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Based on observation, interview and record review, the facility failed to provide the preferred language for the care and treatment for blood transfusion (a procedure in which blood is put into a patient's bloodstream through a vein) provided for two (2) of thirty sampled patients (Patient 5 and Patient 12) according to facility policy and procedure. Patient 5 and Patient 12 indicated their primary language was Spanish.

This deficient practice resulted to Patient 5 and Patient 12 not receiving a consent for blood transfusion and blood transfusion information in Spanish. The deficient practice had the potential for ineffective communication for care and treatments provided to Patient 5 and Patient 12.

Findings:

1. A review of patient 5's History and Physical (H &P), demonstrated that Patient 5 was admitted for hemoptysis (coughing up blood) and ecchymosis (bruising), thoracic compression fracture (when a bone in the spine collapses in the thoracic spine (the middle portion of the spine)), and normocytic anemia (anemia is a blood problem having a low number of red blood cells).

Additional record review of Patient 1's Admission Assessment of preferred language, on 03/21/2023 at 10:09 AM, indicated Patient 1's preferred language was Spanish.

A review of a document titled "Condition of Service" demonstrated that Patient 5, on 03/14/2023 at 12:20 PM, initialed and signed the English form of the consent for hospital admission demonstrating no documentation of translator services used when consent was signed.

During an observation and concurrent interview on 03/20/2023 at 11:57 AM, Patient 5 was observed in his room, conversing in Spanish language over the phone. The nurse was observed removing IV tubing. During an interview with Patient 5, he stated he just received blood products and stated he came to the hospital because of a big bruise on his right side of the body and bleeding. Patient 5 stated his English was not good and then asked for a Spanish speaking person to translate if more details about his treatment and care were needed. Patient 5 stated and verbalized his preferred language was Spanish.

During an interview on 03/20/2023 at 11:59 AM, Registered Nurse 2 (RN 2) stated Patient 5 was admitted with bruising and coughing up blood and just received cryoprecipitate (blood product). RN 2 stated the consent for the procedure was obtained by the hospitalist.

During an interview and concurrent record review of Patient 5's Authorization and Informed Consent to Blood Component Transfusion in English, on 03/20/2023 at 12:00 PM, Charge Nurse (CN) provided a copy of Patient 5's Authorization and Informed Consent to Blood Component Transfusion in English. The Informed Consent was signed by Patient 5, on 03/20/2023 at 09:24 AM. CN confirmed that Patient 5's consent was obtained in English.

During an interview on 03/21/2023 at 09:33 AM, Unit Manager stated the process for obtaining consents was for the doctors prepare, obtain consents for treatments, procedures, and provide explanation to the patient. The Unit Manager stated patients whose preferred language is different from that of English language were expected to be provided with translator services. The Unit Manager stated she did not know what the facility's policy stated pertaining to obtaining consents in different than English languages and using interpretive services. The Unit Manager stated, Nurses were expected to provide consents written in the primary spoken languages. Unit Manager stated if available on hospital's intranet an interpretive service would be provided at no cost to patients.

During an interview and concurrent record review on 03/21/2023 at 09:40 AM, the facility verified the availability of Spanish written consents currently used by the facility. During a concurrent interview, the Unit Manager stated that nurses were expected to assess the language skills of the patient on admission, every shift, and as needed and update the primary language preferences in electronic medical records (EMR) as needed.

During an interview on 03/21/2023 at 9:41 AM, with the Unit Manager, she stated when a translator service was utilized, a confirmation number was to be generated on the consent form.

During an interview on 03/21/2023 at 9:44 AM, Director of Service Lines and Medical Surgical Unit (DSM), stated if the patient was to express the desire to use interpretive services, such services were to be provided to the patient as per facility's policy. The DSM also stated that if the form was available in the preferred language as requested by the patient, the form was to be provided as well. She stated, "Currently, the facility had two, English and Spanish forms of consent for Blood Transfusion on the hospital's intranet."

During an interview and concurrent record review, on 03/21/2023 at 09:48 AM, facility had an Authorization and Informed Consent to Blood Component Transfusion form available in Spanish language, including a copy of the brochure, "A Patient's Guide to Blood Transfusions." The Authorization and Informed Consent to Blood Component Transfusion brochure printed concurrently when consent was printed. This process was verbally verified with the Director of Service Lines and Medical Surgical Unit.

