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Based on observation, interview, medical record review, and facility policy review, the hospital failed to ensure the effective delivery of nursing services to provide safe and quality care to patients when:

1. There was a lack of documented evidence of the delivery of nursing care according to physician orders, facility policy and standards to prevent complications following surgery for patients when:

A. For Patients 1, 2, 6, 7, 10, 28, 29, and 30, (8 of 33 sampled patients) there was a lack of consistent documented evidence that nursing staff applied Sequential Compression Devices (SCDs-medical device that uses inflatable cuffs to squeeze the legs and help prevent blood clots, also known as Intermittent Pneumatic Compression- IPC) to patients as ordered by physicians (refer to A0398);

B. For Patients 1, 2, 3, 5, 6, 7, 9, 14, 28, and 29 (10 of 33 sampled patients) there was a lack of consistent documented evidence that nursing staff ensured patients performed incentive spirometry (IS- deep breathing exercises using a device to improve lung function and prevent lung infections) as ordered by physicians (refer to A0398) and;

C. For Patients 26 and 32 of (2 of 33 sampled patients) Intravenous (IV, fluids given directly into the bloodstream) tubing and IV medications were not labeled according to facility policy (refer to A0398).

2. The facility failed to ensure one of 33 sampled patients (Patient 6), received prescribed and scheduled Advair (name brand) Fluticasone propionate/Salmeterol inhaler twice a day (indicated for maintenance treatment of asthma- a lung disease that makes breathing difficult) medication administration when:

A. Advair inhaler medication evening dose not administered for 3 days (refer to A0411);

B. Advair inhaler administration omissions were not reported as errors per facility policies and procedures (refer to A0411); and

C. No physician notification of the 3 missed Advair doses were documented. (refer to A0411)


These failures resulted in the potential for complications such as the potential for patients to develop blood clots, potential for infection in the lungs or blood which could result in longer hospitalization and poor outcomes. The failures contributed to Patient 6 missing inhaler medication doses as ordered with potential for worsening breathing and lung conditions and the missed opportunities to correct failures with proper reporting of medication errors.

The cumulative effect of these failures resulted in the hospital's inability to provide effective, safe and quality nursing services in accordance with the statutorily-mandated Conditions of Participation Nursing Services.

Based on interview and record review, the facility failed to demonstrate an effective grievance process when the investigation by Nurse Manager (NM) 3's findings in a grievance response letter (GRL) did not accurately reflect the documented nursing care provided for one of two sampled patients (Patient 1) and the Quality Department did not review the investigation.

This failure resulted in unsatisfactory resolution of the grievance, continued grief and mental anguish for Patient 1's family after her death, and a missed opportunity to evaluate and correct potential nursing care failures that may have contributed to Patient 1's outcome.

Findings:

In undated grievance letter from the family of Patient 1, the letter alleges, "...Long periods in which Intermittent Pneumatic Compression stockings (otherwise known as Sequential Compression Devices (SCDs)- a device that uses inflatable cuffs to squeeze the legs and help prevent blood clots) were not placed on [Patient 1] legs while she was in bed...and I witnessed staff repeatedly neglecting to keep the IPC (Intermittent Pneumatic Compression) devices on her legs for hours while she was in bed, specifically on the dates of 08/29- 08/30/22". The letter continued, "[Patient 1] CoD (cause of death) was listed on the autopsy report report as DVT (deep vein thrombosis - a blood clot) originating in her leg...However, no additional preventative measures nor tests appear to have been taken, and the preventative measures that were prescribed and required to be taken wee negligently administered.". The grievance asserted, "The care staff at the [Hospital Name] facility failed to mitigate risk, neglected to identify the clearly presented symptoms of DVT, and were derelict in their duty to uphold the standard of care to properly administer what preventative measures were available."

During a concurrent interview and record review with Member Services Director (MSD) on 2/5/25 at 1:40 p.m., the response letter regarding Patient 1's family's grievance letter, dated 1/29/25, was reviewed. GRL indicated "The Nurse Manager confirmed that based on documentation, Sequential Compression Devices (SCD) were applied to both of your mother's legs consistently from August 25, 2022 to August 29, 2022. Your mother began walking over 100 feet on August 29, 2022, so SCD were no longer indicated." The MSD stated letter was based on the investigation conducted by the unit's Nurse Manager (NM) 1.

