy.

Review of Patient #13's urine pregnancy test performed on 9/18/22 at 10:16 AM resulted negative.

The ED orders for Patient #13 dated 9/18/22 at 10:14 AM directed ibuprofen tablet 600 mgs once.

The ED medications administration documentation identified ibuprofen 600 mgs was administered at 10:18 AM and identified Patient #13 had a pain score of 9 of 10 at the time of medication administration.

An ED provider note dated 9/18/22 at 10:32 AM identified the RN indicated Patient #13 was having a panic attack and was trembling and tearful. The note identified that after staff calmed the patient down Patient #13 asked to leave and left with her girlfriend.

The RN ED note date 9/18/22 at 11:05 AM indicated Patient #13 was no longer in the waiting room.

In addition, Patient #13 was admitted to the ED for the second time on 9/18/22 at 11:55 AM, brought in by ambulance with complaint of nausea and vomiting.

The ED RN note dated 9/18/22 at 12:00 PM identified Patient #13 arrived at the ED with complaints of nausea and vomiting and with a pain score of 7 of 10.

Review of the ED lab results dated 9/18/22 identified laboratory blood work was collected for Quantitative Human chorionic Gonadotropin (HCG) level, CBC, and Basic Metabolic Panel at 12:50 PM. HCG resulted less than 5 (negative for pregnancy).

Review of the ED administration documentation identified Patient #13 received Droperidol (for nausea) 0.62 mgs at 12:48 PM and ketorolac (for pain) 5 mgs intravenous on 9/18/22 at 1:07 PM.

An ED RN note dated 9/18/22 at 2:46 PM identified the RN went to Patient #13's room and patient was no longer in the room and identified patient was noticed by a bystander to leave the department with another person.

The ED note dated 9/18/22 at 2:50 PM identified that Patient #13's friend reported that Patient #13 was not receiving proper treatment and left.

Patient #13's clinical record lacked documentation pain reassessment was performed after administration of intravenous ketorolac.

An interview with Manager #1 on 11/18/22 at 11:45 AM identified it was the expectation patients in the Emergency department were assessed for pain with vital signs and prior to and after the administration of pain medication. Manager #1 indicated response to pain should be documented 1 hour after oral medications and 15- 30 minutes after intravenous medication.

Review of the Documentation of the Nursing Process and Care policy directed to document pain assessment on admission, with each assessment, and to document interventions provided and the post intervention response (time frames will vary based on the specific intervention and mode of administration)

The Hospital's patient Rights and Responsibilities policy directed patients have the right to appropriate assessment and management of pain.


e. Patient #17 was admitted to the emergency department with diagnosis of abdominal pain.

The ED provider note dated 11/9/22 at 6:25 AM identified Patient #17 presented to the Emergency Department for evaluation of abdominal pain and lightheadedness and reported chronic abdominal pain for the past 2 months which worsened after a colonoscopy procedure on the day the patient presented to the Emergency Department.

Review of Patient #17's surgical history and physical dated 11/10/22 at 12:01 AM identified Patient #17's gall bladder was significantly enlarged with evidence of stones and ongoing tenderness was concerning for cholecystitis with plan to consent and add on for surgery.

The physician's order dated 11/10/22 directed Hydromorphone 1 mg intravenous every 4 hours as needed for pain.

Review of Patient #17's medication administration documentation identified Patient #17 received Hydromorphone 1 mgs intravenous on 11/10/22 at 3:03 AM and at 9:00 AM.

Patient #17's clinical record lacked documentation assessment and documentation of pain levels were completed prior to and after the administration of intravenous Hydromorphone.

An interview with Manager #1 on 11/18/22 at 11:45 AM identified it was the expectation patients in the Emergency department were assessed for pain with vital signs and prior to and after the administration of pain medication. Manager #1 indicated response to pain should be documented 1 hour after oral medications and 15- 30 minutes after intravenous medication.

Review of the Documentation of the Nursing Process and care policy directed to document pain assessment on admission, with each assessment, and to document interventions provided and the post intervention response (time frames will vary based on the specific intervention and mode of administration)

The Hospital's patient Rights and Responsibilities policy directed patients have the right to appropriate assessment and management of pain.


41683

Based on clinical record review, job descriptions, interviews, and hospital policy review, for three of six patients reviewed for medication administration (Patient #1, #2, #11) the hospital failed to ensure the patients received medications timely. The findings include:


a. Patient #1 was admitted to the hospital on 9/29/22 with diagnoses that included congestive heart failure, mitral regurgitation, ventricular aneurysm, and chronic renal failure. Physician orders dated 10/10/22 directed Epinephrine intravenous (IV) infusion continuous at 13.1 ml/hr (discontinued on 10/30/22). Physician's orders dated 10/20/22 directed Norepinephrine intravenous infusion continuous at 3.6 ml/hr. (discontinued on 10/30/22). Patient #1's medication dispense record identified Norepinephrine was dispensed on 10/26/22 at 6:42 PM and the MAR lacked documentation that a new bag was hung at this time. Patient #1's medication dispense record or MAR dated 10/27/22 noted the IV Epinephrine was dispensed on 10/27/22 at 12:57 AM and hung at 1:04 AM. Although RN #26 documented on the MAR that she hung a bag of Epinephrine at 10:05 AM, the medication dispense record lacked documentation that the medication was dispensed during this time.

The incident report (Midas) dated 10/27/22 at 5:45 PM identified Patient #1's Norepinephrine was found on hold at approximately 4:00 PM, a second bag of Norepinephrine was infusing into a pump set for an Epinephrine infusion and Epinephrine was not infusing.

Review of staffing dated 10/27/22 identified RN #26 cared for Patient #1 from 7:00 AM to 3:00 PM and RN #23 provided care from 3:00 PM to 7:00 PM on 10/27/22.

