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Based on observation, interview, and record review, the hospital did not have an effective GB that carried out the functions required of a GB to provide a safe and secure environment for patients as evidenced by:

1. The GB failed to ensure the rights of the patients were promoted and protected in a safe environment. Cross reference to A115.

2. The GB failed to develop, implement, and maintain an effective, ongoing, hospital wide, data driven quality assessment and performance improvement program. Cross reference to A263.

3. The GB failed to ensure a well-organized or well-staffed nursing service to meet the needs of patients. Cross reference to A385.

The cumulative effect of these systemic problems resulted in the facility's failure to deliver care in compliance with the CoP for GB and failure to provide a safe and secure environment for patients.

Based on interview and record review, the medical staff failed to ensure quality of care was provided for one of 33 sampled patients (Patient 11) as the RT failed to ensure the physician's order for BIPAP setting was implemented for Patient 11. This failure posed an increased risk of substandard health outcomes to the patient.

Findings:

Review of the hospital's P&P titled Application of BIPAP Ventilator, origination date 3/05 and unknown review date, showed in part:

* Purpose was to establish a policy for provision of Non Invasive Ventilatory Support of the patient to correct for respiratory insufficiency.

* Procedure:
- Receive orders for the following of initial set up such as patient name, IPAP, EPAP, FIO2 and Back up RR.
- Plug in the ventilator to a red electrical outlet and turn power on....
- Set parameters as per physician's order....
- Record all parameters and pertinent information in the EMR.

On 3/24/22 at 1410 hours, interview and concurrent medical record review was conducted with the CI. The medical record showed Patient 12 arrived at the ED on 3/23/22 at 0133 hours.

Review of the ED MD note dated 3/23/22, showed Patient 11 was seen in the ED at 0208 hours, complaining of worsening shortness of breath in the last four to five days.

Review of the ED MD order showed the order dated 3/23/22 at 0346 hours for BIPAP at FIO2 50%, RR 16, IPAP 12, and EPAP 5, to keep oxygen saturation level above 90%.

Review of the RT's documentation of Non Invasive Ventilator Setting for Patient 11 showed on 3/23/22 at 0347 hours, the BIPAP was initiated with the settings of IPAP 12 and EPAP of 5. However, there was no back up RR documented until the BIPAP was discontinued at 0730 hours, when the patient was intubated.

On 3/25/22 at 1030 hours, an interview and concurrent medical record review was conducted with the RT and CI. The RT was asked to show the documented evidence of the BIPAP's back up RR for Patient 12. The RT stated the BIPAP's back up RR should have been documented on the Noninvasive Ventilator Frequency Mandatory; however, it was missed on this one.

Based on observation, interview, and record review, the hospital failed to protect and promote the rights of the patients as evidenced by:

1. Failure to ensure the written grievance resolution letters were sent to the patients. Cross reference to A123.

2. Failure to ensure the patients received care in a safe environment. Cross reference to A144.

3. Failure to ensure the patients were free from restraints. Cross reference to A154.

The cumulative effect of these systematic practices resulted in the hospital's inability to provide quality health care in a safe environment.

Based on interview and record review, the facility failed to ensure the written grievance resolution letters contained the results of the grievance process and the date of completion were sent to five of 33 sampled patients (Patients 1, 2, 5, 6, and 7). This failure had the potential to result in the patients not being satisfied with actions that were taken on the patient's behalf.

Findings:

Review of the hospital's P&P titled Patient Complaints and Grievances dated 3/11/20, showed in part: the Procedure - Patient Notification: the hospital will inform patients, in writing, of their right to make complaints and grievances and the mechanism to do so during the registration process.

* Grievances should be resolved and the patient notified of the response in 7 days.
* Each grievance will be followed up with a written notice of decision in a manner and language that the patient and the patient's legal representative understands within 30 days. The written response will contain the following minimum elements:

- Date of receipt of Grievance
- Name of the hospital contact person for patient follow up if needed
- Steps taken to investigate and results
- Date of investigation completion

On 3/24/22 at 1430 hours, an interview and concurrent review of the Grievance log CY 2022 was conducted with the Quality Department Coordinator. When asked why there were no letters sent out to Patients 1, 2, 5, 6, and 7, the Quality Coordinator stated after checking the file of Patient 1, the department did not receive any call backs, so the case was closed. When asked if a letter had been sent out to the patient or family concerning the final results of the investigation, the Quality Coordinator stated no.

Further review of the log and concurrent interview showed the following:

- Patient 2's family member called to the grievance committee on 2/1/22, about the patient's lost lower dentures. On 2/22/22, the grievance committee documented in the grievance log that a call made and left messages on the son's phone. On 2/3/22, someone spoke to the family member and requested a receipt for the dentures. On 2/11/22, the log showed the QI Manager was asking for the receipt for cost of denture. On 3/2/22, the QI Manager did not receive the receipt, therefore, closed the case. When asked if anyone had followed up with the family member regarding the outcome of the investigation by sending him a letter, the Quality Coordinator stated no.

- Patient 5's family member sent an email on 1/7/22, regarding a visit that the patient had in the hospital's ED. The document showed the complaint was about sending the patient home in a taxi, and the patient got home and fell. Also, the patient's family member complained about a specific RN being rude and hanging up on him. The family member was told to call the taxi company and complained, and the case was closed. The Quality Coordinator confirmed no investigation was initiated concerning the complaint and no letter of notification was sent to Patient 5 or family thereafter.

- For Patients 6 and 7, no letters had been sent to the patients or their families concerning the outcome of the investigation of their complaints due to no answering of their phones. When asked why no one sent the letters, the Quality Coordinator stated possibly due to not being able to reach them by phone, so the cases were closed.

The Quality Coordinator confirmed no letters were sent out for various reasons such as, no call backs from the patients, or no answers when the department called them. However, per the hospital's P&P, the hospital should have followed their grievance process and responded with the follow-up letters of the outcome if not able to resolve it in person or on the phone.

Based on observation, interview, and record review, the hospital failed to ensure the patients received care in a safe setting as evidenced by:

1. Temperature and humidity level were not monitored for the months of January, February, and March 2022 where the supply packages and repacked resteriled instruments were stored in ED 1 clean utility room.

2. The used/empty IV bag and IV tubing was discarded in the clean utility room garbage can.

3. Several containers of Super Sani cloth/Cavi wipe (disinfectant) were stored in the dirty utility room.

4. The clean utility door was peeling off and the bottom of the door was stained black.

5. The dirty Utility room door surface was peeling off.

6. In ED 2, 11 Supply Carts with needles and 10 ml saline flushes were unlocked.

7. ED 2 medicine refrigerator temperature was observed out of range.

8. ED 2 linen warmer temperature was out of range on several dates.

9. In ED 1, Room A, the call Light was chipped/broken.

10. The clean equipment was not properly stored.

11. The call light was not within the patient's reach.

12. The used IV bag was left in bed.

13. The vital signs machine was left charging in the bathroom.

These failures created unsafe environment for the patients.

Findings:

According to the CDC Infection Control, the storage of wrapped surgical trays remained sterile for varying periods depending on the type of material used to wrap the trays. Safe storage times for sterile packs vary with the porosity of the wrapper and storage conditions (e.g., open versus closed cabinets). Although some hospitals continue to date every sterilized product and use the time-related shelf-life practice, many hospitals have switched to an event-related shelf-life practice. This practice recognizes that the product should remain sterile until some event causes the item to become contaminated (e.g., tear in packaging, packaging becomes wet, seal is broken). The Event-related factors that contribute to the contamination of a product include bioburden (i.e., the amount of contamination in the environment), air movement, traffic, location, humidity, insects, vermin, flooding, storage area space, open/closed shelving, temperature, and the properties of the wrap material.

On 3/22/22, an observation of ED 1 and concurrent interview was conducted with the Director of IP, Director of ED, and RN 5. The following were observed:

1. For the clean utility room/medication room in ED 1, the humidity was 55%. RN 5 was asked for the Clean Utility/Medication room temperature and the humidity monitoring log, RN 5 showed the the following:

- For the month of 1/22, all the dates from 1/1/22 to 1/30 were blank, except for 1/6/22.

- There was no documented evidence of monitoring log for the month of 2/22. When asked for the month of 2/22 log, RN 5 stated it must have been given to the Director of ED.

- For the month of 3/22, the log was left blank from 3/1/22 to 3/22/22, except for 3/19/22.

Review of the temperature and humidity monitoring log showed if the temperature and humidity were out of range, report to Engineering. When asked what range of humidity and temperature would the staff report to the Engineering, the Director of ED and RN 5 could not answer. When asked who assigned to check the temperature and humidity of the clean utility room/medication room, RN 5 stated the EMT was assigned to check the humidity and temperature. When asked the reason for checking the temperature and humidity, RN 5 stated the kits were stored in the clean utility/medication room.

On 3/22/22 at 1130 hours, an observation and interview was conducted with the HVAC Technician. The HVAC Technician was asked what temperature and humidity in the clean utility room/medication room would the staff report to the Engineering. The HVAC Technician stated the staff should report the humidity below 30% and above 60% and for the temperature below 68 degrees F and above 73 degrees F. However, the ED 1 current monitoring log did not show what temperature and humidity ranges for the staff to report to the Engineering.

On 3/23/22, at 0832 hours, observation and concurrent interview was conducted with the Clinical Educator. The Clinical Educator was asked what the sterile and resterile repacked kits stored were in the clean utility/medication room. The Clinical Educator showed the following kits:

- pediatric and adult lumbar puncture tray
- thoracenthesis tray
- chest tubes drainage kits
- chest tubes
- pneumothorax kit
- burn pack
- ER/ED plastic tray
- cut down tray
- thoracotomy tray
- laceration tray

2. An empty IV fluid bag with used IV tubing was observed discarded in the garbage bin in the clean utility/medication room.

3. Several containers of disinfectant wipes were stored in the dirty utility room. The Director of IP stated the containers of disinfectant wipes should not be stored in the dirty utility room.

4. The clean utility/medication room door was peeling off and the bottom of the door was stained black. The Director of IP stated she had mentioned and requested to address these with the Administration.

5. The Dirty Utility room door surface was observed to be peeling off. The Director of IP stated she understood this was a concern for infection control.

6. In ED 2, Rooms B to L, 11 Supply Carts with needles, IV catheters, and 10 ml saline flushes were observed to be unlocked. The cart for OB delivery with suture needles, ABG kits, needles, and IV catheters was observed to be unlocked. The Director of ED stated the supply cart should be plugged in the electrical outlet to lock the supply carts or use the key. RN 5 stated she had one key for the supply carts.

