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Based on document review and interview, it was determined that for 2 of 2 Transporters (E #9 and E #10), the Hospital failed to provide care in a safe setting by ensuring that the transporters followed the procedure to request assistance to move a patient for transport that required a two-person assist.

Findings include:

1. On 2/14/2023, the clinical record for Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital with diagnoses of UTI (urinary tract infection) and acute pyelonephritis (inflammation of the kidneys). The clinical record indicated that Pt. #1 needed two-person assist when moving while in bed.

2. On 2/15/2023, the Transporter Sheet on 1/04/2023 was reviewed. The sheet indicated that at approximately 10:24 AM, E #10 transported Pt. #1 from Pt. #1's room to radiology for a CT (computerized tomography) scan. At approximately 11:41 AM, E #9 transported Pt. #1 from the CT scan back to Pt. #1's room.

3. On 2/15/2023, the Hospital's Transport Department's Standard Operating Procedure (undated) was reviewed and included, "... The Transport (Department) covers the entire hospital... The Transporter will notify the patient's nurse of the move and ask for assistance with moving patient to wheelchair or (cart)..."

4. On 2/15/2023 at approximately 9:30 AM, an interview was conducted with E #5 (Registered Nurse). According to E #5, Pt. #1 required two-person assistance when being moved from the bed. E #5 said that she was not aware when the transporter took and brought Pt. #1 back to the room.

5. On 2/15/2023 between 9:50 AM and 10:08 AM, interviews were conducted with E #9 and E #10. E #9 and E #10 stated that they did not notify the nurse when they moved Pt. #1. E #10 stated that normally, only one transporter transfers a patient from the bed to the cart.

Based on document review and interview, it was determined that for 1 of 2 patients' (Pt. #8) clinical records reviewed for restraints, the Hospital failed to ensure documentation of a one-hour face-to-face evaluation was completed, as required.

Findings include:

1. On 02/15/2023 at approximately 10:30 AM, the Hospital's policy titled, "Restraint" dated 10/2021, was reviewed and included, " ...Violent Restraints ...Assessment and Reassessment ...within one hour of the initiation of restraint for violent , self-destructive behavior, a face-to-face assessment must be completed by a physician, or licensed independent practitioner, regardless if the restraint has been discontinued ..."

2. On 02/15/2023 at approximately 11:00 AM, the clinical record of Pt. #8 was reviewed. Pt. #8 was admitted to the Emergency Department (ED) on 01/30/2023 at 11:05 AM, with a diagnosis of bipolar disorder. The clinical record indicated that Pt. #8 was aggressive and was threatening hospital staff. A physician order dated 01/30/2023 at 11:25 AM, indicated to place Pt. #8 on 4 point violent restraints. Pt. #8 was placed on four-point violent restraints on 01/30/2023 at 11:25 AM and discontinued on 01/30/2023 at 2:10 PM. Pt. #8's clinical record did not include the one-hour face to face evaluation within 1 hour of the initiation of the violent restraints.

3. On 02/15/2023 at 11:30 AM, the Nurse Director (E #4) was interviewed. E #4 stated that the one-hour face-to-face should have been completed for the behavioral violent restraints. E #4 stated that she was not sure why it was not done.

4. On 02/15/2023 at 2:00 PM, findings were discussed with the Chief Nurse Officer (E #8). E #8 could not provide documentation on one-hour face-to-face evaluation for Pt. #8.

A. Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #1) clinical records reviewed for nursing pain assessments, the Hospital failed to ensure that the registered nurse (RN) supervised and evaluated the nursing care for each patient by failing to follow the pain management procedure, as required.

Findings include:

1. On 2/15/2023, the Hospital's policy titled, "Pain Management" (effective 2/2022) was reviewed and required, "...All patients have the right to appropriate... assessment and management of their pain... 5. The physician will be notified when pain interventions are not effective in achieving the patient's acceptable level of pain. 6. Perform reassessment within 30 minutes for any (intramuscular or intravenous medications)..."