Interview with RN #23 on 11/10/22 at 10:02 AM indicated she assumed care of Patient #1 around 4:00 PM on 10/27/22 and found two IV bags of Norepinephrine hanging. She identified the Norepinephrine connected to the pump programmed for Norepinephrine was on hold and a Norepinephrine IV was infusing into the pump set for Epinephrine. RN #23 noted a bag of Epinephrine was not hung or infusing. RN #23 identified she notified the Physician's Assistant and removed the incorrect bag of Norepinephrine, hung an IV bag of Epinephrine and restarted the Norepinephrine.

Interview with Manager #3 on 11/10/22 at 11:00 noted she visualized Patient #1 on 10/27/22 and two bags of Norepinephrine were hanging at the same time. Manager #3 further indicated she spoke with RN #26 and RN #26 recalled hanging a bag of IV Epinephrine at 10:05 AM on 10/27/22.

Interview with MD #3 (cardiac surgeon) on 11/16/22 at 12:15 PM noted Norepinephrine and Epinephrine were similar acting medications and Patient #1 did not have a negative outcome as a result of the error.

Further review of staffing dated 10/27 22 identified Patient #1 was receiving continuous renal replacement therapy (CRRT) and RN #23 and #26 cared for this patient and a second CICU patient, Patient #8.

Interview with Manager #3 on 11/17/22 at 10:30 AM noted patients receiving extracorporeal membrane oxygenation (ECMO), CRRT, or who have a balloon pump or impella (cardiac devices) should receive 1:1 nursing care. Patient #1 did not receive 1:1 care on 10/27/22 when the medication error was made.

The hospital Criteria Based Job Description- Registered Nurses identified job knowledge/experience included executing the medical regimen under the direction of a licensed physician.


b. Patient #2 was admitted to the hospital on 10/7/22 with diagnoses to include coronary artery disease, congestive heart failure, and stage III chronic kidney disease. The physician order dated 10/16/22 directed Lasix 100 mg/100 ml IV continuous at 10 ml/hour. The administration record identified RN #27 hung a new bag of IV Lasix at 10:04 AM on 10/16/22. Urine assessments dated 10/26/22 noted Patient #2's output from 12:01 AM to 6:00 PM was 5 ml to 10 ml per hour.

CICU staffing dated 10/16/22 indicated RN #28 assumed care of Patient #2 at 3:00 PM on 10/16/22 as well as two additional patients (Patients #50, #62).

Interview with RN #19 on 11/9/22 at 10:40 AM identified one evening was very busy, RN #28 had three patients, should not have had more than two patients, and Patient #2's Lasix IV ran dry. Interview with RN #25 on 11/16/22 at 9:50 noted she received report from P #2's nurse at 7:00 PM and found the Lasix IV pump turned off, Lasix was not infusing and turned the pump back on. RN #25 further indicated she immediately informed the Physician's Assistant and the Charge Nurse.

Interview with Manager #3 on 11/10/22 at 11:31 AM indicated she spoke with RN #28, RN #28 stated she would not turn off a continuous IV Lasix if the Lasix was ordered continuously.

Review of Patient #2's medical record and interview with the Respiratory Supervisor on 11/10/22 at 2:51 PM identified P #2 did not have a change in respiratory status due to the lack of Lasix medication on 10/16/22. Interview with MD #3 on 11/16/22 at 12:15 PM noted Patient #2 went into full blown renal failure 48 hours prior to the omission of the Lasix and the lack of 30mg of Lasix would not affect Patient #1 at all.

The hospital Criteria Based Job Description- Registered Nurses identified job knowledge/experience included executing the medical regimen under the direction of a licensed physician.


c. Patient #11 was admitted to the Emergency Department at 1:05 PM with a diagnosis of positive blood culture and triaged as Emergency severity Index (ESI) level 2 (Requiring reassessment every 2 hours or more frequently).

Review of the Emergency Department provider note dated 7/23/22 at 4:48 PM identified Patient #11 was recalled to the ED for abnormal blood cultures gram + Cocci with concerns for Methicillin resistant staphylococcus aureus (MRSA) identified in blood cultures of 7/21/22. The provider note identified repeat laboratory tests and intravenous antibiotics including Vancomycin and ceftriaxone were ordered.

The Physician's order dated 7/23/22 at 2:08 PM directed blood cultures, send prior dose of antibiotics. (Blood cultures sent prior to antibiotics treatment ensure the specific organism to target in treatment decisions are identified).

Review of Patient #11's laboratory results identified two blood cultures for P #11 were completed on 7/23/22 at 7:21 PM and a second at 8:16 PM (5 hours after physician's order).

Patient #11's clinical record identified the first dose of Vancomycin was administered at 2:14 AM on 7/24/22 (6 hours after the blood cultures were obtained).

An interview with RN#22 on 11/16/22 at 1:15 PM identified the delay with Patient #11's laboratory test, and initiation of antibiotics may have been lack of resource or human error. RN #22 indicated she was unable to recall Patient #11 but stated it may have been a very busy day as the department had nurses who were floated to the ED from other areas.

An interview with Director #1 on 11/16/22 at 10:24 AM indicated if a phlebotomist was not available it was the responsibility of the RN to obtain laboratory specimens in the Emergency room. Director #1 indicated all specimen draws were considered STAT (at once).

The Hospital's laboratory call and panic values Policy directed Emergency/STAT specimens from receipt to test completion is 1 hour.

The medication ordering and Administration Policy directed medications need to be administered no later than one hour after the scheduled time.

The Hospital's RN job description directed the RN should execute the medical regimen under the direction of a licensed physician.



41683