7. ED 2 medicine refrigerator was observed to have the freezer with a thick ice build up and the temperature reading was 30 degrees F. Medications stored inside the refrigerator were as follows:

- 4 vials of Cardizem (heart medication) 25 mg/5 ml
- 4 vials of roncoronium (can relax muscles during surgery and medical procedures)15 mg/5 ml
- 1 vial of Humulin Insulin (controls the amount of glucose) 100 ml
- 6 vials Pepcid (antacid) 20 mg/2 ml
- 3 doses of 0.5 ml of tetanus vaccine (vaccine that protects you from getting tetanus).
- 5 Aspirin (reduce fever and relieves mild pain) suppository 300 mg
- 4 vials of succinylcholine (can relax the muscles during surgery or other medical procedures) 200 mg/10 ml

Review of the Hospital's P&P titled Storage of Medications review date 5/21 showed medications are stored according to the manufacturer's recommendations or, in the absence of such recommendations, according to a pharmacist's instructions. Medications are stored under proper conditions and sanitation, temperature, light, moisture, ventilation, segregation, and security. Medications will be stored at appropriate temperatures according to manufacturer's recommendations. Refrigerator temperature will be between 36 degrees F and 46 degrees F. Monthly unit inspections: the pharmacist will conduct at least monthly inspections of all nursing areas or other areas where medications are dispensed, administered or stored. Medication refrigerator will be checked daily at the nursing stations by the nursing staff, and in the pharmacy by pharmacy staff for temperature readings between 36 F and 46 F. For the refrigerators used to store vaccines (pharmacy, ED,...) the temperature will be monitored and recorded twice daily.

8. Blanket Warmer temperature in ED 2 was observed at 120 degrees F for the upper compartment and 116 F for the lower compartment.

Review of the ED 2 Temperature Log for Blanket Warmer for the month of 3/22 showed to record temperatures daily, temperature must be less or equal to 120 degrees F and if temperature are not in proper range, to call Engineering and document action. The ED 2 Temperature Log for Blanket Warmer for the upper and lower compartment temperatures showed the following:

- 3/3/22, 121 degrees F and 119 degrees F
- 3/4/21, 120 degrees F and 122 degrees F
- 3/5/22, 121 degrees F and 124 degrees F
- 3/6/22, 120 degrees F and 122 degrees F
- 3/7/22, 122 degrees F and 124 degrees F
- 3/8/22, 122 degrees F and 124 degrees F
- 3/11/22, 124 degrees F and 124 degrees F
- 3/12/22, 129 degrees F and 123 degrees F
- 3/13/22, 124 degrees F and 126 degrees F
- 3/14/22, 128 degrees F and 120 degrees F

9. On 3/22/22 at 1140 hours, observation of Room A with the Director of IP, Director of ED, and RN 5 was conducted. The Director of ED stated the equipments that were considered ligature could be removed if they would admit a patient who needed a close observation or monitoring with suicidal ideation. When the call light was inspected, the call light was observed to be broken, chipped, and cracked on the side.

The findings were verified with the Director of IP, Director of ED and RN 5.


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10. a. On 3/22/22 at 1056 hours, a tour of M2 was conducted with Director of Rehabilitation and Clinical Manager 1.

The following was observed inside the storage room:

- The room was divided into a clean and dirty area by a red line on the floor.
- On the wall, the yellow signs were posted showing Clean Area and Dirty Area.

When asked, Manager 55 stated the clean equipment should be bagged with a clear plastic bag and labeled 'Clean.'

However, in the Clean Area, multiple IV Pumps were observed unbagged and not labeled 'Clean.'

Clinical Manager 1 acknowledged the finding.


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b. On 3/22/22 at 1105 hours, a tour of M2 East and M1 units with RNs 13 and 14. An observation of the shower on M2 East unit next to the nurse manger's office was dirty with hair and was being used as a storage space for clean supplies for the patients' dressing changes. RN 13 confirmed the shower room was being used as storage space and needed cleaning by environmental services.

11. Observed of the call light in Room 125 Bed A showed it was wrapped around the bed rail and underneath the patient's mattress, out of reach for the patient.

12. An observation of an empty/used IV bag had been left on the patient's bed wetting the sheets in Room 129 Bed A.

13. The vital signs machine was placed in the patient's bathroom in Room 130 and left there charging, creating a safety risk when the patient had to use the bathroom. Confirmed with RN 13, the nurse should not have used the bathroom as a charging station for the vital sign machine.

Based on observation, interview, and record review, the hospital failed to ensure eight of the 33 sampled patients (Patients 15, 16, 21, 22, 23, 24, 25, and 26 ) were free from restraints. This failure had the potential to restrict the patients from moving freely and created unsafe environment for the patients.

Findings:

Review of the hospital's P&P titled Restraint and Seclusion dated 12/2020 showed in part:

Definitions: Restraint" means any method, physical or chemical, or mechanical device, materiel, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body.

Authorization and Ordering of Restraints: restraint is initiated only upon the order of a physician or LP.

* If restrain continues to be clinically justified, continued use of restraint must be authorized by the physician or other LP. Restraint orders must be renewed on a daily basis. The attending physician or LIP's progress note must address the need for continue use of non-violent restraints every calendar day.

* Restraint orders must be dated and timed when signed by the physician or LIP, and include: 1) criteria for release
2) type of restraint used
3) reason for restraint
4) and specify duration of restraint order

Non-violent or Medical Support Restraint Track:
* Assess patient for minimum type of restraint needed. Consider 2 point first, then 3 point.

On 3/22/22 at 1105 hours, a tour of the M2 unit was conducted with RN 13.

At 1135 hours, during an observation, Patient 15 was observed lying in bed and appeared to be watching the TV that was pushed close in front of her. Patient 15 was observed to be in two point soft restraints with all four siderails in the up position.

At 1240 hours, medical record review and concurrent interview was conducted with the Clinical Manager and the 1:1 sitter. When questioned why all side rails were up and Patient 15 was in 2 points restraints, the 1:1 sitter stated the patient was confused and sometimes tried to get of bed. When asked if there were doctor's orders for all 4 siderails to be up, the clinical manager was unable to locate any orders.

On 3/24/22 at 1330 hours, a visit to the M2 was conducted with the Clinical Educator and Director of Nursing. Patients 21, 22, 23, and 24 were observed to have all 4 siderails in the up position.

On 3/24/22 at approximately 1345 hours, a visit to the M2 unit was conducted with the Director and Clinical Educator. Patients 16, 25, and 26 were observed to have 4 siderails in the up position. When asked if a physician's order was needed to have all siderails up, the Director stated yes. The Director then told the nurse manager to "go educate the nurses and take one siderail down" on every patient who had 4 siderails up.

Record review of the physician's orders for Patients 15, 16, 21, 22, 23, 24, 25, and 26 were reviewed. There were no documentation of the physician's orders for all siderails up. The Director confirmed there were no orders for siderails used as restraints for any of these patients.

Based on observation, interview, and record review, the hospital failed to develop, implement, and maintain an effective, ongoing, hospital wide, data driven quality assessment and performance improvement (QAPI) program as evidenced by:

1. Failure to ensure documentation of GB oversight of staffing issues. Cross reference to A315.

2. Failure to ensure an organized and sufficiently staffed nursing service to mee the needs of patients. Cross reference to A385.

The cumulative effect of the facility's failure to have a quality assurance system in place to ensure oversight of the hospital's nursing services resulted in the facility's failure to deliver and provide care to their patients in a safe environment.

Based on interview and record review, the hospital failed to ensure the GB meeting minutes included documentation related to quality data and analysis reports regarding multiple staffing issues. There was no documentation in the meeting minutes that the GB made any recommendations regarding the multiple staffing issues. As a result, there was no documented evidence the GB was ensuring that adequate resources were provided for the hospital's operation and care of patients which has the potential to negatively affect patient care.

Findings:

1. During the Complaint Validation survey from 3/17/22 to 3/25/22, the deficient practices were identified as the nurse-to-patient ratios were not maintained for the ED, M1, M2, M3, SDU, and ICU/CCU as required. Cross reference to A392.

Review of the GB meeting minutes dated 11/18/21, was conducted on 2/23/22 at 1045 hours. The GB meeting minutes documented the nurse staffing complaints were substantiated with regulatory finding, no actions or follow up by the GB was documented.

There was no GB meeting minutes for December 2021 or January 2022.

The February 24, 2022, GB meeting minutes documented a CNO report which did not contain the follow up information regarding the nurse staffing issues from the November meeting minutes and no updates regarding new staffing complaints. The section of GB Actions/ Follow up was left blank.

An interview with the CNO regarding staffing issues and quality/tracking was conducted on 3/23/22 at 1132 hours. The CNO stated the staffing issues were tracked, monitored, and reported in the Medical Executive (Med Exec) meetings, critical care, and nurse executive meetings. The CNO acknowledged that the GB minutes did not reflect that staffing issues being tracked and monitored, and no recommendations were documented by the GB in the minutes.

An interview with the ED Medical Director was conducted on 3/23/22 at 1215 hours. The ED Medical Director stated she had worked for 18 years at this hospital and acknowledged that there have been staffing issues off and on which did impact patient care. When the staffing ratios were off, the nursing staff must carry five to six patients, it could delay care such as it might take 90 minutes to give antibiotics or hang an IV. The ED Medical Director stated that the laboratory staff for the ED had been short for a year and the nurses must draw blood in addition to carrying more patients than the staffing ratio permittted.

An interview with the members of the GB was conducted on 3/24/22 at 1435 hours. The GB stated they had been provided the staffing issues reports and were involved in recommendations for implementing improvement for the staffing issues. The MEC had been meeting weekly and staffing had been discussed frequently.

Review of the Performance Improvement Plan dated 02/20 was conducted on 3/23/22 at 1544 hours. The plan showed, "The scope of the plan extends to all aspects of patient/customer management as they apply to the medical staff departments, clinical departments, administrative departments and support departments. These aspects and key functions include leadership, provision of care, management of human resources, management of information, medication management, medical staff, rights and responsibilities, environment of care, emergency management, life safety and risk management and improving organizational performance....the Governing Board is ultimately accountable for the safety and quality of care, treatment and services."


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2. Review of the hospital's P&P titled Critical Values and STAT tests revised date 1/18, showed in part Stat tests are those ordered by the physician requiring a rapid turnaround time for the purposes of evaluating a patient with The "stat" priority should be used exclusively for such test orders. The goal for Stat tests is to report results within 1 hour of receipt of the specimen. Results are communicated immediately (within 5 minutes of results verification) to the requesting physician or responsible licensed member of the hospital staff via telephone, electronic record and/or fax.

Procedure: STAT Testing

- Laboratory tests that are needed STAT may be ordered in the hospital information system (HIS) with a STAT priority. Depending on the specimen type, the individual responsible (phlebotomist, nurse, MD) will collect the specimen as soon as possible and deliver to the laboratory for analysis. BNP can be expected to be available within one hour of specimen receipt in the Laboratory.

- Once the specimen is received, the laboratory will expedite processing and testing so that, ideally, results are available in 60 minutes or less.

On 3/23/22 at 1310 hours, on interview and concurrent medical record review was conducted with the CI.