During a concurrent interview and record review on 2/3/25 at 2:25 p.m., with Nurse Manager (NM 3) and Quality Nurse Consultant (QN 2), Patient 1's "Physician Admission Orders," dated 8/25/22 at 7:25 a.m. was reviewed. The Physician Admission Orders did not include any orders for chemoprophylaxis (the use of medications to prevent the formation of blood clots). The Physician Admission Orders indicated "Apply Sequential Compression Device (SCD- a specific type of intermittent compression device to prevent blood clots)."According to NM 3 and QNC 2, SCD documentation was to be done once per shift 8 hour nursing shift (AM shift, PM shift, and NOC (night) shifts). During a review of Patient 1's SCD nursing flowsheet documentation dated 8/25/22 to 8/31/22, the flowsheets revealed SCD documentation that SCDs were not applied on one of 3 shifts (NOC Shift) on 8/28 and not on 1 of 3 shifts (NOC shift) on 8/29/22. The flowsheet indicated there was no documentation on any shift for 8/30/22. NM 3 confirmed inconsistent nursing SCD's documentation.

During a further review of Patient 1's flowsheet it indicated Patient 1 ambulated on 8/29/22 with distances of "a little bit" and "0-20 feet" and one ambulation of a distance of over 100 feet. The flowsheet lacked documentation of ambulation on 8/30/22. NM 3 confirmed this documentation.

During a concurrent interview and record review with NM 1 on 2/5/25 at 4 p.m., Patient 1's flowsheet and GRL were reviewed. NM 1 acknowledged a discrepancy between the lack of documented evidence on the flowsheets of Patient's adequate ambulation and ordered application of SCDs and the inaccurate statements made in the GRL.

During an interview with Clinical Nursing Director (CND) on 2/6/25 at 10:45 a.m., CND indicated Patient 1's nursing care grievance investigation should have included review of physician orders and flowsheet documentation of both ambulation and SCD application. The CND stated she was aware NM 1 was conducting an investigation of Patient 1's care, NM 1 conducted the investigation independently, and the investigation was not reviewed by the Quality Department. CND acknowledged Patient 1 had an active order for SCD from 8/25/22 to 8/31/22, and Flowsheets lacked consistent documentation of ambulation of over 100 feet. The CND confirmed there was no order placed indicating SCDs were no longer indicated. The CND acknowledged statements in the GRL were not an accurate reflection of the documented nursing care.

During a review of the facility's policy and procedure (P&P) titled "Hospital Patient Grievance", created 4/26/2010 and last revised 1/10/24, it directed, "All written grievances are referred directly to Member Services, which resolves the grievance in the timeframe consistent with those outlined in policies under section 6.0 of this policy." Section 6.0 "References/Appendices" directed, "... In California the following policies apply: Non-Member Hospital Complaint Policy..."

During a review of the facility's P&P titled "California Non-Medicare Grievance and Appeals", dated 1/1/25, P&P indicated "Potential Quality of Care Issues: Grievances that contain one or more potential quality of care issues will be referred to the Quality Department for investigation and review."

During a review of the facility's P&P titled "Program-wide Non Member", with an effective date of 11/18/2019, Section 6.4 Investigation stipulated, "Potential quality of care issues: Grievances that contain one or more potential quality of car issues will be referred to the appropriate Health Plan department for independent investigation and review. The outcome of this review will remain confidential and will have no bearing on the decision of the case. The Quality Department's oversight process assures that there are effective quality assurance systems in place for the potential quality of care referral activities. These activities will be handled in a manner consistent with federal and state law..."

Based on observation, interview and record review, there was a lack of documented evidence that the facility ensured the delivery of nursing care according to physician orders, policy and standards to prevent complications following surgery when:

A. For eight (Patients 1, 2, 6, 7, 10, 28, 29, and 30) of 33 sampled patients, there was a lack of consistent documented evidence that nursing staff applied Sequential Compression Devices (SCDs-medical device that uses inflatable cuffs to squeeze the legs and help prevent blood clots, also known as Intermittent Pneumatic Compression- IPC) to patients as ordered by physicians.

B. For ten (Patients 1, 2, 3, 5, 6, 7, 9,14, 28, and 29) of 33 sampled patients, there was a lack of consistent documented evidence that nursing staff ensured patients performed incentive spirometry (IS- deep breathing exercises using a device to improve lung function and prevent lung infections) as ordered by physicians.

C. For two (Patients 26, 32) of two sampled patients, Intravenous (IV, fluids given directly into the bloodstream) tubing and IV medications were not labeled according to facility policy.

These failures had the potential for Patients 1, 2,3, 5, 6, 7, 9, 10, 14, 26, 28, 29, 30, and 32, to develop blood clots or infections in their lungs or blood which could result in longer hospitalization and may have contributed to post-surgical complications resulting in death for Patient 1.

Findings:

A. During a concurrent interview and record review on 2/3/25 at 2:25 p.m., with the Nurse Manager (NM 3) and the Quality Nurse Consultant (QNC 2), Patient 1's "History and Physical (H&P)," dated 8/25/22 was reviewed, the "H&P" indicated, Patient 1 was a transfer from another facility who had undergone a lumbar spinal fusion (lumbar spinal surgery to permanently join together two or more bones in the spine so there is no movement between them) surgery. Patient 1 developed a severe compressive hematoma (a localized collection of blood) requiring emergency wound evacuation of the hematoma.