A review of the policy and procedure (P& P) titled, "Consent to Treatment-Obtaining and Verifying," last revised 9/27/2022, section "Foreign Language Consent," indicated foreign language consents may be obtained by the provider though interpreter services company 24/7 with documentation on the consent form or progress note identifying the person interpreting and that person's position/title or relations to the patient. When utilizing the interpreter services, also documentation the identification (ID) number in the progress note was required. a) Consents written in Spanish are available on the hospital intranet.

2. During an observation on 3/20/2023 at 12:25 PM, Patient was observed in bed and a unit of blood (quantity of blood components to be infused into patient who, typically, have low amount of oxygen carrying blood cells) was hanging from an IV pole (metal pole able to hold transfusable fluids like antibiotics or blood).

During an interview on 3/20/2023 at 12:27 PM, Patient 12 stated that patient rights were presented to her upon admission to the facility. Patient 12 said that there are many nurses in the facility that speak Spanish, which she stated was her primary language. These statements were provided through the facility's call-in translation service. Patient 12 stated the procedure (blood transfusion) was explained to her by a Spanish speaking nurse. Patient 12 stated the blood transfusion had just started.

During a record review of Patient 12's signed Authorization and Informed Consent to Blood Component Transfusion, including the document information indicating common reason for, benefits of, and risks of blood transfusion, dated 3/20/2023 at 12:43 PM, the consent and document information were in English.

During an interview on 3/21/2023 at 9:35 AM, the Nurse Manager stated physicians usually discuss the prescribed procedures with the patient, and the consent for said procedure was usually signed with the help of a translator service if the patient does not speak English. The Nurse Manager stated she was not sure why a Spanish speaking patient would sign a consent for transfusion that was written in English.

During an interview on 3/21/2023 at 9:37 AM, Clinical Informatics Tech stated consent forms were available in 20 different languages.

A review of the facility's P&P for Interpreter Services Policy, last revised on 04/26/2022, indicated the hospital to provide effective communication to patients who have difficulty communicating for any reason. The policy also indicated to provide for communication of information contained in vital documents including but not limited to, waivers of rights, consent to treatment, and other documents necessary to continue care.

Based on observation, interview and record review, the facility failed to ensure licensed nurses provide nursing care for three (3) out of thirty (30) sampled patients (Patient 1, Patient 4, and Patient 9). The facility failed to:

1. Respond to the Patient 1's telemetry reading (display of the patient's heart rhythm, respiratory rate, and oxygen saturation on a monitor or screen) of low oxygen saturation (fraction of oxygen-saturated blood cells in the blood) in a timely manner.

This deficient practice resulted to led to three-minute delay for the Code Blue team (a medical team that responds to a possible cardiac or respiratory arrest) to response to Patient 1's low oxygen saturation level experienced by Patient 1, on 12/22/2021 at 10:20 p.m.

2. Manage Patient 4's pain after having a right ankle surgery after a fall by not providing alternative measures and providing accurate information of care provided to manage Patient 4's pain.

This deficient practice resulted to Patient 4 having constant pain and had the potential to cause the patient significant discomfort, negatively affecting Patient 4's limiting the ability to participate in physical therapy.

3. Provide off-loading (minimizing or removing weight or pressure) and reposition every two hours for Patient 9, who had pressure ulcer wounds (an injury that breaks down the skin and underlying tissue caused when an area of skin is placed under pressure).

The deficient practice resulted in Patient 9 not being consistently turned every two hours. Patient 9 had the potential to have disrupted blood flow to areas identified with skin breakdown/injuries and can impede the heeling process or worsen the existing pressure ulcer wounds.

Findings:

1. A review of Patient 1's History & Physical (H & P) dated 12/18/2021 indicated Patient 1 was admitted for Urinary Tract Infection (UTI, infection of the bladder) and pneumonia (lung inflammation caused by bacterial or viral infection). Patient has a history of Chronic Obstructive Pulmonary Disease (COPD, diseases that cause airflow blockage and breathing-related problems).

During a review of the telemetry reading strip (monitoring strip of a patients with a continuous monitor for heart rhythm and oxygen saturation [(amount of oxygen you have circulating in your blood]), for Patient 1, dated 12/22/2021, indicated the following:
a. On 12/22/2021 at 10:00 PM the oxygen saturation level was 90%.
b. On 12/22/2021 at 10:10 PM the oxygen saturation level was 90%.
c. On 12/22/2021 at 10:20 PM the oxygen saturation level was 48%.