Patient 5's medical record showed the patient was registered at the ED on 3/23/22 at 1527 hours, was triaged at 1528 hours complaining of shortness of breath for three days. The patient was seen by the physician's order at 1544 hours. .

Review of the phycician's orders on 3/21/22 at 1549 hours, showed to perform BNP laboratory test STAT. The blood specimen was collected at 1549 hours, the blood specimen was dispatched and was in the laboratory at 1645 hours. However, the test was completed at 2244 hours. The BNP result was 1917 pg/mL and that was high. The CI was asked what was the expectation for the test to be completed or resulted when the order was STAT and why the BNP resulted after seven hours. The CI could not answer.

On 3/23/22 at 1620 hours, an interview was conducted with the Director of Laboratory. When asked about the staffing of the Laboratory, the Director of Laboratory stated the laboratory staff should be checking the pending tests. For Patient 5, the CBC blood test was ran first and would use the same blood specimen for the BNP. This one was missed and delayed to process the BNP test. The Director of Laboratory stated his staff was very very lean, were short of laboratory assistant, phlebotomist, and CLS. The ED got very busy at times and there were only two laboratory technicians. When the laboratory staff was short, the ED and the ICU staff drew their patients' blood. The laboratory had been short of phlebotomist for almost a year now.

On 3/25/22 at 1120 hours, an interview was conducted with the Director of Laboratory. The Director of Laboratory stated there was no dedicated staff 24/7 for processing samples in the microbiology when the staff left at 1530 hours. The micorbiology department had staff from 0700 to 1530 hours, from Monday to Sunday.

During the GB meeting on 3/24/22 at 1445 hours, the CNO stated the ED RNs had to draw the patients blood for the tests when needed due to shortage of phlebotomist.

Based on observation, interview, and record review, the hospital failed to have an effective, organized nursing service to provide quality care to the patients as evidenced by:

1. Failure to ensure sufficient staffing in the ED, telemetry, medical-surgical, step down, and critical care units as evidenced by not maintaining the nurse-to-patient ratios as required. Cross reference to A392.

2. Failure to ensure the RN supervision and evaluation of the nursing care provided. Cross reference A395.

3. Failure to ensure the nursing staff devleoped individualized nursing care plan. Corss reference A396.

4. Failure to ensure the hospital's P&P for patient care was implemented. Cross reference A398.

5. Failure to ensure the nursing staff administered medications as per the physician's orders and pharmaceutical standards. Cross reference A405.

6. Failure to ensure the blood transfusion was administered timely as per the physician's order. Cross reference to A410.

The cumulative effect of these systemic failures resulted in the hospital's inability to provide quality healthcare in a safe environment to the patients.

Based on observation, interview, and record review, the hospital failed to ensure the adequate numbers of nursing staff to provide nursing care to the patients as evidenced by:

1. Failure to maintain the nurse-to-patient ratio for M1, M2, and M3 as required.

2. Failure to maintain the nurse-to-patient ratio for SDU as required.

3. Failure to maintain the nurse-to-patient ratio for ICU/CCU as required.

4. Failure to maintain the nurse-to-patient ratio for ED as required.

5. Failure to ensure the charge nurse was assigned for each shift as per the hospital's staffing plan and failure to ensure the CNA was assigned as needed.

6. Failure to implement the corrective plan regarding the nurse-to-patient ratio

These failures had the increased potential of patient care being compromised, adverse events, inferior clinical outcomes, inpatient deaths and poorer patient experience of care.

Findings:

On 3/17/22 at 0905 hours, an unannounced visit to the hospital was conducted in response to the Department receiving over 40 complaints alleging the hospital was not maintaining the nurse-to-patient ratios at all times as required in the ED, M1, M2, M3, SDU, and ICU/CCU units from February 2022 through March 2022.

Review of the hospital's P&P titled Staffing Plan dated 5/27/21, showed in part:

* Scope of this P&P is for all patient care area.

* The purpose is to maintain adequate number of nursing staff and appropriate skill mix to meet patient care needs.

* The Patient Classification System determines staffing needs on a shift-to-shift basis.

* Staffing schedules are completed in six (6) week increments.

* The staffing schedule is posted 14 days prior to implementation.

* Departments will be staffed by professional and non-professional personnel to meet the patient care needs and remain in compliance with internal and external standards.

* Staffing will be maintained at a level that will allow appropriate response in a crisis.

* A charge nurse will be designated for each nursing floor, each shift.

* Staffing assignments are made each shift by the charge nurse and are based on the patient care needs, skill of the care giver (competency) and degree of supervision required by the RN. A RN completes patient assessment, planning and evaluation of care for each patient.

* When there is an unexpected increase in patient acuity, or volume, the following plan of action will be taken to meet these increased needs:

- The Charge Nurse assesses the situation and notifies the RN Administrative Supervisor or designee. The Charge Nurse documents above actions on staffing roster, notifies the Director/Clinical Manager if unable to meet required staffing level, calls contract agencies for staff, calls in available [hospital] resource staff, and assesses the situation and reviews in-house resources for re-allocation.

* The Nursing Director or nursing manager will review the schedule to make sure that the staff numbers and mix are adequate for projected needs. If a shortage is identified, the nursing director or nurse manager will work with the staffing coordinator to schedule the additional staff.

Review of the hospital's P&P titled Patient Classification and Assignment Policy dated 5/27/21, showed the following:

* The purpose of this P&P is to provide a systematic method for evaluation patients' condition, predict the number and types of required resources, and make equitable and safe patient assignments.

* The PATIENT ASSIGNMENTS section showed all assignments will be made in accordance with state-imposed ratios and regulations.

1. The California Code of Regulations, Title 22, Division 5, Chapter 1, Article 3, §70217, showed the following:

(a) Hospitals shall provide staffing by licensed nurses, within the scope of their licensure in accordance with the following nurse-to-patient ratios.

(10) The licensed nurse-to-patient ratio in a telemetry unit shall be 1:4 or fewer at all times.

(11) Licensed nurse-to-patient ratio in medical/surgical care units shall be 1:5 or fewer at all times.

a. On 3/17/22 at 0950 hours, an interview was conducted with the Director of ICU/CCU. When asked, the Director of ICU/CCU stated M1, M2, and M3 did not maintain the nurse-to-patient ratios as required on 3/16/22, for the night shift from 1900 hours to 0700 hours. M1 and M2 were the telemetry/medical/surgical units. M3 was the medical/surgical unit.

On 3/17/22 at 0930 hours, the Interim Director Clinical Quality was asked to provide documentation showing the days the hospital had not maintained the nurse-to-patient ratios as required from 2/15/22 through 3/16/22.

Review of the hospital's documentation from 2/15/22 through 3/16/22, showed the hospital had not maintained the nurse-to-patient ratios as required. The following nursing units were out of ratios::

* M1 had the nurse-to-patient out of ratios on 2/20, 2/27, 2/28, 3/3, 3/4, 3/5, 3/6, 3/10, 3/12, 3/13, 3/14, and 3/16/22.

* M2 had the nurse-to-patient out of ratios on 2/19, 2/20, 3/5, 3/10, 3/12, 3/13, 3/14, and 3/16/22.

* M3 had the nurse-to-patient out of ratios on 2/27 and 3/15/22.

However, the document did not show the number of RNs out of ratio, the number of patients assigned per RN or the shift that was out of ratio, 0700 to 1900 hours (day shift) or 1900 to 0700 hours (noc shift).

The Interim Director Clinical Quality and Acting Risk Management Director acknowledged the findings.

b. On 3/24/22, the hospital's report titled Assignment by Staff Member for 3/27/22 through 3/22/22 was reviewed for M1, M2, and M3.

The following were the examples of additional dates the hospital failed to maintain the nurse-to-patient ratios as required (not all inclusive):

* For M1:
- 3/17/22: 1 RN day/1 RN noc
- 3/18/22: 1 RN day/1 RN noc
- 3/19/22: 1 RN day/4 RNs noc
- 3/20/22: 1 RN noc
- 3/21/22: 3 RNs days/2 RNs noc
- 3/22/22: 1 RN days

* For M2:
- 3/17/22: 1 Nurse noc
- 3/19/22: 1 RN day
- 3/21/22: 1 RN noc

2. The California Code of Regulations, Title 22, Division 5, Chapter 1, Article 3, §70217, showed the following:

(a) Hospitals shall provide staffing by licensed nurses, within the scope of their licensure in accordance with the following nurse-to-patient ratios.

(9) The licensed nurse-to-patient ratio in a step-down unit shall be 1:3 or fewer at all times.

On 3/24/22, the hospital's report titled Assignment by Staff Member for 2/20/22 through 3/22/22 was reviewed for SDU. The following were the examples of dates the hospital failed to maintain the nurse-to-patient ratios as required (not all inclusive):

- 2/20/22: 1 RN day
- 2/26/22 1 RN day
- 3/4/22: 1 RN day
- 3/7/22: 1 RN noc
- 3/8/22: 1 RN day
- 3/9/22: 1 RN day
- 3/10/22: 2 RN noc
- 3/14/22: 1 RN noc

3. The California Code of Regulations, Title 22, Division 5, Chapter 1, Article 3, §70217, showed the following:

(a) Hospitals shall provide staffing by licensed nurses, within the scope of their licensure in accordance with the following nurse-to-patient ratios.
(1) The licensed nurse-to-patient ratio in a critical care unit shall be 1:2 or fewer at all times.

On 3/24/22, the hospital's report titled Assignment by Staff Member for 2/20/22 through 3/22/22 was reviewed for the Critical Care Departments or ICU/CCU. The following were the examples of dates the hospital failed to maintain the nurse-to-patient ratio as required (not all inclusive):

- On 2/24/22: 1 RN assigned 3 patients noc
- On 2/24/22: 1 RN assigned 4 patients noc
- On 3/16/22: 1 RN day 3 patients noc

4. The California Code of Regulations, Title 22, Division 5, Chapter 1, Article 3, §70217, showed the following:

(a) Hospitals shall provide staffing by licensed nurses, within the scope of their licensure in accordance with the following nurse-to-patient ratios.
(8) The licensed nurse-to-patient ratio in an emergency department shall be 1:4 or fewer at all times.

At least one of the licensed nurses shall be a registered nurse assigned to triage patients. The registered nurse assigned to triage patients shall be immediately available at all times to triage patients when they arrive in the emergency department. When there are no patients needing triage, the registered nurse may assist by performing other nursing tasks. The registered nurse assigned to triage patients shall not be counted in the licensed nurse-to-patient ratio.

When licensed nursing staff are attending critical care patients in the emergency department, the licensed nurse-to-patient ratio shall be 1:2 or fewer critical care patients at all times. A patient in the emergency department shall be considered a critical care patient when the patient meets the criteria for admission to a critical care service area within the hospital.

A minimum registered nurse-to-critical trauma patient ratio of 1:1 shall be maintained at all times.

a. On 3/17/22 at 1037 hours, review of ED Shift Summary for 2/18/22 through 3/17/22 and a concurrent interview was conducted with RN 20.