During a concurrent interview and record review on 2/3/25 at 2:25 p.m., with the Nurse Manager (NM 3) and the Quality Nurse Consultant (QNC 2), Patient 1's "HBS Progress Note" for Hospital Day 1, signed by a physician on 8/25/22, revealed Patient 1, "...underwent hematoma evacuation. She denies taking blood thinning medication." and, "DVT (Deep Vein Thrombosis- a blood clot in the leg which can be caused by immobility post surgically) prophylaxis: Yes- SCD".

During a continued review of physician notes, a "Discharge Summary", dated 8/31/22 indicated, on Day 7 of hospitalization, Patient 1 was "in the process of walking 50 feet with [Physical Therapy] when she reported feeling nauseous and dizzy." Patient 1 then , "loss consciousness and a code blue (medical emergency - heart stopped or stopped breathing) was called. Unfortunately, [Patient 1] never recovered was was pronounced dead..."

Review of Patient 1's autopsy document titled, "Provisional Death Certification Sheet," dated 9/14/22, indicated, "CAUSE OF DEATH: A. ACUTE PULMONARY THROMBO-EMBOLISM [blood clot in the lungs], B. DEEP VEIN THROMBOSIS OF LEGS. C. STATUS, POST ORTHOPEDIC SPINAL SURGERY."

During a concurrent interview and record review on 2/3/25 at 2:25 p.m., with Nurse Manager (NM 3) and Quality Nurse Consultant (QN 2), Patient 1's "Physician Admission Orders," dated 8/25/22 at 7:25 a.m. was reviewed. The Physician Admission Orders did not include any orders for chemoprophylaxis (the use of medications to prevent the formation of blood clots). The Physician Admission Orders indicated "Apply Sequential Compression Device (SCD- a specific type of intermittent compression device to prevent blood clots)."According to NM 3 and QNC 2, SCD documentation was to be done once per shift 8 hour nursing shift (AM shift, PM shift, and NOC (night) shifts). During a review of Patient 1's SCD nursing flowsheet documentation dated 8/25/22 to 8/31/22, the flowsheets revealed SCD documentation that SCDs were not applied on one of 3 shifts (NOC Shift) on 8/28 and not on 1 of 3 shifts (NOC shift) on 8/29/22. The flowsheet indicated there was no documentation on any shift for 8/30/22. NM 3 confirmed a lack of evidence SCDs were applied.

During a concurrent interview and record review on 2/4/25 at 12:15 p.m., with NM 3 and QNC 1, Patient 2's "Discharge Summary," dated 9/5/22 was reviewed. The summary indicated, Patient 2 was admitted for management of an epidural abscess (a collection of pus in the spine) and underwent a lumbar laminectomy (surgical procedure that involves removing part of the lower back bone to relieve pressure on the spinal cord). Patient 2's Physician Admission Orders, dated 8/24/22 at 10:11 p.m., indicated "Apply Sequential Compression Device (SCD)". Review of nursing documentation of application of SCDs history, dated 8/25/22 to 9/5/22, showed inconsistent documentation. Flowsheets indicated, no SCD documentation on 8/27/22 and documentation only on 2 of three shifts on 9/3, 9/4 and 9/5. NM 3 confirmed a lack of evidence SCDs were applied.

During a concurrent interview and record review on 2/5/25 at 11:35 a.m., with Education Department Manager (EDM) and QNC 1, Patient 6's "History and Physical (H&P)," dated 8/25/22 was reviewed, the "H&P" indicated, Patient 6 had a history of asthma, sepsis (a serious condition in which the body responds improperly to an infection), and an epidural abscess. Patient 6's "Physician Admission Orders", dated 8/25/22 at 9:13 p.m. was reviewed. The Physician Admission Orders indicated, "Apply Sequential Compression Device (SCD)." Review of Patient 6's SCD Flowsheet documentation dated 8/25/22 to 8/31/22 indicated documentation SCDs were not applied for two of three shifts on 8/27, 8/28 and 8/29/22. Flowsheets indicated SCDs were not applied on two of 3 shifts on 8/30/22. EDM confirmed lack of evidence SCDs were applied.

During a concurrent interview and record review on 2/5/25 at 3:05 p.m., with EDM and QNC 1, Patient 7's "History and Physical (H&P)," dated 8/24/22 was reviewed, the "H&P" indicated, Patient 7 had a history of hypertension (high blood pressure), diabetes (blood sugar), deep vein thrombosis (blood clots), fusion of cervical spine, and breast cancer. Patient 7's Physician Admission Orders", dated 8/29/22 at 9:02 a.m. was reviewed. The Physician Admission Orders indicated "Apply Sequential Compression Device (SCD)." Review of Patient 7's SCD Flowsheet documentation dated 8/29/22 to 9/6/22 indicated, SCD documentation was missing on two shifts on 8/31, 9/2, 9/3. No SCD documentation on 9/4 and 9/5/22. EDM confirmed a lack of evidence SCDs were applied.