During a review of Patient 1's Code Blue Record (a medical team that responds to a possible cardiac or respiratory arrest) dated 12/22/2021, indicated CPR (cardio pulmonary resuscitation, emergency procedure consisting of chest compressions and/or artificial ventilation to maintain brain function to restore blood circulation and breathing) was initiated at 10:23 PM, Patient 1 was intubated (insertion of a tube through a person's mouth or nose, then down into their windpipe in order to supply oxygen) and the family was notified of this event at on 12/22/2021 at 10:32 PM.

A review of the document titled, "Job Description - Position Title: Unit Secretary/Monitor Technician'," indicated "Professional Accountabilities" of a Unit Secretary or Monitor Technician, not all inclusive: Verbalizes and demonstrates the ability to obtain and interpret cardiac rhythms, measures and maintains appropriate record for rhythm strips, recognizes deviation in rhythm strips and provides timely notification to registered nurse.

During an interview on 3/23/2023 at 2:16 PM, the Monitor Technician stated she was on a break while a Rapid Response (team of health care providers that responds to patients with early signs of deterioration on non-intensive care units to prevent respiratory or cardiac arrest) was called for Patient 1. Monitor Technician stated the Charge Nurse was covering monitoring the heart rhythms and oxygen saturation levels of patients on the unit. The Monitor Technician stated when she came back from her break, a code blue was called for Patient 1. The Monitor Technician stated she could not comment on what happened during her break.

During an interview, on 3/23/2023 at 5:11 PM, Charge Nurse said the Monitor Technician asked for a break, and he (Charge Nurse) was to monitor the patients' telemetry monitors, on 12/22/2021 at about 10:20 PM. Charge Nurse stated after about two (2) minutes the Monitor Technician returned to her station (telemetry monitor station), and he, Charge Nurse, returned to his office. Charge Nurse stated after about another two (2) minutes, he (Charge Nurse) heard the Bipap (bilevel positive airway pressure: machine that delivers two [2] different pressure levels to aid patient breathing, one [1] for beathing in and one [1] for breathing out) alarm, and Respiratory Therapist (RT) had responded to the alarm. Charge Nurse stated he did not hear an alarm while monitoring patients but that oxygen saturation levels are recorded on telemetry monitor and should be monitored.

2. A review of Patient 4's H&P, dated 3/18/2023 at 06:08 PM, indicated Patient 4 had a history of accidental fall, diabetes mellitus (a disease of inadequate control of blood levels of glucose) and hypertension (HTN, high blood pressure). Patient 4 was brought in from home for right ankle pain and right knee pain after she fell backwards. Patient 4 was alert and oriented times three and able to follow commands (patient knows self, place, and time).

A review of Patient 4's Physician Progress Note, dated 3/18/2023 at 06:08 PM, indicated Patient 4 sustained right proximal and distal tibial fractures( fractures of the long bone below the knee) and was admitted to telemetry unit (under constants electronic heart activity for pain control and bowel regimen and orthopedic (the branch of medicine dealing with the correction of deformities of bones or muscles) following.

A review of Patient 4's Operative Report, dated 03/19/2023 at 09:37 AM, indicated patient underwent the following operation: 1. Open treatment right ankle syndesmosis (stabilization of the bones to allow healing in the proper alignment) 2. Open reduction internal fixation (ORIF, a surgical procedure that puts pieces of a broken bone into place) of right medial malleolus (the small prominent bone on the inner side of the ankle. 3. Closed management of proximal fibular shaft (a break in the long, narrow part of the lower leg bones) fracture (external immobilization and manipulation, without surgery to stabilize a fracture by applying external device to hold bones in place).

A review of Patient 4's Internal Medicine Progress Note, dated 3/20/2023 at 10:57 AM, indicated, Patient 4 was seen by the hospitalist Day 1 after surgery, on 3/20/2023 indicated Patient 4 had the following medication order standing for pain: Dilaudid (pain medication) injection, 0.5 milligrams (mg), IV ( intravenous) push, every six (6) hours, as needed for severe pain.