The 2/18/22 ED Shift Summary showed the following:

- One RN was assigned to room 5, 6, 7, 8, and H3
- One RN was assigned to room 1, 2, 3,4, and H2
- One RN was assigned to room 9, 10, 11, 12 and C.

When asked, RN 20 defined H2, H3, and C as the following:

- H3 (Hallway 3) and H2 (Hallway 2) were locations in the ED hallways where patients were placed until an ED bed/bay became available

- 'C' meant Chair 1 (or C1), Chair 2 (or C2), Chair 3 (or C3), and Chair 4 (or C4). The four chairs were designated for patients requiring simple treatments or procedures.
RN 20 acknowledged the ED nurse-to-patient ratio was one nurse to four patients. When asked if the RNs were out of ratio, RN 20 did not provide a response.

Review of the ED Shift Summaries dated 3/10, 3/14, 3/16, and 3/17/22, showed the following:

* On 3/10/22:
- "...RNs out of ratio...23 admission, Only 1 ER Nurse doing T1, T2, ER pts [sic] with admissions..."

* On 3/14/22:
- " Shift: 0600 CN; Staff [name of RN]; Assignment: T1, T2 "

* On 3/16/22:
- "Holding 24 Admissions...ED 2 with holds..."
- "Admin [sic] refused to close for diversion..."
- "Nurses out of Ratio 5 pts [sic] each...no breaks...lunches..."
- Shift: 1800 CN (Charge Nurse); Staff: [name of RN]; Assignment: T1, T2, ER pts [sic]
- Shift: 1900 RN; Staff: [name of RN]; Assignment: T1, T2, Chairs, hallways.

* On 3/17/22:
- "25 holds...nurses out of ratio"
- Shift: 0600; Staff: [name of RN]; Assignment: T1, T2, H3

When asked, RN 20 defined CN, T1, and T2 as the following:
- CN was the Charge Nurse.
- T1 was the Triage Nurse with no patient assignment.
- T2 was the nurse who provided care to the patients in the waiting area and/or to patients assigned to C1, C2, C3, and C4.

When asked if T1 was counted in the licensed nurse-to-patient ratio on 3/10/22, 3/14/22, 3/16/22, and 3/17/22, RN 20 did not provide a response.

When asked if it was acceptable for the Triage Nurse to also take the CN assignment in addition to the chair and hallway patient assignments on the same shift as shown in the ED Shift Summary dated 3/16/22, RN 20 did not provide a response

b. Review of the patient the ED admitted log from 3/13/22 at 1730 hours to 3/15/22 at 1842 hours, showed the followings:

* Five patients who had admitted to ICU/CCU were physically located in ED as follows:

- On 3/14/22 from 1120 hours to 2119 hours (9 hours)
- On 3/14/22 from 1620 hours to 3/15/22 0756 hours (15 hours)
- On 3/14/22 from 1630 hours to 3/15/22 0830 hours (16 hours)
- On 3/14/22 from 1639 hours to 3/15/22 0857 hours (16 hours)
- On 3/14/22 from 2206 hours to 3/15/22 1000 hours (11.50 hours)

* One patient who had admitted to SDU, was physically located in ED

- On 3/13/22 from 1947 hours to 3/14/22 0810 hours (11 hours)

Review of the ED staffing sheet dated 3/14/22, showed the following:

* For the day shift:
- CN was assigned to T1 on 0600 to 0700 hours and T2 from 0600 to 0900 hours
- 4 RNs from 0700 to 1900 hours.
- 1 RN from 0900 hours assigned to T1
- 1 RN from 0900 to 1500 hours
- 1 RN from 1200 assigned to T 2
- 1 RN from 1500 hours

* For the night shift:
- 1 CN from 1800 to 0600 hours.
- 4 RNs from 1900 hours.
- 1 RN from 1900 assigned to T1 and no T 2

On 3/22/22 at 1035 hours, an interview and observation of the ED 1 was conducted with the Director of IP, Director of ED, and RN 5. RN 5 stated the hospital had EDs 1 and 2. ED 1 had 12 bed capacity with 4 chairs. ED 2 had 11 bed capacity and eight chairs for stable patients.

RN 5 stated the ED staffing for the day shift included one CN scheduled from 0600 to 1800 hours; five RNs scheduled from 0700 hours to 1900 hours; at 0900 to 0930 hours, two RNs were assigned to ED 2; one RN scheduled at 1200 hours to break the staff; one RN scheduled at 1100 hours; and one RN scheduled at 1500 hours. RN 5 stated the RN who was scheduled to come at 1100 hours, called in today.

RN 5 stated the ED staffing for the night shift included five RNs scheduled from 1900 to 0700 hours; one CN scheduled from 1800 to 0600 hours. RN 5 further stated one unit secretary and one EMT would be scheduled per shift.

RN 5 was asked what type of patients were dedicated for the 4 chairs in ED 1. RN 5 stated the patients placed on the chairs (C1 to C4) needed treatment such as splinting, basic medications such as Tylenol (a medication used for fever or pain) or patients needed IV hydration.

On 3/22/22 at 1440 hours, an interview was conducted with the RN 4. When asked, RN 4 stated she worked 12-hour shift, from 0700 to 1900 hours for the ED. When asked if they had been out of ratio in the ED at any time during the month of March, RN 4 stated on 3/12/22, she was assigned to care for an ICU patient and 3 telemetry patients at ED 1; and on 3/14/22, she was assigned to care for five patients at the start of the shift with two ICU patients and ended with three patients before the shift ended.

On 3/23/22 at 1425 hours, an interview was conducted with RN 6. RN 6 was asked about the staffing in the ED. RN 6 stated T1 would triage the patients who came to the ED and supported the ED waiting room. T2 supported T1, the ED waiting room, patients who were assessed with ESI 4 and 5 and physically located in the chairs (Cs 1, 2, 3, and 4) in ED 1, and the PA or NP. T2 could also be pulled from doing T2 tasks to take high acuity patients like the patient with code stroke. The ED 2 had 11 beds and eight chairs. RN 6 stated the ED had a lot of patients held in the ED and were waiting for beds in the hospital. The ED staff were caring for these patients who held in the ED. For ICU patients who physically located in the ED, the RN should only have two patients; however, that did not happen. The administration kept the ED open to paramedics; the ED was not closing to paramedics to bring in patients although the ED was saturated with patients. RN 6 stated at night shift, it was not always the CNO who decided to close the ED; it could be anyone in the administration with no medical background. RN 6 was asked about the ED shift summary shift occurrence. RN 6 stated the ED CN should be documenting on the shift occurrence.

On 3/24/22 at 1130 hours, an interview and concurrent record review was conducted with the Director of ED and Interim Director Clinical Quality. When asked how many RN the ED would have for night shift. The Director of ED stated there should be five RNs for 1900 to 0700 hours; one RN from 1500 to 0300 hours, and one RN from 1800 to 0600 hours. When asked where the patients held in the ED would be placed while waiting for beds in the units to be admitted, the Director of ED stated the patients held in ED would stay in ED 2. When asked about the ED shift summary for 3/14/22, the Director of ED and the Interim Director Clinical Quality stated the day shift CN was assigned to T1 and T2 from 0600 to 0900 hours, the CN would take care the patients physically located on the chairs (4 chairs) when there was no assigned as T2.

On 3/25/22 at 0815 hours, interview and record review was conducted with the Director of ED and the CI. The Director of ED was asked who took care of the ED patients when there were four Critical Care and one SDU patients held in the ED with telemetry hold and medical surgical patients on hold based the ED staffing. The Director of ED could not answer.

5.a. Review of the Position Description for Charge Nurse dated 7/23/10, showed in part:

* JOB SUMMARY:

- The Charge Nurse is a management position responsible for organizing, planning, directing, coordinating, and providing high quality, individualized patient care pursuant to the position accountabilities set forth below.

* POSITION ACCOUNTABILITIES:
- Make daily patient assignments, and schedule breaks, meal periods for each shift.
- Makes independent scheduling decisions and consider each employee's skills, abilities, competency, experience, and expertise given such factors as patient census, patient acuity, complexity of treatment, and the language needs of patients
- In the event of a staffing shortage or emergency, the Charge Nurse shall cover the shortfall by reassigning personnel to make the most effective utilization of unit resources.
- Supervise and delegate work to all unit employees during the Charge Nurse's shift including staff registered nurses, licensed vocational nurses, nursing assistants, unit secretaries, and technicians
- Completes computerized system staffing, scheduling, acuity, etc.
- Rounding hourly for patient satisfaction and safety.

On 3/24/22, the hospital's report titled Assignment by Staff Member from 2/20/22 through 3/22/22 was reviewed for M1, M2, M3, Step Down Unit, and ICU/CCU units to ensure a charge nurse was designated for each nursing floor, each shift as per the Staffing Plan P&P.

The report showed the following units did not have a designated charge nurse on either the day shift or the night shift (not all inclusive):

- For M1: 3/1, 3/3, 3/5, 3/10, 3/11, 3/13, 3/14, 3/15, 3/17, 3/19, 3/20, 3/23.
- For M2: 2/20, 2/21, 2/22, 2/24, 2/25, 3/15, 3/16, 3/17, 3/23.
- For M3: 2/21, 2/22, 2/23, 2/24, 3/13, 3/9, 3/10, 3/12, 3/19, 3/21/22, 3/23.
- For SDU: 2/26, 2/28, 3/14, 3/15, 3/18, 3/19, 3/20, 3/21.
- For ICU/CCU unit: 2/20, 2/21, 2/22, 2/23, 2/25, 2/26, 3/5, 3/7, 3/11, 3/12, 3/21.

b. Review of the Position Description for Nursing Assistant dated 2/21/20, showed in part:

* JOB SUMMARY:
- Work under the direction of a Registered Nurse
- Responsible for providing direct patient
- Data collection and care appropriate to the age of the patients served
- The constant observer maintains constant direct observation and visualization of identified patient(s)

* ESSENTIAL FUNCTIONS:
- Rounding hourly for patient satisfaction and safety
- Ensures food delivery and sets up trays for patient's convenience.
- Feeds patients when necessary and considers patient's ability to chew and swallow.
- Ensures that fresh water and nourishment are provided regularly when appropriate.
- Communicates changes in patient's condition to primary nurse.
- Promptly answers any patient call lights, and immediately provides appropriate assistance.
- Specimen collection, labeling accurately, and timely routing to Laboratory.
- Documents and accurately maintains intake and output.
- Assists in maintaining a safe and clean environment

On 3/24/22, the hospital's report titled Assignment by Staff Member from 2/20/22 through 3/22/22 was reviewed for M1, M2, M3, and ICU/CCU units to ensure the units were staffed with nurse assistants.

The report showed M2 was not staffed with nurse assistants on either the day or on the night shift (not all inclusive) on 3/11, 3/12, 3/13, 3/15, and 3/21/22.