According to a review of Patient 10's "History and Physical (H&P)," Patient 10 was admitted for back pain and a back surgery on 8/30/22. During review of Patient 10's, "Orders," dated 8/30/22, the "Orders" indicated, "APPLY SEQUENTIAL COMPRESSION DEVICE (SCD)". During collaborative reviews of Patient 10's flowsheeys on 2/5/25 at 3:57 p.m. with NM 4, QNC 2, and Chief Nurse Executive (CNE), a lack of evidence SCDs were applied was confirmed with missing documentation of SCDs on 8/31/22 from 3:28 p.m. until 9/1/22 at 7:21 a.m., missing SCD documentation on 9/2/22 from 8:45 a.m. until 11:00 p.m., SCDs documented as "off" on 9/2/22 from 11:00 p.m. until 7:40 a.m. with no documented patient refusal or doctor notification, and SCDs documented as "off" on 9/3/22 from 4:15 p.m. until 9/4/22 at 7:30 a.m. with no documented refusal or doctor notification.

During another collaborative interview and review of Patient 10's flowsheets on 2/6/25 at 3:57 p.m. with NM 4 and QNC 2, inconsistent documentation for Patient 10's SCDs was again confirmed for the above dates and times and NM 4 confirmed that SCD refusal should be documented and the doctor notified, otherwise, SCDs should be left on when not ambulating or showering.

During an initial tour of 4 East on 2/3/25 at 10:26 a.m., an observation was made of Patient 28 lying in bed with no SCDs on.

A review of Patient 28's "History and Physical (H&P)," indicated Patient 28 was admitted 1/29/25 for Chronic Obstructive Pulmonary Disease (COPD, a chronic lung disease causing difficulty breathing), Respiratory Syncytial Virus (RSV, a virus that causes infection in the lungs), and Pneumonia (PNA, an infection/inflammation of the lungs). During collaborative reviews of Patient 28's flowsheets on 2/4/25 at 3:26 p.m. with Nurse Manager 4 (NM 4), Quality Nurse Consultant 2 (QNC 2), and CNE, inconsistent documentation for SCDs was confirmed for Patient 28 as no SCDs were documented from 2/2/25 at 0700 until 2/3/25 at 4:00 p.m. which is consistent with the Department's observations at 10:26 a.m. on 2/3/25. During review of Patient 28's, "Orders," dated 1/29/25, the "Orders" indicated, "APPLY SEQUENTIAL COMPRESSION DEVICE...Nurse: Ensure SCDs are properly used as ordered."

Patient 29's "History and Physical (H&P)," indicated they were admitted for back pain and had back surgery on 2/4/25. During review of Patient 29's, "Orders," dated 2/4/25, the "Orders" indicated, "APPLY SEQUENTIAL COMPRESSION DEVICE". During a concurrent interview and collaborative review of Patient 29's flowsheets on 2/4/25 at 4:01 p.m. with NM 4, QNC 2, and CNE, a lack of evidence SCDs were applied was confirmed for Patient 29 on 2/5/25 from midnight until 3:58 p.m.

A review of Patient 30's "History and Physical (H&P)," indicated they were admitted for back pain and back surgery on 1/30/2025. During review of Patient 30's, "Orders," dated 1/31/25, the "Orders" indicated to, "APPLY SEQUENTIAL COMPRESSION DEVICE..." During collaborative reviews of Patient 30's flowsheets on 2/4/25 at 4:24 p.m. with NM 4, QNC 2, and CNE, a lack of evidence SCDs were applied for Patient 20 was confirmed for 1/31/25 from 8:00 a.m. until 2/1/25 at 1:00 a.m., on 2/3/25 from 11:35 p.m. until 2/4/25 at 3:28 p.m.

During an interview on 2/4/25 at 4:01 p.m. with NM 4 and CNE, CNE and NM 4 confirmed that's SCDs are used to prevent blood clots and that if not on, the patient is at risk to develop a blood clot.