A review of the Patient 4's Orthopedic Surgery Progress Note, dated 3/20/2023 at 7:59 PM, indicated Patient 4 was alert and oriented and verbalized complaints of unrelieved pain overnight.

A review of Inpatient Physical Therapy (PT) Examination notes, dated 3/20/2023 at 11:59 AM, indicated Patient 4 was evaluated on 03/20/2023 at 08:20 AM by PT and indicated Patient 4's participation in physical therapy exercises and mobility was limited due to severe pain.

A review of Patient 4's Pain Assessment Levels and administration of Medication records, dated 3/20/2023, indicated Patient 4 reported pain level ( 0 means no pain; 1 [one] to 3 [three] mild pain; 4 [four] to six [6] means moderate pain, seven [7] to 10 means severe pain) as follows:
a. 9/10 at 5:49 AM and received Dilaudid 0.5 mg,
b. 4/10 at 6:19 AM,
c. 5/10 at 7:00 AM,
d. "Severe," at 08:20 AM,
e. 5/10 at 11:00 AM,
f. 5/10 at 3 PM,
g. 5/10 at 7 PM
h. 8/10 at 9:35 PM and received Dilaudid 0.5 mg
i. 0/10 pain at 22:05 PM.

A review of Patient 4's medical records titled "Pain Management Flowsheet," dated 3/20/23 for the 7 AM to 7 PM shift, indicated Patient 4's personal goal for pain relief was two (2) out of ten(10) .

During a concurrent observation and concurrent interview, on 03/20/2023 at 12:08 PM, Patient 4 was observed in bed. Patient 4's right ankle observed to be wrapped with bandage. Patient 4 stated she was admitted for surgery, because she fell at home and broke her right ankle. She stated she was in constant pain. She stated she had PT this morning, but she was in pain and could not engage in many activities with PT. Patient 4 stated she had pain medication in the morning, given to her around 5 or 6 AM. Patient 4 also verbalized that nurses do ask about her pain levels frequently but stated her pain was still constant and unrelieved and defined her pain level at about 4 to 5 on a scale 0-10.

During an interview on 3/23/2023 at 09:22 AM, Registered Nurse 1 (RN 1), stated Patient 4 was admitted after the ORIF to a telemetry unit. RN 1 verified, on 3/20/2023, she reviewed Patient 4's Care Plan (CP) and documented Patient 4's stated pain goal to be 3/10 during her pain assessments that day. RN 1 also stated that she recalled Patient 4 to be in pain and when she assessed her in the morning, she recalled Patient 4 reporting her pain 7/10 at that time. RN 1 stated she did not administer pain medication to Patient 4, because her pain medication was not due at that time. RN 1 stated she did not offer alternative measures to the patient. RN 1 admitted she did not follow the guidance for the effective pain control as indicated by the hospital's policy. RN 1 was not able to demonstrate documentation evident of communicating her findings with the healthcare team (another nurse, charge nurse, and/or physician).

During an interview on 3/23/2023 at 09:39, Director of Clinical Education (DCE) stated nurses were expected to document findings during nursing assessment, evaluate, and intervene accordingly within their scope of practice. DCE verified nursing documentation of communication with the healthcare team and interventions provided for patients was facility's standard of care requirement necessary to demonstrate adherence to facility's standards of care.

A review of the facility's policy and procedure (P&P) titled, "Pain Assessment and Management," on Appendix 6, titled "Verbal Descriptors of Pain," last revised on 9/22/2020, defined moderate pain as, "It Interferes with any activities." Pain level 5 was defined as very distressing and described as, "Strong deep, piercing pain, that not only is always noticeable, but also makes the person preoccupied with managing it." The P&P indicated, "When objective pain scores are used, such as verbal pain score from 0-10 valid pain tool," to interpret as follows:
A. 1-3 =mild pain
B. 4-6= moderate pain
c. 7-10= Severe Pain

A review of the facility's policy and procedure (P&P) titled, "Pain Assessment and Management," last revised on 9/22/2020, indicated the purpose of the policy is to provide guidance for the effective control and management of acute pain for all patients using an individualized interdisciplinary approach to pain management to enhance patient comfort and satisfaction. The policy stated: " .... Self-report will be used as the most reliable indicator of the presence of pain and intensity of pain ....".
The P&P indicated that it is the responsibility of all healthcare providers to facilitate the pain-relieving process and expedite the intervention within their scope of practice ... Establish an individual plan of care based on the comprehensive assessment for pain and pain screening. Consider pharmacological and/or nonpharmacological therapies and implement as appropriate. Notify the primary care physician of unrelieved pain. Instruct the patient on reporting inadequate pain relief. Educate on safe and effective use of around the clock, as needed, and break through pain dosing concepts as appropriate to the regimen and pain management.