On 3/25/22 at 1322 hours, an interview was conducted with the CNO. The CNO confirmed a charge nurse was not always designated for each nursing floor, each shift. The CNO was asked to clarify the following, "Departments will be staffed by...non-professional personnel to meet their patient care needs." When asked if a non-professional staff meant "Certified Nurse Assistant (CNA)," the CNO stated yes. The CNO acknowledged the Staffing plan stipulated the department would be staffed by CNAs. The CNO also confirmed nursing assistants were not always assigned for each nursing floor, each shift.

6. Review of the hospital's corrective plan for failure to ensure the nurse-to-patient ratio were maintained at all times in the ED, M1, M2, and ICU/CCU with the completion date as of 2/15/22, showed the hospital would make efforts, but not limited to
- Implementing a bonus structure (financial incentives) for RN proactively when creating monthly schedules.
- Reaching out to all RNs on an as needed basis via text/phone call.
- Offering day & night bonuses on a shift-by-shift basis.
- Realigning schedules to back-fill staff that are out on LOA's.
- Offering rapid rate to all available staffing agencies
- Master booking registry and traveler RN.
- Pulling staff from other departments.
- Utilizing nursing leaders.
- Staff forecasting based on the volume and acuity, done by leaders daily at 11 am, 2 pm, and 4 pm.
- Consider acceptance of patient volume via direct admissions by the CNO.
- Review elective procedure admissions by CNO and COO.
- Reaching out to the Department for a staffing waiver and the Medical and Health Operational Area Coordinator (MHOAC) for assistance on 1/5/22.
- Operationalizing Surge Plan and Diversion Plan.
- Follow the recommendations within AFL 20-46.3 Request for Urgent Staffing Resources for COVID-19 and report these issues as an unusual occurrence to the local Department licensing team within 24 hours.

During a complaint validation survey from 3/17/22 to 3/25/22, the following was identified:

* The nurse-to patient ratio was not maintained for M1, M2, and M3 as required. Cross reference to A392, example # 1.

* The nurse-to patient ratio was not maintained for SDU as required. Cross reference to A392, example # 2.

* The nurse-to patient ratio was not maintained for ICU/CCU as required. Cross reference to A392, example # 3.

* The nurse-to patient ratio was not maintained for ED as required. Cross reference to A392, example # 4.

* There was no charge nurse assigned for each shift as per hospital ' s staffing plan. Cross reference to A392, example # 5.

On 3/17/22, the hospital was asked to provide documentation of the efforts exhausted to obtain additional staff including contacting the Department and MHOAC, from 2/15 through 3/17/22.

On 3/17/22, the hospital provided documentation of the bonuses offered to RNs. However, there was no data available for 2/27, 3/16, and 3/17/22.

On 3/17/22, the hospital provided documentation of the number of RNs contacted by staffer with no response. However, there was no data available for 2/27, 2/28, 3/3, and 3/17/22.

On 3/18/22, the hospital did not provide documented evidence to show their most recent corrective plan had been implemented in its entirety from 2/15 through 3/17/22, including:

- Contacting the Medical and Health Operational Area Coordinator (MHOAC) for assistance
- Following the recommendations within AFL 20-46.3 Request for Urgent Staffing Resources
- Reporting staffing issues as an unusual occurrence to the Department within 24 hours.

The CNO acknowledged MHOAC and CDPH were not contacted for urgent staffing resources. The CNO stated per "my interpretation," we did not meet the criteria stipulated in AFL 20-46.3.

Based on observation, interview, and record review, the hospital failed to ensure the RN supervised and evaluated the nursing care for 11 of 33 sampled patients (Patients 5, 12, 16, 17, 18, 27, 29, 30, 31, 32, and 33) as evidenced by:

1. Failure to conduct the pain assessments as per the hospital's P&P for Patients 5, 16, 17, and 18.

2. Failure to supervise the Constant Observer when the Constant Observer was assigned for Patient 16.

3. Failure to ensure a P&P was developed and approved, including approval by the governing body, prior to the implementing of a practice for cardiac rhythm interpretation and failure to ensure the cardiac rhythm interpretations were conducted every 4 hours for 14 patients, including Patients 5, 29, 30, 31, 32, and 33 who were on telemetry monitoring.

4. Failure to notify the physician of the patient's change of condition or nutritional status for Patient 27.

5. Failure to ensure the nursing staff reassessed Patient 12 after Ativan (anti anxiety) 4 mg IVP was administered.

These failures created the increased risk of poor health outcomes to the patients.

Findings:

1. Review of the hospital's P&P titled Pain Management dated 4/21, showed in part:

* Purpose: To describe and support the care of patients experiencing pain including assessment, reassessment and treatment throughout the continuum of care.

* Policy: Assessments and reassessments will be made:

(a) A minimum of every four hours

(b) After any:

- Known pain -producing event

- Pain management intervention

- Change in the level of care

(c) With vital signs or per unit policy

(d) Within 30 minutes following medication administration

(e) As needed.

a. On 3/22/22 at 1030 hours, an interview and concurrent review of Patient 18's medical records was conducted with RN 13.

Patient 18's medical record showed the patient was admitted to the hospital on 3/3/22.

Review of the MAR showed the following:

* The physician's orders for pain medications were written on 3/4/22 at 0820 hours, for Norco one tablet every six hours for pain. Norco (a pain medication) was administered to the patient on 3/5/22 at 1228 hours.

* Another pain medication order was written on 3/3/22 at 2305 hours, for morphine (a pain medication) 1 mg IV Push every three hours for moderate pain. Morphine was administered to the patient on 3/5/22 at 1331 hours.

Request was made for pain assessment flowsheets, but it was not provided.

There was no documented evidence to show the nursing staff had reassessed Patient 18 for pain within 30 minutes after administering the above Norco and morphine to the patient as per the hospital's P&P. In addition, there was no documented evidence to show the nursing staff had conducted the pain assessments for the patient every four hours on 3/5/22, as per the hospital's policy.

RN 13 confirmed the findings.

b. On 3/23/22 at 1130 hours, an interview and concurrent review of Patient 16's medical record was conducted with RN 16.

The medical record showed Patient 16 was admitted to the hospital on 3/19/22.

Review of Patient 16's MAR showed the physician's order to start the medications for the patient on 3/19/22 at 1044 hours as follows:

* Norco one tablet every six hours as needed for moderate pain (on a 0-10 pain scale, with 0=no pain and 10=worst pain).

* Percocet (a pain medication) two tablets every six hours as needed for severe pain.

* Morphine 2 mg IV Push every two hours as needed for moderate pain.

Review of Patient 16's pain assessment record showed there was no documented evidence to show the pain assessments were conducted every four hours for the patient on 3/22/22 (from 0115 to 0800 hours), 3/23/22 (from 0400 to 1600 hours), and 3/24/22 (from 0400 to 1347 hours) as per the hospital's P&P.

RN 16 confirmed the findings.

c. On 3/23/22 at 1130 hours, an interview and concurrent review of Patient 17's medical record review was conducted with RN 13.

The medical record showed Patient 17 was admitted on 2/24/22.

The H&P examination dated 2/24/22, showed the patient had chronic neck pain.

Review of the MAR showed the physician's orders for Percocet 1 tablet every four hours as needed for moderate pain or for the pain level from four to six.

The MAR showed Patient 17 received the pain medications but was not reassessed for pain 30 minutes after the pain medication administration as follows:

* On 2/26/22 at 1255 hours, one tablet of Percocet was administered to the patient. However, there was no documentation to show the effectiveness after the medication administration.

* On 2/27/22 at 0812 hours, one tablet of Percocet was given to the patient. However, the effectiveness was not documented until an hour later or at 0912 hours.

RN 13 confirmed the findings.

d. Review of Patient 5 medical record was initiated with the CI on 3/23/22 at 1310 hours.

Patient 5's medical record showed the patient arrived at the ED on 3/21/22 at 1527 hours, and was admitted to M2 on 3/22/22 at 1703 hours.

Review of Patient 5's physician's order dated 3/21/22 at 1954 hours, showed to admit the patient to telemetry observation.

Review of Patient 5's Pain Assessment on 3/21/22 at 1528 hours, showed the pain level was 0 at the ED triage. When asked for the pain assessment after the triage, the CI stated after the triage, the pain assessment was on 3/22/22 at 0800 hours. There was no documented evidence Patient 5's pain level was assessed and reassessed on the night shift, from 3/21/22 at 1900 hours to 3/22/22 at 0700 hours. The CI stated the initial pain assessment was zero so the pain reassessment was not indicated or needed.

2. Review of the hospital's P&P titled Constant Observer Assessment, Implementation, and Discontinuation for Non-Behavioral Health Patients in Non-Behavioral Health Settings dated 01/22, showed the purpose of this policy is to outline the process for the use of Constant Observers for the non-behavioral health patient including patient assessment, ordering and initiation, staffing, implementation, discontinuation, monitoring/tracking and use of alternatives means of patient monitoring. The section of the Implementation of Constant Observer showed the following:

* The nurse assigned to the patient remains responsible for the nursing care throughout the shift regardless of the presence of a Constant Observer. Other caregivers will also continue to provide care as indicated by the patient's needs.

* The nurse assigned to the patient will document the assessments and observations relative to the continued need for the Constant Observer use per unit assessment frequency protocol.

* The Constant Observer will document patient observation every 15 minutes on the designated flow sheet as indicated and as instructed by the nurse.

On 3/23/22 at 1100 hours, a tour of M1 was conducted with RN 16, the Charge Nurse for the day. When asked if any patients on the unit were on close observation, RN 16 stated there were two patients. In Room 155 Bed B, Patient 16 was observed in bed with 2 point soft restraints to his wrist, but there no sitter at the bedside. CNA 3 was assigned to Patient 16 for close observation, but was observed providing care to another patient in another bed. The curtains was observed drawn completely around the patient, obstructing line of sight for Patient 16.

On 3/23/22 at 1439 hours, an interview was conducted with CNA 3 who assigned to Patient 16. When asked which patient she was assigned to, CNA 3 stated Patient 16. When asked why she was providing care to another patient, CNA 3 stated she was helping another nurse who wasn't there at the time.

On 3/23/22 at 1439 hours, an interview was also conducted with the Acting Risk Management Director, RN 16, and RN 15 about the policy related to Constant Observation. When asked to explain the responsibilities of a staff assigned as the Constant Observation, the Acting Risk Management Director stated staff assigned as the Constant Observer needed to focus and sight on the patient whom he or she was assigned to. When asked if the Constant Observer staff assigned to a patient could also provide care to other patients, the Acting Risk Management Director stated no. When informed of CNA 3 providing care to another patient in the room and not observing Patient 16, the RNs both stated this was not their policy; and the Constant Observer staff should not have been caring for another patient although in the same room, because it was not her assignment. RN 16 confirmed the Constant Observer was assigned to Patient 16 and was not assigned to another patient who was in the same room with Patient 16.