B. During a concurrent interview and record review on 2/3/25 at 2:25 p.m., with the Nurse Manager (NM 3) and the Quality Nurse Consultant (QN 2), Patient 1's "Physician Admission Orders", dated 8/25/22 at 7:25 a.m. was reviewed, the Physician Admission Orders indicated "Initiate Incentive Spirometry (IS) every 2 hours while awake." Review of IS flowsheet dated 8/25/22 to 8/31/22 indicated, inconsistent documentation of IS done every 2 hours as ordered.
Missing IS documentation:
8/26/22: 8:00 a.m., 10:00 a.m., 12:00 a.m. 2:00 p.m., 6:00 p.m.
8/27/22: 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m.., 8:00 p.m.
8/28/22: 9:00 a.m., 11:00 a.m., 1:00 p.m., 3:00 p.m.., 6:00 p.m., 8:00 p.m.
8/29/22: 10:00 a.m., 2:00 p.m., 6:00 p.m., 8:00 p.m.
8/30/22: 10:00 a.m., 1:00 p.m., 3:00 p.m., 7:00 p.m.
8/31/22: 12:00 p.m., 2:00 p.m.
NME confirmed Patient 1's nursing missing IS documentation.

During a concurrent interview and record review on 2/4/25 at 1:55 p.m., with the NM 3 and QN 1, Patient 2's Physician Admission Orders dated 8/25/22 at 5:02 a.m. was reviewed, the Physician Admission Orders indicated "Initiate Incentive Spirometry (IS) every 2 hours while awake." Review of IS flowsheet dated 8/25/22 to 9/5/22 indicated inconsistent documentation of IS done every 2 hours as ordered.

Missing IS documentation:
8/25/22: 10:00 a.m., 12:00 p.m., 2:00 p.m., 6:00 p.m., 10:00 p.m.
8/26/22: 10:00 a.m., 12:00 p.m., 2:00 p.m., 10:00 p.m.
8/27/22: 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m., 6:00 p.m., 10:00 p.m.
8/28/22: 10:00 a.m., 12:00 p.m., 2:00 p.m., 8:00 p.m.,10:00 p.m.
8/29/22: 7:00 a.m., 11 a.m., 3:00 p.m., 7:00 p.m., 9:00 p.m.
8/30/22: 11:00 a.m., 1:00 p.m., 3:00 p.m., 7:00 p.m., 9:00 p.m.
8/31/22: 11:30 a.m., 1:30 p.m., 3:30 p.m., 5:30 p.m., 7:30 p.m.
9/1/22: 8:00 a.m., 10: a.m., 3:00 p.m., 5:00 p.m., 7:00 p.m., 9:00 p.m.
9/2/22: 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., 8:00 p.m.
NM 3 confirmed Patient 2's nursing IS missing documentation.

During a concurrent interview and record review on 2/4/25 at 2:15 p.m., with NM 3 and QN 1, Patient 3's "Discharge Summary (DS)", dated 8/26/22 was reviewed, the DS indicated Patient 3 was admitted for a lumbar laminectomy. The "Physician Admission Orders," dated 8/23/22 at 1:59 p.m. was reviewed, the Physician Admission Orders indicated "Initiate Incentive Spirometry (IS) every 2 hours while awake." Review of IS flowsheet dated 8/23/22 to 8/25/22 indicated inconsistent documentation of IS done every 2 hours as ordered.

Missing IS documentation:
8/24/22: 9:00 a.m., 11:00 am., 10:00 p.m.
NM 3 confirmed Patient 3's missing IS documentation.

During a concurrent interview and record review on 2/4/25 at 3:25 p.m., with NM 3 and QN 1, Patient 5's "Discharge Summary (DS)", dated 9/2/22 was reviewed, the DS indicated Patient 5 was admitted for worsening back pain, worsening epidural abscess and underwent a lumbar laminectomy. Review of IS flowsheet dated 8/26/22 to 9/2/22 indicated inconsistent documentation of IS done every 2 hours.

Missing IS documentation:
8/27/22: 10:00 a.m., 12:00 p.m.
8/30/22: 10:00 a.m., 12:00 p.m., 2:00 p.m., 9:00 p.m.
8/31/22: 8:00 a.m., 10:00 a.m., 12:00 p.m., 2:00 p.m.
9/1/22: 12:00 p.m., 2:00 p.m., 6:00 p.m., 8:00 p.m.
9/2/22: 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., 6:00 p.m., 8:00 p.m.
NM 3 confirmed Patient 5's nursing IS missing documentation.

During a concurrent interview and record review on 2/5/25 at 11:35 a.m., with EDM and QNC 1, Patient 6's "Physician Admission Orders", dated 8/25/22 at 3:44 p.m. was reviewed, the Physician Admission Orders indicated "Initiate Incentive Spirometry (IS) every 2 hours while awake." Review of IS flowsheet dated 8/25/22 to 9/1/22 indicated inconsistent documentation of IS done every 2 hours as ordered.
NM 3 confirmed inconsistent documentation of IS by nursing.

Missing IS documentation:
8/27/22: 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., 6:00 p.m.,
8/28/22: 10:00 a.m., 12:00 p.m., 2:00 p.m., 6:00 p.m.
8/29/22: 6:00 p.m., 8:00 p.m., 10:00 p.m.
8/31/22: 10:00 a.m., 12:00 p.m.,
9/1/22: 10:00 a.m., 12:00 p.m., 2:00 p.m., 4:00 p.m., 6:00 p.m.
EDM confirmed Patient 6's nursing inconsistent and missing IS documentation.