A review of the P& P titled "Provision of Patient Care", section I. General Standards of Care, revised on 8/23/2022, indicated patient can expect to have effective management of pain. The P&P indicated registered nurses to provide documentation of ... assessments, re-assessments, and interventions, and the patient's response to interventions ... and it was an expected standard of patient care for the patients to be given measures that provide comfort and relief from pain.

3. A review of Patient 9's H&P, dated 3/17/2023 at 6:06 PM, indicated Patient 9 was admitted for a wound to the left lower leg. Patient 9 had weakness, dementia, recent hip s/p repair w/ post-op infarction, and stage 3 and 4 pressure ulcers on sacrum.

A review of Patient 9's Wound Assessment and Progress Record, dated 3/18/2023 at 1:38 PM, indicated, Patient 9 had multiple wounds, including, Sacro-gluteal unstageable pressure injury with necrotic tissue, with daily recommendations to provide off-loading every two hours, to the left and right sides only.

During an observation and a concurrent interview, on 3/20/2023, at 12:14 PM, Patient 9 was observed in bed, laying on his right side, with a pillow used for offloading. Patient 9's Charge Nurse stated, "Patient is not able to make decisions, his wife is the decision maker for him."

During an interview on 3/20/2023 at 2:06 PM, Charge Nurse (CN) stated that patient has multiple unstageable sacral wounds and needs to be turned every 2 hours as per wound care nurse recommendations.

During an observation on 3/20/2023 at 2:08 PM, Patient 9 observed in
bed, in his room, on BIPAP. Patient 9 observed positioned on his right side, pillow used for offloading.

During an interview on 3/20/2023, at 2:08 PM., Patient 9's spouse stated, coming to the hospital around 10:00 AM and only witnessed patient being turned one time since her arrival. The spouse stated Patient 9 was very sick and has multiple skin issues.

During an interview, on 3/20/2023 at 2:25 PM, with RN 3, she stated Patient 9 has multiple skin issues including sacrum pressure sore. RN 3 stated patient needed to be turned every 2 hours. RN 3 3 stated Patient 9 was positioned on his back last time RN 3 turned him. RN 3 demonstrated documentation of the VS documented at 12:49 PM, with documented positioning of Patient 9 as "Sitting". RN 3 stated the documentation for turning was done every two hours in the electronic medical records. Nurse 3 was not able to demonstrate documentation of turning in the electronic medical records (EMR) as it was black. RN 3 stated she did not remember exact time of last repositioning.

During an interview on 3/20/2023 at 2:33 PM, with CN, she stated nurses were expected to document turning and repositioning of patients with orders for repositioning every two hours in the EMR.

During an interview and concurrent record review of Patient 9's record medical record, on 3/21/2023 at 12:00 PM, the Nurse Administrator, she verified that Patient 9's Braden score was 12 on admission (12 indicated at risk for skin breakdown). Nurse Administrator stated Patient 9 was admitted with unstageable pressure ulcer to the sacrum.

A review of Patient 9's Activities of Daily Living documentation, documented on 3/20/2023, indicated, Patient 9 required maximum assistance with activities, and "Patient Position in bed," was documented as follows:
a. Supine at 1:00 AM
b. Left at 3:00 AM
c. Left at 7:00 AM
d. Right at 10:00 AM
e. Supine at 12:35 PM
f. Left at 2:20 PM
g. Supine at 7:00 PM
h. Left at 9:00 PM
i. Supine at 11:00 PM

A review of the facility's P&P titled, "Skin Assessment and Pressure Injury Management," last revised on 2/28/2023, the P&P indicated, "All clinical personnel will prevent development and promote healing of pressure injuries and/or skin breakdown."

A review of the facility's P&P titled, "Skin Assessment and Pressure Injury Management," last revised on 2/28/2023, the P&P, Section F. # 12. indicated, to "Turn patients at least every two hours if unable to