On 3/24/22 at 0930 hours, review of Patient 16's Constant Observer Flow Sheet dated 3/22, 3/23, and 3/24/22, showed the form was signed by the Constant Observer. However, the sections of "RN Name" and "RN Signature" were left bank.


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3.a. On 3/23/22 at 1056 hours, a review of cardiac rhythm strips and a concurrent interview was conducted with RN 21.

RN 21 stated the current practice and requirement included the following:

- The telemetry monitoring technician printed out the cardiac rhythm strip every four hours for all patients on cardiac telemetry monitoring (e.g., 0800, 1200, 1600, 2000, 0000, and 0400 hours).

- The rhythm strips were mounted on the EKG Strip Flow Sheet and placed in a binder.

- Every four hours, the RNs interpreted the rhythm strips in the binder and documented on the EKG Strip Flow Sheet the date, time, interpretation, RN signature and title within one hour of the rhythm strip being posted in the binder.

When asked, RN 21 stated the hospital did not have a written P&P that reflected M2's current practice and requirement, for cardiac rhythm interpretation.

On 3/23/22 at 1144 hours, an interview was conducted with Clinical Manager 1 and the Director Medical/Surgical/Telemetry. They confirmed the requirement for interpreting rhythm strips. They stated the requirement was for the RN to document the interpretation of the rhythm strip every 4 hours on the EKG Strip Flow Sheet that would be filed in the binder by the Telemetry Technician.

On 3/24/22 at 1340 hours, an interview and concurrent review of the hospital's P&P related to the cardiac monitoring was conducted with the Clinical Educator and the Director Medical/Surgical/Telemetry.

Review of the hospital's P&P titled Centralized Cardiac Telemetry Monitoring Model Policy and Procedure with an original effective date of 1/27/22, did not reflect the unit's current practice and the unit's requirement. The P&P showed the registered nurse to obtain, evaluate (interpret), and post a rhythm strip in the eMR at least once per shift. Further review of the hospital's P&P did not show an Approval Date, Review Dates, and P&P Number.

In a concurrent interview, the Clinical Educator confirmed cardiac rhythm strips could not be posted in the eMR at this time.

The Director Medical/Surgical/Telemetry confirmed there was no written P&P for the unit's current practice and the unit's requirement, for interpreting rhythm strip every 4 hours.

b. On 3/23/22 at 1056 hours, a review of cardiac rhythm strips and a concurrent interview was conducted with RN 21. Review of the cardiac rhythm strips showed the RNs were not interpreting the cardiac rhythm strips every 4 hours. The review of rhythm strips for Patients 5, 29, 30, and 31, showed the patients' cardiac rhythm strips had not been interpreted by the RN on 3/23/22 at 0800.

The findings were shared with RN 21.

c. On 3/23/22 at 1115, review of cardiac rhythm strips for 14 patients on telemetry monitoring was conducted and showed that the cardiac rhythm strips had not been interpreted every four hours.

The following were examples of the patients for which the cardiac rhythm strips were not interpreted (not all inclusive):

- For Patient 32, eight rhythm strips had not been interpreted from 3/21 through 3/23/22.

- For Patient 33, 12 rhythm strips had not been interpreted from 3/20 through 3/23/22.

On 3/23/22 at 1144 hours, an interview and concurrent review of document was conducted with Clinical Manager 1. Clinical Manager 1 confirmed the findings.

4. Review of the hospital's P&P titled Patient Assessment/Reassessment dated 10/6/20, showed in part:

- The goal of the assessment and reassessment process is to provide the patient with the best and most appropriate individualized care and treatment.

- Responsibility for this P&P includes all disciplines involved in direct patient care

- For all patient, reassessment is at a specified, regular intervals related to significant change in the patient condition.

- Nursing reassessment is completed every shift in-patient care areas or more frequently as indicated by patient condition. Documentation is completed in the patient medical record. Reassessment includes but is not limited to nutritional status.

On 3/24/22 at 1011 hours, Patient 27's record review and concurrent interview was conducted with Clinical Manager 2.

Patient 27's medical record showed the patient was admitted to the hospital on 2/24/22. The patient had advanced dementia with declining function and behavior disturbances and was taking antipsychotics per psychiatry.

The Rehab Note dated 3/2/22 at 1534 hours, showed the swallow evaluation was attempted, but the patient was spitting out food. The ST will reattempt tomorrow.

The SLP evaluation dated 3/3/22 at 1339 hours, showed the recommendations included to continue dysphagia, with nectar thick diet; and strict aspiration precautions: all liquids via tsp., fold pillow behind head to reduce neck extension as needed. The RN was notified.

The Rehab Note dated 3/4/22 at 1017, showed the ST attempted swallow intervention; however, the patient was unarousable. Per the sitter at bedside, the patient was unable to sustain adequate wakefulness levels for breakfast. The RN was unable to administer medications to the patient.

Review of the meal intake documentation from 2/24 through 3/5/22, showed the meal percentage was not documented for the following:

- 2/24 (dinner), 2/25 (lunch and dinner), 2/27 and 2/28 (breakfast, lunch, and dinner), 3/1 (lunch), 3/2 (breakfast, lunch, and dinner), 3/5/22 (breakfast).

Review of the medical record, Patient 27 refused to eat on 3/3 (lunch and dinner), 3/4 (breakfast, lunch, and dinner), and 3/5/22 (breakfast).

The patient's medical record did not show documentation the RN had reported the patient's change in condition/nutritional status to the physician.

The Clinical Manager acknowledged the findings.


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5. Review of hospital's P&P titled Patient Assessment and Reassessment dated 10/20, showed in part: Reassessment is a component of the patient care plan and is conducted at key determined intervals, as well as throughout the continuum. Reassessment is the evaluation of patient's response to treatment and care, in order to determine, the appropriateness and effectiveness of the care decisions. The goal of the assessment and reassessment process is to provide the patient with the best and most appropriate individualized care and treatment.

On 3/24/22 at 0830 hours an interview and concurrent review of Patient 12's medical record was conducted with the CI.

Patient 12's medical record showed the patient arrived to the ED on 3/22/22 at 0430 hours.

Review of the ED Note-Physician dated 3/22/22 at 0620 hours, showed Patient 12 was seen at 0621 hours. Patient 12 presented to ED with alcohol withdrawal with the symptom of shaking. The Physical Exam section showed the patient was moderately tremulous, alert and oriented to person, place, time and situation.

Review of the physician's order and the EMAR showed the following:

- Ativan 2 mg IVP STAT with the start date as of 3/22/22 at 0446 hours. The EMAR showed, Ativan 2 mg IVP was administered to Patient 12 on 3/22/22 at 0530 hours.

- Ativan 2 mg IVP STAT with the start date as of 3/22/22 at 0543 hours. The EMAR showed, Ativan 2 mg IVP was administered to Patient 12 on 3/22/22 at 0555 hours.

The CI was asked for the reassessment for Patient 12 after the two doses of Ativan 2 mg IVPs were administered to the patient. The CI stated there was no documented evidence the patient was reassessed after the two doses of Ativan (total of 4 mg) IVP were given. The CI stated it did not require to document the reassessment on the EMAR. When asked how Patient 12 would be assessed if the treatment provided was effective or appropriate. The CI could not answer. The CI stated she could bring this up.

On 3/24/22 at 1130 hours, an interview was conducted with the Director of ED. When asked what the expectation of the RNs was after administered two doses of Ativan 2 mg IVP to the patient with alcohol withdrawal and with diagnosis of delirium tremens. The Director of ED stated Patient 12 should have been reassessed less than 60 minutes after the 2 doses of Ativan IVP were administered.

Based on interview and record review, the hospital failed to develop and maintain the care plans to address the care needs for four of 33 sampled patients (Patients 15, 16, 17, and 18). This failure posed an increased risk of substandard health outcomes to these patients.

Findings:

Review of the hospital's P&P titled Interdisciplinary Plan of Care revised 6/2021 showed in part:

Purpose - To ensure that care, treatment, and rehabilitation are planned and appropriate to the patient's needs and severity of illness. (B) To identify individualized patient care goals and interventions and to achieve those goals in a collaborative, interdisciplinary manner.

The RN will initiate a Plan of Care after completion of the admission assessment.

* The plan of care will be reviewed every shift and updated as patient progress indicates.

* The patient, and family, and/or partner -in-care will participate in the plan of care as appropriate.

* The plan of care will be reviewed, modified as needed, or completed and/or discontinued at least once a shift.

1. On 3/22/22 at 1240 hours, a medical record review for Patient 15 was conducted with RN 13. The medical record showed Patient 15 was admitted to the hospital on 3/20/22.

Review of the H&P examination dictated on 3/20/22 at 2229 hours, authenticated and edited by the physician on 3/21/22 at 0716 hours, showed Patient 15 had altered mental status, probable secondary to seizure disorder.

Review of Patient 15's care plans did not show a problem list for cognition care concerning altered mental status.

2. On 3/23/22 at 1030 hours, medical record review for Patient 18 and concurrent interview was conducted with RN 13. The medical record showed Patient 18 was admitted to the hospital on 3/3/22.

Review of Patient 18's H&P examination dated 3/3/22, showed Patient 18 came to the hospital with chief complaints of "altered X 1 wk, worsened pressure ulcer." The patient had an unstageable pressure injury to his left buttocks with bone exposed.

The physician's orders for Norco (a pain medication) 5 mg oral table as needed for moderate/severe pain was written on 3/4/22 at 0820 hours, and administered at 1228 hours on 3/5/22, for moderate pain level of 5 (on a 0-10 pain scale, with 0 = no pain and 10 = worst pain).

However, Patient 18's care plan problems including skin integrity care plan were not initiated until 3/8/22. In addition, there was no care plan problem initiated or implemented for Patient 18's pain issue. There was no problem list for AMS (Altered Mental Status) which was the complaint on Patient 18's admission.

RN 13 confirmed the care plan problems should have been initiated on admission.

3. On 3/23/22 at 1130 hours, an interview and medical record review for Patient 16 was conducted with RN 16. The medical record showed Patient 16 was admitted to the hospital on 3/19/22.

* Review of the H&P examination dated 3/20/22, showed Patient 16 was admitted for alcoholic cirrhosis and symptomatic ascites.

Review of the care plans for Patient 16 showed a problem list for liver condition was not initiated when the patient was admitted.

* Review of the nurse's documentation on the flowsheet dated 3/21/22, showed Patient 16's mental status had changed, whereas he became agitated, and confused. However, the care plan was not initiated until 3/23/22, and not updated to show changes in Patient 16's cognition.

* Review of Patient 16's physician's orders, dated 3/19/22 showed pain medications of morphine (a pain medication) and Norco to be given for moderate pain as needed. However, Patient 16's care plan showed no problem list for pain interventions was initiated or implemented.

4. On 3/23/22 at 1130 hours, a review of Patient 17's medical record and concurrent interview was conducted with RN 13. The medical record showed Patient 17 was admitted on 2/24/22.