During a concurrent interview and record review on 2/5/25 at 3:05 p.m., with EDM and QNC 1, Patient 7's "Physician Admission Orders", dated 8/29/22 at 9:25 p.m. was reviewed, the Physician Admission Orders indicated "Initiate Incentive Spirometry (IS) every 2 hours while awake." Review of IS flowsheet dated 8/29/22 to 9/5/22 indicated inconsistent documentation of IS done every 2 hours as ordered. The following indicated dates and frequency IS was documented and not every 2 hours as ordered:

8/31/22: One documented IS.
9/1/22: Three documented IS.
9/2/23: Three documented IS.
9/3/22: Three documented IS.
9/4/22: Two documented IS.
9/5/22: Three documented IS.
EDM confirmed Patient 7's missing nursing IS documentation.

During a review of Patient 14's "History and Physical" (H&P), dated 1/28/25, the H&P indicated Patient 14 was admitted 1/28/25 with pneumonia (infection in the lungs). Patient 1's medical history included lung cancer, lung resection (a surgical procedure where a diseased part of the lung is removed) and chronic obstructive pulmonary disease (COPD, lung disease that cause airflow obstruction and breathing problems). During a review of Patient 14's "Orders", dated 1/28/25, indicated "Initiate incentive spirometry 10 breaths every two hours while awake..."

During a concurrent interview and record review with Nurse Manager (NM) 3 on 2/4/25 at 1:22 p.m., Patient 14's Care Plan (CP), initiated on 1/28/25, was reviewed. CP indicated nursing team was to initiate cough-enhancement and airway-clearance techniques. NM 3 stated incentive spirometry was a cough-enhancement and airway-clearance technique and according to the order, it should be done every two hours during patient's wake cycle, at least eight times per calendar day.

During continued concurrent interview and record review with NM 3 on 2/4/25 at 1:22 p.m., Patient 14's flowsheet (FS) was reviewed. The Flowsheet indicated the dates and and times IS was documented and not every 2 hours as ordered:
1/30/25 7:48 a.m.
1/30/25 9:05 a.m.
1/30/25 11:01 a.m.
1/30/25 11:47 p.m.
1/31/25 7:30 a.m.
1/31/25 8:00 a.m.
1/31/25 8:54 a.m.
1/31/25 11:18 p.m.
NM 3 confirmed there were gaps in documentation of IS use as ordered by the physician or indicated on the CP.

A review of Patient 28's "History and Physical (H&P)," indicated Patient 28 was admitted 1/29/25 for Chronic Obstructive Pulmonary Disease (COPD, a chronic lung disease causing difficulty breathing), Respiratory Syncytial Virus (RSV, a virus that causes infection in the lungs), and Pneumonia (PNA, an infection/inflammation of the lungs).

During review of Patient 28's, "Orders," dated 1/29/25, the "Orders" indicated, "INITIATE INCENTIVE SPIROMETRY EVERY 2 HOURS WHILE AWAKE." During a collaborative review of Patient 28's flowsheet on 2/4/25 at 3:43 p.m. with NM 4, QNC 2, and CNE, Patient 28's IS was confirmed with inconsistent and missing documentation on:

1/30/25: 7:00 a.m., 9:00 a.m., 11:00 a.m., and 1:00 p.m., 5:00 p.m., 7:00 p.m., and 9:00 p.m. ;
1/31/25: 9:00 a.m., 11:00 a.m., 1:00 p.m., 3:00 p.m., 7:00 p.m., and 9: 00 p.m. ;
2/1/25: Missing documentation between 8:20 a.m. and 12:15 p.m., missing documentation between 12:15 p.m. and 4:22 p.m.,7:00 p.m. and 9:00 p.m. ;
2/2/25: 11:00 a.m., 1:00 p.m., 5:00 p.m.., 7:00 p.m., 11:00 p.m.; and
2/3/25: 10:00 a.m. and 1:21 p.m., and 9:00 p.m.

During an interview 2/4/25 at 3:59 p.m. with CNE, CNE stated that documentation was inconsistent in patient 28's mediical record and that IS was done as preventative measures to prevent complications such as pneumonia.