2. On 2/14/2023, the clinical record for Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital with diagnoses of UTI (urinary tract infection) and acute pyelonephritis (inflammation of the kidneys). The clinical record included:

- On 12/23/2022, the pain assessment rating at 6: 55 AM was 7 (unacceptable pain level). There was no documentation if any interventions were provided to Pt. #1.
- On 1/04/2023 at 12:38 PM, Pt. #1 had a pain rating of 10 (severe pain) and Morphine 2 milligrams (intravenous pain medication) was given. A pain reassessment was conducted at 1:53 PM (1 hour and 15 minutes).
- On 1/04/2023 at 4:53 PM, Pt. #1 had a pain rating of 10 and Morphine 2 mg intravenous injection was given. A pain reassessment was conducted at 6:18 PM (1 hour and 25 minutes).

3. On 2/16/2023 at approximately 9:30 AM and 11:30 AM, findings were discussed with E #8 (Chief Nursing Officer). E #8 could not provide documentation if an intervention was provided to Pt. #1 on 12/23/2022. E #8 added that pain reassessments should be documented 30 minutes after administration of intravenous medication.



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B. Based on observation, document review, and interview, it was determined that for 2 of 2 patients' (Pt. #2 and Pt. #3) reviewed for intravenous therapy, the Hospital failed to ensure that a registered nurse supervised and evaluated the nursing care by failing to conduct IV site assessments and ensure that IV administration set was changed every 96 hours, as required.

Findings include:

1. On 02/14/2023 between 9:30 AM - 11:30 AM, an observational tour of the 2nd Floor Medical Surgical Unit was conducted. The following was observed:

-At 10:10 AM, Pt. #2 in Room #203-02 was seen with intravenous normal saline 1000 ml (milliters) bag infusing via the IV site located in her right anti-cubital area (inner part of the elbow) with no date and time at the IV dressing site and no date and time label on the IV tubing.

- At 10:15 AM, Pt. #3 in Room #207-02 was seen with intravenous ringers lactate 1000 ml (milliters) bag infusing via the IV site located in her right ante-cubital area, with no date and time at the IV dressing site and no date and time label on the IV tubing.

2. On 02/15/2023, Pt. #2's clinical record was reviewed. Pt. #2 was admitted to the Hospital on 01/31/2023 at 6:46 AM, with the diagnoses of pressure injury of skin, and urinary tract infection. Pt. #2's clinical record included a physician order dated 02/01/2023 at 4:40 PM, sodium chloride 0.9 percent normal saline at 75 ml/hr (milliliters per hour). Pt. #2's clinical record lacked IV site shift assessments from 1/31/2022 through 2/14/2022.

3. On 02/15/2023, Pt. #3's clinical record was reviewed. Pt. #3 was admitted to the Hospital on 02/12/2023 at 8:09 AM, with a diagnosis of gallstones. Pt. #3's clinical record included a physician order dated 02/13/2023 at 5:00 PM, dextrose 5 percent lactated ringers at 100 ml/hr. Pt. #3's clinical record lacked IV site shift assessments from 2/12/2023 through 2/14/2023.

4. On 02/15/2023, the Hospital's policy titled, "IV [intravenous] Therapy Guidelines" dated 12/2022, was reviewed and included, " ...Replace administration sets that are continuously used ...no more than 96-hours ...all catheter insertion sites will have a dressing ...is changed every 96 hours ...the nurse will continue to document assessment of the site every shift ..."

5. On 02/14/2023 at 10:30 AM, the Registered Nurse (E #1) for Pt. #2, was interviewed. E #1 stated that he was not sure since which date the IV tubing was connected to the bag since there was no label on it.

6. On 02/14/2023 at 10:45 AM, the Registered Nurse (E #2) for Pt. #3, was interviewed. E #2 stated that he did not get chance to see the IV site dressing change and was not sure when the site was started since there was no label indicating date and time of IV site dressing.

7. On 02/15/2023 at 10:30 AM, the Nursing Director (E #4) was interviewed. E #4 stated that the IV tubing and the IV site must be dated and labeled to avoid any types of infection. E #4 stated that IV site shift assessments should be documented in the nursing flowsheet.