Review of the H&P examination dated 2/24/22, showed Patient 17 fell out of bed approximately two to three hours prior to arrival to the hospital. The assessment/plan section of the H&P examination showed the patient had chronic neck pain.

* The physician's orders were written for pain interventions on 2/24/22. Patient 17 received Percocet for moderate pain on 2/26/22. However, review of Patient 17's plan of care showed no care plan problem addressing Patient 17's pain issues until 3/10/22.

* There was no care plan problem addressing Fall Risk until 3/10/22.

* Review of the Wound Care Note dated 3/4/22 at 1121 hours, showed Patient 17 had a DTI to the sacral/coccyx area. There was no care plan problem was initiated or implemented for skin integrity until 3/5/22.

RN 13 confirmed these problems should have been listed at time of admission.

Based on interview and record review, the hospital failed to ensure the nursing staff adhered to the hospital's P&Ps as evidenced by:

1. Failure to ensure the crash carts were checked daily for M1, M2, M3, SDU, Critical Care Departments, and ED as per the hospital's P&P.

2. Failure to ensure the nursing staff conducted the assessment of restrained patient status every two hours for four hours as per the hospital's Restraint and Seclusion P&P for one of 33 sampled patients (Patient 27).

3. Failure to ensure the nursing staff documented an event in the patient's medical record for one of 33 sampled patients (Patient 2).

4. Failure to ensure the nursing staff documented a change in conditions for one of 33 sampled patients (Patient 16).

These failures had the potential to put the patients at risk for negative health outcomes.

Findings:

1. Review of the hospital P&P titled Crash Cart Maintenance dated 7/30/21, showed in part:

* DEFINITION:

- A crash cart is a secured portable cart that contains a defibrillator, medications and supplies that may be needed in an emergency and/or code situation.

* PURPOSE:
- To assure that all crash carts are in a state of readiness for use in an emergency situation.

* CRASH CART CHECKLIST:
- Crash carts are checked twice daily for 24-hour care units.

* PROCEDURE FOR CRASH CART CHECK AND MAINTENANCE
- Every shift, the RN or unit technilogist performing the check will sign his/her name indicating that the check was completed.

a. On 3/22/22 at 1056 hours, a tour of M2 was conducted with Director of Rehabilitation and Clinical Manager 1.

The M2 Crash Cart Checklist for March 2022 was reviewed. The following was identified:

- No signature indicating that the crash cart check was performed for 3/3/22 (day shift), 3/4, 3/5, 3/6, 3/7, 3/9, 3/11, 3/12, 3/13, 3/15, 3/16, and 3/19/22 (noc shift).

Clinical Manager 1 confirmed the findings that the CN was not checking the crash cart daily as per the hospital's P&P.

b. The Crash Cart Checklists for August 2021 through March 2022 were requested and reviewed for M1, M2, M3, SDU, Critical Care Department, and the ED. The following was identified:

- For M1, M2, M3: there was no signature indicating the crash cart check was completed for at least 200 shifts.
- For SDU: there was no signature indicating the crash cart check was completed for at least 30 shifts.
- For Critical Care Department: there was no signature indicating the crash cart check was done for at least 15 shifts.
- For ED: there was no signature indicating the crash cart check was done for at least 20 shifts.

On 3/24/22 at 1011 hours, the Clinical Manager 2 was interviewed and stated there was no auditing to confirm if the crash cart checks were performed as per the hospital's P&P.

2. Review of the hospital's Restraint and Seclusion P&P dated 2/11/21, showed in part:

- Monitoring and Reassessments: Real-time documentation of assessment of restrained patient status at a minimum of every two hours for two point restraints.

On 3/24/22 at 1011 hours, an interview and concurrent review of Patient 27 medical record review was conducted with Clinical Manager 2.

Patient 27's medical record showed Patient 27 was admitted to the hospital on 2/24/22, for hypertension and UTI.
The patient had advanced dementia with declining function and behavior disturbances and was taking antipsychotics per psychiatry.

Further review of Patient 27's medical record showed the patient was in two point soft bilateral upper extremity restraints from 2/25/22 through 3/4/22. The restraints were ordered for interfering with medical devices.

Review of the Restraint Placement/Monitoring from 3/3/2 at 1600 hours to 3/4/22 at 0600 hours, showed Patient 27 was assessed on 3/3/22 at 1600 and 2000 hours when the patient was in two point soft restraint. However, there was no documentation the RN conducted the monitoring and reassessment on 3/3/22 at 1800 hours as per the hospital's P&P.

Clinical Manger 2 confirmed the findings.


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3. Review of hospital's P&P titled Nursing Documentation last revised 1/21, showed the policy specified "Documentation of patient care is to be pertinent, concise, and reflect the patient's status/outcome(s) to care."

Patient 2's medical record was reviewed on 3/23/22 at 0800 hours.

The case management reassessment document dated 3/22/22 at 1450 hours, showed SW 1 documented "on the way out of the ED (emergency department) waiting room SW saw patient ha[s] a seizure, when the nurse...were next to her". There was no other documentation in Patient 2's medical record regarding this incident.

An interview with SW 1 was conducted on 3/23/22 at 0840 hours. Per SW 1, Patient 2 had blood drawn and suddenly started having a "seizure". SW 1 stated a male nurse came out and put the patient in a wheelchair and took the patient back to the ED. Patient 2 arrived at the ED at 1300 hours and was still in ED waiting for Psychiatric Emergency Team to perform an assessment.

An interview with RN 2, a triage nurse was conducted on 3/23/22 at 1040 hours. RN 2 stated the incident was less than one minute, Patient 2 started to slide down from the chair and RN 2 came to the patient to support the patient's head. RN 2 called Patient 2's name and noted Patient 2 was tracking, had no loss of muscle or loss of consciousness and she followed commands. RN 2 stated he did not consider it a seizure and he asked the patient's family member who said the patient did not have history of seizure. RN 2 did not document this in the patient's medical record because he did not believe it was a true seizure.

An interview with the Director of ED was conducted on 3/23/22 at 1140 hours, the Director of ED acknowledged that RN 2 should have documented Patient 2's event as per the hospital's P&P.


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4. Review of the hospital's P&P titled Nursing Documentation dated 1/21, showed in part:

* (H) Changes in a patient condition and communication with the other licensed independent practitioners shall be documented.

* VI. Surge Standards of Nursing Documentation: Patient Assessments: Ongoing patient assessments will continue to be performed as required by each unit's guidelines of care. However, documentation these assessments will be made by exception. "By exception" means that a notation is made only when there is a deviation from baseline, deviation from normal limits, or an unexpected outcomes.

On 3/23/22 at 1130 hours, medical record review for Patient 16 was initiated. The medical record showed Patient 16 was admitted to the hospital on 3/19/22.

Review of H&P examination dictated on 3/20/22, showed Patient 16 was alert and oriented.

On 3/23/22 at 1430 hours, an interview and concurrent review Patient 16's medical record was conducted with RN 16. Review of the flowsheet showed documentation of Patient 16's mental status change began on 3/21/22.

Review of the nurse's assessment flowsheet from 3/20/22 to 3/24/22, showed Patient 16 started to become disorganized in his thought process on 3/20/22 at 1956 hours. On 3/20/22 at 1948 hours, Patient 16's neurological check showed thought process was confused and anxious as well on 3/21/22 at 0722 hours and 3/22/22 at 2140 hours, in which he remained anxious and confused and was then ordered by the physician on 3/21/22 for constant observations and two point soft restraints due to confusion.

An interview was conducted with RN 16 concerning documentation per hospital's policy. RN 16 stated nurses only documented by exception or changes in condition. When asked if a change in Patient 16' mental status was considered a change in condition, or an exception, RN 16 stated yes. However, there were no documentation for Patient 16's changes in conditions for 3/20/22 through 3/22/22.

Based on observation, interview, and record review, the hospital failed to ensure the nursing staff administered the medications to two of 33 sampled patients (Patients 11 and 12) as per the hospital's P&P and physician's ordered as evidenced by:

1. The nursing staff failed to assess the patient's BP when restarting norepinephine (a medication to treat low BP) for Patient 11 and failed to assess the patient's RASS score and titrate propofol (an anesthetic medication or sedative) when administering profopol for Patient 11.

2. The nursing staff failed to ensure Ativan (a medication to treat alcohol withdrawal symptoms) was administered to Patient 12 as per the physician's order. In addition, the nursing staff did not assess Patient 12's vital signs after Ativan was administered and failed to assess the patient for severe withdrawal symptoms before Ativan was administered.

These failures posed the increased risk of substandard health outcomes to the patients.

Findings:

1. Review of the hospital's P&P titled IV Infusion Titration Per Pharmacy Protocol revised 2/2021 showed in part:

- Titration orders: orders for medication whereby the dose maybe increased or decreased in response to patient condition, physiologic target, or therapeutic goal.

- The timeframe of the RASS score documentation will be at minimum of every two hours and as needed based on the titration dose administered by the nursing staff.

- Any emergent drip titration orders outside of the approved protocol will be covered by policy as long as patient condition and documentation support the titration and a provider is notified and updates the order. This will include the nurse initiating emergency measures (i.e. stopping the medication) in the event that the patient becomes hemodynamically unstable while awaiting for a return call from the physician.

On 3/23/22 at 0852 hours, a tour of the ICU/CCU unit was conducted with the Director of ICU/CCU and Clinical Educator.

Patient 11 was in RM M and intubated. Norepinephrine and propofol drips were infusing through the right neck central venous catheter. The Director of ICU/CCU stated Patient 11 was recently admitted to the unit.

On 3/24/22 at 1410 hours, an interview and concurrent review of Patient 11's medical record review was conducted with the CI.

Patient 11's medical record showed Patient 11 departed ED on 3/23/22 at 0715 hours to be admitted to ICU.

Review of the ED Note-Physician dated 3/23/22 at 0206 hours, showed Patient 11 came to the hospital's ED on 3/23/22, with a chief complaint of shortness of breath. Patient 11 was intubated and the patient's SBP dropped to 86 mmHg on 3/23/22 at 0600 hours.

a. Review of the physician's order dated 3/23/22 at 0633 hours, showed the following:

* To administer norepinephrine 4 mg in 250 ml NS (normal saline solution).
* Start at 1 mcg/min.
* Titrate up or down by 1 mcg/min every three minutes to keep the SBP more than 90 mmHg or MAP more than 65 mmHg.
* If clinical response was not achieved at 50 mcg/min, notify the MD.
* The maximum dose was 50 mcg/min.

Review of Patient 11's EMAR for the infusion titration of the norepinephrine dated 3/23/22 and the Vital Signs. showed the following:

- At 0600 hours, the norepinephrine drip was initiated at 5 mcg/min, the patient's BP was 86/54 mmHg and MAP was 65 mmHg.

- At 0653 hours, the norepinephrine drip was turned off. The patient's BP was 153/110 mmHg and MAP value was left blank.