Patient 29's "History and Physical (H&P)," indicated they were admitted for back pain and had back surgery on 2/4/25. During review of Patient 29's, "Orders," dated 2/4/25, the "Orders" indicated, "INITIATE INCENTIVE SPIROMETRY Encourage cough and deep breathing EVERY 2 HOURS WHILE AWAKE." During a collaborative review of Patient 29's flowsheets on 2/4/25 at 4:01 p.m. with NM 4, QNC 2, and CNE, Patient 29's IS was confirmed with inconsistent and missing documentation on:

1/31/25: 9:00 a.m., 11:00 a.m., 1:00 p.m., 3:00 p.m., 7:00 p.m., 9:00 p.m.
2/1/25: 10:00 a.m., 2:00 p.m., 6:00 p.m., and 8:00 p.m.
2/2/25: 11:00 a.m., 1:00 p.m., 5:00 p.m., 7:00 p.m., 9:00 p.m., 11:00 p.m.
2/3/25: 8:00 a.m., and 12:00 p.m.


Patient 9's "History and Physical (H&P)," indicated they were admitted for back pain and had back surgery on 8/30/22. During review of Patient 9's, "Orders," dated 8/30/22, the "Orders" indicated, "INITIATE INCENTIVE SPIROMETRY 10 breaths EVERY 2 HOURS WHILE AWAKE." During a collaborative review of Patient 9's flowsheet on 2/5/25 at 10:49 a.m. with NM 4, QNC 2, and CNE, Patient 34's IS was confirmed with inconsistent and missing documentation on:

8/31/22: 11:00 a.m.
9/1/22: 8:39 a.m. and 12:30 p.m.,12:30 p.m. and 3:50 p.m.
9/3/22: 11:00 a.m., 1:00 p.m., 5:00 p.m., 7:00 p.m., 9:00 p.m., and 11:00 p.m.

During a review of the facility's policy and procedure (P&P), titled, "Basic Unit Care Standards for Medical/Surgical," dated 1/24, the P&P indicated, "5.2.13 Ensure patient's use of the Incentive Spirometer every 2 hours per shift ...5.2.19 Sequential Compression Devices will be removed at bath time and/or at least once per shift."

During a review of the facility's Clinical Pathways and Standards of Practice (CP-SOP) titled "Postoperative care", dated 2025, CP-SOP indicated standard postoperative care for general surgeries included "coughing and deep-breathing exercises ... and incentive spirometry use as indicated and prescribed" and "venous thromboembolism (VTE, a condition where a blood clot forms in a vein) prophylaxis [prevention], such as using sequential compression sleeves or boots [device]according to the practitioner's order".

During a review of the facility's Competency Evaluation titled, "PATIENT CARE SERVICES-VALLEY Competency Evaluation Clinical and Professional Performance REGISTERED NURSE," undated, the Competency Evaluation indicated, "The nurses demonstrates competency by: Managing a standard patient care assignment integrating multiple Standards of Care/Clinical Pathways and Standards of Practice ...Providing a safe environment ...Implementing and evaluating the Standard of Practice for: ...4. documentation."

During a review of the facility's Standard of Practice titled, "STAT!Ref Postoperative care," undated, the Standard of Care indicated, " ...Continue venous thromboembolism (VTE) prophylaxis, such as using sequential compression sleeves or boots, according to the practitioner's order or facility protocol. Encourage coughing and deep-breathing exercises... and incentive spirometer use, as indicated and prescribed."

During a review of the facility's policy titled "Basic Unit Care Standards for Medical/Surgical (BUS M/S)," dated 6/21 and 11/24, the BUS /MS indicated, ... "Ensure patient's use of the Incentive Spirometer every 2 hours while awake, unless contraindicated. ...Sequential compression devices will be removed at bath time and/or at least once per shift."

C. During an initial tour of 1 West on 2/3/25 at 9:38 a.m., an observation was made of Patient 26 sitting in the hallway in a chair and connected to an IV pole that had two IV bags hanging on it. The primary and secondary IV tubing was observed not having labels with infusion names, expected change dates and times on them.

During an interview with Nurse Manager 2 (NM 2) on 2/3/25 at 9:38 a.m., NM 2 stated that IV tubing should be labeled with date, time, and nurse's initials.

During an initial tour of 4 West on 2/3/25 at 10:21 a.m., an observation was made of Patient 32 lying in bed with a primary and secondary IV hung on the IV pole with no labels indicating infusion names, expected change dates and times.

During an interview with Registered Nurse 7 (RN 7) on 2/3/25 at 10:26 a.m., RN 7 acknowledged that IV bags were supposed to be labeled with the patient's name and date hung and that medication labels were missing. RN 7 also confirmed that IV tubing needs a label showing when to change and confirmed that the IV tubing was not labeled with change date or time for Patient 32.

During review of facility policy titled, "Vascular Access NCAL Regional Policy," dated 9/24, the policy indicated that, " ...5.6.10.1. Note: all tubing must be labeled with expected change date and time. Infusion name label is also recommended."

During a review of the facility's Competency Evaluation titled, "PATIENT CARE SERVICES-VALLEY Competency Evaluation Clinical and Professional Performance REGISTERED NURSE," undated, the Competency Evaluation indicated, "The nurses demonstrates competency by: Managing a standard patient care assignment integrating multiple Standards of Care/Clinical Pathways and Standards of Practice ...Providing a safe environment ...Implementing and evaluating the Standard of Practice for: ...2. infection control 3. intravenous infusions 4. documentation 5. medication administration ..."

During a review of the facility's Standard of Practice titled, "STAT!Ref IV therapy preparation," undated, the Standard of Care indicated, " ...Label the IV bag with the patient's name and identification number, date and time, the bag number (if applicable), ordered rate and duration of infusion, and your initials ...Label the IV administration set tubing with the date of initiation or the date when change is required ..."

Based on observation, interview and record review the facility failed to ensure one of 35 sampled patients (Patient 6), received prescribed and scheduled Advair (name brand) Fluticasone propionate/Salmeterol inhaler twice a day (indicated for maintenance treatment of asthma- a lung disease that makes breathing difficult) medication administration when:

1. Advair inhaler medication evening dose not administered for 3 days;

2. Advair inhaler administration omissions were not reported as errors per facility policies and procedures; and

3. No physician notification of the 3 missed Advair doses were documented.

These failures resulted in Patient 6 missing three scheduled medication inhaler doses as ordered and the potential for Patient 6 worsening breathing and lung conditions and missed opportunities to correct failures with proper reporting of medication errors. .

Findings:

During a review of Patient 6's "History and Physical (H&P)," dated August 25, 2022, the "H&P" indicated, Patient 6 had a history of asthma.

During a review of Patient 6's "Medication Administration Record (MAR)," the MAR indicated "Advair/Wixela (generic name) 250-50 mcg/dose (microgram- a unit of measurement) Diskus Inhaler 1 puff 2 times a day."

Patient 6's MAR dated 8/25/22 indicated, "Advair/Wixela 250-50 mcg dose Diskus Inhaler 1 Puff 2 Times A Day 2126 (9:26 p.m.). Not Given."

Patient 6's MAR dated 8/27/22 indicated, "Advair/Wixela 250-50 mcg dose Diskus Inhaler 1 Puff 2 Times A Day. 1820 (6:20 p.m.). Not Given."

Patient 6's MAR dated 8/28/22 indicated, "Advair/Wixela 250-50 mcg dose Diskus Inhaler 1 Puff 2 Times A Day. 2215 (10:15 p.m.). Not Given."

During a concurrent interview and Patient 6's MAR review on 2/5/25 at 11:15 a.m., with the Pharmacist 1 and the Respiratory Therapy Assistant Manager (RTAM), the Pharmacist 1 and RTAM confirmed the Advair medication evening doses were not administered on 8/25/22, 8/27/22, and 8/28/22 and confirmed no physician notification was documented.

During an interview on 2/5/25 at 12 p.m., with the Quality/Risk Director (QRD), the QRD stated that the Quality Department had no reported electronic Responsible Report (eRRF - internal facility self-reporting process of incidents) for Patient 6. QRD further indicated that it is the expectation that the staff complete an eRRF when the event meets the facility reporting criteria such as omissions.

During a review of the facility's policy titled "Respiratory Therapy Treatment Protocol (RTTP)," dated 2/24/21, the RTTP indicated, "Respiratory Therapy Protocols will be initiated by Respiratory Care Practitioners (RCP's) upon receipt of any physician order for Respiratory Care ...RCP's will initiate the Protocol process within one hour of receipt of a physician's order ... A patient's participation in the protocols may be discontinued by a physician writing an order to "Discontinue or Cancel Respiratory Therapy Protocols."

During a review of the facilities policy titled "Basic Unit Care Standards for Medical Surgical (BUCS MS)," dated 6/22/21, the BUCS MS indicated, ... "Administer medication as ordered and assess patient's response. ...Consult with provider for dosage/frequency adjustment to meet Patient's needs."

During a of the facility's policy titled "Medication Administration (MA)," dated 4/13/21, the MA indicated, ... " the licensed personnel administering medications must follow the physician's Admin [administration] Instructions detailed under the medication listed on the electronic MAR ...Doses delayed so excessively that the next dose becomes due shall be considered omission errors ...Report all medication errors, including near misses via the responsible reporting (RRF/eRRF) methods."

During a review of the facility's policy titled "Responsible Reporting of Medical Errors, Adverse Events, and Near Misses (RRME/AE&NM)," dated 7/12/22, the RRME/AE&NM indicated, "Report all medical errors ...and near misses so that systems and processes can be improved and future errors, adverse events and/or near misses prevented. ... All employees ...will complete an electronic Responsible Reporting Form ...witnessing, discovering or most familiar with the event. Examples of adverse events or near misses include the following: Medication-related errors ...prescription order communications ...administration."