- At 0721 hours, the norepinephrine drip was restarted at 5 mcg/min; however, there was no documented evidence the nursing staff assessed the patient's BP was measured. There was no documented evidence showing the reason to restart the norepinephrine drip.

Review of the RN note did not show documented evidence to support for restarting the norepinephrine drip.

The CI verified the finding.

b. Review of the physician's order dated 3/23/22 at 0657 hours, showed the following:

* Administer propofol 1000 mg in 100 ml, concentration 10 mg/ml.
* Start at 5 mcg/kg/min
* Titrate by 5 mcg/kg/min every five minutes, for the goal RASS score of minus two
* The maximum dose of 100 mcg/kg/min.

Review of Patient 11's EMAR for the propofol infusion and the RASS monitoring showed the following:

* On 3/23/22:

- At 0600 hours, the propofol drip was started at 5 mcg/kg/min. However, there was no documented evidence the nursing staff had assessed the patient's RASS score.

- At 0644 hours, the propofol drip was increased to 10 mcg/kg/min. However, there was no documented evidence the nursing staff had assessed the patient's RASS score.

- At 0653 hours, the propofol drip was increased to 15 mcg/kg /min. However, there was no documented evidence the nursing staff had assessed the patient's RASS score.

- At 0700 hours, the patient's RASS score was minus two.

- At 0721 hours, the propofol drip was increased to 20 mcg/kg/min. However, there was no documented evidence the nursing staff had assessed the patient's RASS score.

- At 1900 hours, the propofol drip was at 50 mcg/kg/min, and the patient's RASS score was minus two.

- At 2000 to 2300 hours the propofol drip was at 50 mcg /kg /min and the RASS score were minus three hourly (over sedated). There was no documented evidence the RN had attempted to decrease the dose to achieve the goal of RASS score of minus two.

* On 3/24/22:

- From 0000 to 0700 hours, the propofol drip was at 50 mcg /kg/min and the RASS score were minus three hourly (over sedated). There was no documented evidence the RN attempted to decrease the dose to achieve the goal of RASS score of minus two.

- At 0800 hours, the propofol drip was increased to 70 mcg/kg/min with the RASS score of minus two. The rate of the propofol drip was remaining at 70 mcg/kg/min until 1400 hours with the RASS score of minus two.

- At 1500 hours, the propofol drip was decreased to 35 mcg/kg/min with the RASS score of plus three. When asked what was the reason for the 50% decreased of the propofol dose, the CI could not find the reason why the propofol dose was decreased.

On 3/25/22 at 1100 hours, an interview and concurrent review of Patient 11's medical record was conducted with the Clinical Educator. The Clinical Educator was asked what was the reason for the increase of the propofol drip to 70 mcg/kg/min when the patient's RASS score was minus two. The Clinical Educator could not find the reason why the rate was propofol drip was increased to 70 mcg/kg/min. When asked for the reason why the propofol dose was decreased to 35 mcg/kg/min (50%) with the RASS score of plus three, the Clinical Educator could not find the reason why the propofol drip dose was decreased to 35 mg/kg/min.

3. Review of the hospital's document for CIWA (undated) showed the CIWA score will be assessed as the total scores of 10 categories as following:

* Nausea/Vomiting: the score of this category will be from 0 to 7.
* Tactile disturbances: the score of this category will be from 0 to 7.
* Tremor: the score of this category will be from 0 to 7.
* Auditory disturbances: the score of this category will be from 0 to 7.
* Paroxysmal Sweats: the score of this category will be from 0 to 7.
* Visual disturbances: the score of this category will be from 0 to 7.
* Anxiety: the score of this category will be from 0 to 7.
* Headache: the score of this category will be from 0 to 7.
* Agitation: the score of this category will be from 0 to 7.
* Orientation/Clouding of Sensorium: the score of this category will be from 0 to 4.

Review of the hospital's CIWA Score showed "Patients scoring less than 10 do not usually need additional medication for withdrawal."

On 3/24/22 at 0830 hours, an interview and concurrent review of Patient 12's medical record was conducted with the CI.

Patient 12's medical record showed the patient arrived to the ED on 3/22/22 at 0430 hours and was triaged as ESI level 2.

Review of the ED Note-Physician dated 3/22/22 at 0620 hours, showed Patient 12 was seen at 0621 hours. The patient presented to ED with alcohol withdrawal with the symptom of shaking. The Physical Exam section showed Patient 12 was moderately tremulous, alert, and oriented to person, place, time and situation. Medical Decision Making section showed the differential diagnosis included alcohol withdrawal, alcohol intoxication, delirium tremens, and electrolyte imbalance.

Further review of Patient 12's medical record showed on 3/22 at 0627 hours, Patient 12 was admitted to the telemetry unit. However, the admission order was changed to admit the patient to the SDU at 1319 hours. Patient 12 left the ED at 1530 hours to be admitted to the SDU.

Review of the physician's orders for CIWA with the start date as of 3/22/22 at 0709 hours and the stop date as of 3/22/22 1424 hours, showed the following:

- CIWA every hour for 12 hours; as needed; and assess 15 minutes after each Ativan administration.
- Vital sign every one hour; as needed; and assess BP, HR, RR, and SPO2 15 minute after every Ativan dose.
- CIWA every four hours for 12 hours, for patient scoring from 11 to 25 on CIWA.

a. Review of the physician's order for Ativan showed the following:

- Ativan 2 mg IVP every 1 hour, for 4 doses. The Ativan would be started on 3/22/22 at 0800 hours, stopped on 3/22/22 at 1100 hours. The initial dose is administered for the CIWA score of 11 to 25. The Ativan would be held if RR less than 12 breaths per minute, the Riker score less than 4, SPO2 less than 92% or increasing need for oxygen.

- Ativan 2 mg IVP every hour PRN, for withdrawal symptoms for 12 hours. The Ativan would be started on 3/22/22 at 0739 hours and stopped at 3/22/22 at 1930 hours. If CIWA score continues to escalate after the initial first 2 doses were given hourly, two additional doses might be given to the patient. The Ativan would be started at least 1 hour after the last dose. The Ativan would be held if RR less than 12, Riker score less than 4, SPO2 less than 92% or increasing need for oxygen.

Review of the CIWA assessment, EMAR administration of Ativan, and the Vital Signs dated 3/22/22, showed the following:

- At 0852 hours, the CIWA score was left blank; however, the assessment for each category was performed except for tactile disturbance category. The CIWA score was 25 when added the score from each category.

- At 0907 hours, the EMAR showed Ativan 2 mg IVP was administered to Patient 12. However, there was no documented evidence the VS was assessed for the patient 15 minutes (or at 0922 hours) after the Ativan was administered.

- At 1000 hours, the CIWA score was 16. At 1012 hours, Ativan 2 mg IVP was administered. However there was no documented evidence the VS was assessed for the patient 15 minutes (or at 1027 hours) after the Ativan was administered.

- At 1300 hours, the CIWA scores was 11. At 1315 hours, Ativan 2 mg IVP was administered to Patient 12. At 1415 hours, the patient had agitation and anxiety. However, there was no documented evidence the VS was assessed for the patient 15 minutes (or at 1330 hours) after the Ativan was administered.

- At 1400 hours, there was no documented evidence of CIWA assessment. However, at 1410 hours, Ativan 2 mg IVP was administered to Patient 12.

b. Review of another physician's order for Ativan dated 3/22/22 at 1450 and 1451 hours, showed the following:

- Ativan 1.5 mg IVP every 4 hours as needed, for severe withdrawal symptom, hold for RR less than 12 breaths per minute.

- Ativan 1 mg, 1 tablet every 6 hours as needed, for moderate withdrawal symptoms.

- Ativan 0.5 mg, 1 tablet every 6 hours as needed, for mild withdrawal symptoms.

Review of the CIWA assessment, EMAR administration of Ativan, and the Vital Signs showed the following:

* On 3/22/22:

- At 1500 hours, there was no documented evidence of CIWA assessment.

- At 1556 hours, Ativan 1.5 mg IVP was administered to Patient 12. However, there was no documented evidence Patient 12 was assessed for the severe withdrawal symptoms.

- At 1600 and 1800 hours, the CIWA score was 10 and 6, respectively.

- At 1955 hours, Ativan 1.5 mg IVP was administered. However, there was no documented evidence Patient 12 was assessed for the severe withdrawal symptoms.

- At 2000 hours, the CIWA score was 6. At 2200 hours, there was no documented evidence assessment for CIWA.

* On 3/23/22:

- At 0000 and 0200 hours, the CIWA score was 4 and 8 respectively.

- At 0205 hours, Ativan 1.5 mg IVP was administered to Patient 12. However, there was no documented evidence the patient was assessed for severe withdrawal symptoms.

The CI confirmed the above findings.

The CI was asked what was the severe, moderate, and mild withdrawal and how the RNs assessed the severe, moderate, and mild alcohol withdrawal. The CI could not answer. The CI was asked what was the RNs rationale to administer the Ativan 2 mg IVP Patient 12, The CI could not answer.

On 3/25/22 at 1345 hours, an interview and concurrent record review was conducted with Interim Director Clinical Quality. When asked for the RNs guidance of the assessment for the severe, moderate, and mild alcohol withdrawal symptoms, the Interim Director of Clinical Quality stated the guidance to perform the CIWA assessment was in the EHR. However, the scores did not indicate if severe, moderate, or mild withdrawal symptoms. The CIWA score reference showed for patients scoring less than 10 did not usually need additional medications for withdrawal. The Interim Director of Clinical Quality stated this was an opportunity for the hospital to review the CIWA assessment.

Based on interview and record review, the hospital failed to ensure the nursing staff timely administered the blood products as ordered by the physician for one of 33 sampled patients (Patient 28). This failure had the potential to put the patient at risk for negative health outcomes.

Findings:

On 3/25/22 at 1020 hours, an interview and concurrent review of Patient 28's medical record was conducted with the Clinical Educator.

Patient 28's medical record showed the patient was admitted to the hospital on 2/26/22, for sepsis.

Review of Patient 28's laboratory result showed the following:

* On 2/26/22 at 1705 hours, the platelet count was 43 (low).

* On 2/27/22 at 0805 hour, the platelet count was 14.

Review of the physician's order dated 2/27/22 at 1007 hours, showed to administer two units of platelet STAT for Patient 28.

Further review of Patient 28's medical record showed 1 unit of platelet was administered to Patient 28 on 2/27/22 from 1125 hours through 1233 hours. The second unit of platelet was not administered to the patient until 2/27/22 at 0000 hours (pr approximately 11 hours later).

There was no documentation showing the reason for the delay in administering the second unit of platelet to Patient 28.

In a concurrent interview, the Director of Laboratory was interviewed and stated the two units of platelet were ready for Patient 28 on 2/27/22 at 1015 hours.

The Clinical Educator acknowledged there was the delay in administering the second unit of platelet to Patient 28.