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Based on interview and record review, the hospital failed to ensure the nursing staff documented an assessment for an advance directive for one of seven sampled patients (Patient 1). This failure posed the potential for not honoring the patient's wishes.

Findings:

Review of the hospital's P&P titled Advance Directives dated 3/2/23, showed the nursing staff is to document the information concerning the advance directives or surrogate decision maker on the "Patient Admission History/Assessment" form and individual patient care card as applicable.

Review of Patient 1's medical record was initiated on 2/7/24. Patient 1's medical record showed the patient was admitted to the hospital on 2/3/24.

Review of the Healthcare Directives tab dated 2/3/24 at 2000 hours, did not show the patient was assessed for an advance directive.

On 2/7/24 at 1321 hours, an interview and concurrent record review of Patient 1's medical record was conducted with RN 12. RN 12 acknowledged the above findings. When asked when the nursing staff assessed the patient for the advance directive, RN 12 stated the patient would be assessed for the advance directive upon admission to the nursing unit. RN 12 stated the nurse who admitted the patient would report to the incoming nurse during the change of shift report if the patient had not been assessed for athe advance directive upon admission. RN 12 was asked about the purpose of assessing the patient for the advance directive. RN 12 stated the purpose of the advance directive was for the healthcare staff to know about the patient's healthcare decisions.

On 2/9/24 at 1145 hours, an interview and concurrent medical record review of Patient 1 was conducted with Nursing Director 1. Nursing Director 1 acknowledged the above findings. Nursing Director 1 stated the admitting personnel would check if the patient had the advance directive; however, the nursing staff in the unit would not know about the information collected by the admitting personnel.

Based on interview and record review, the hospital failed to ensure the nursing staff adhered to the hospital's P&Ps when creating the competencies for one ED LVN (LVN 1). This failure created the risk of substandard health outcomes to the patients in the ED.

Findings:

Review of the hospital's P&P titled Competency Assessment, Employee; Organization-wide dated 12/7/23, showed the purpose is to provide a mechanism for directing and validating the competencies required by employees to provide quality healthcare to patients. Competency is defined a combination of observable and measurable knowledge, skills, abilities, and personal attributes that are needed to fulfill organizational, departmental, and work setting requirements. The competency assessment will include core job functions. Core(annual) topics are based on regulatory requirements and completed by clinical and non-clinical staff. Division (annual) topics are based on specific regulatory requirements for a division.

Review of the hospital's P&P titled Triage and Assessment dated 3/2/23, showed the triage assessment shall be performed by the ED RNs who were trained and would validate the competency in the use of the 5-Level Emergency Severity Index.

Review of the Emergency Department Registered Nurse Clinical Skills Checklist for Orientation signed by LVN 1 on 7/20/23, showed the following:

* Once a skill was competently performed without assistance, the preceptor would initial the column for "Independent Demo." If the skill was not able to be completed in front of a preceptor, the alternative method such as policy reviewed and discussed was checked in the validation of competency by preceptor.

* The Triage section showed LVN 1's Self-Assessment was competent in triage including properly applying the 5-Level system. The method for validation of competency was policy reviewed and discussed.

On 2/7/24 at 1148 hours, an interview was conducted with LVN 1. LVN 1 stated the LVN did not function as a RN and had their own skillset and scope of practice. LVN 1 stated the LVN could not assess the patient as the RN, but the LVN could collect data. LVN 1 stated LVN 1 could not perform triage, assess, and assign the patient with the ESI level. LVN 1 stated these skills were out of her scope of practice. LVN 1 stated she had to inform and remind other ED staff of her scope of practice versus the RN's scope of practice.

On 2/8/24 at 1000 hours, an interview and employee file review was conducted with the Clinical Educator. The Clinical Educator stated the competencies were skill assessments and completed through the unit by a preceptor who assessed their skills. These were completed to show if the staff could do the skills. The Clinical Educator verified LVN 1 was hired as an LVN, not an RN. The Clinical Educator verified LVN had a different scope of practice comparing to the RN. The Clinical Educator stated the LVN could not be held to the same expectations of competency as the RN as they had different scope of practice. The Clinical Educator reviewed and verified the LVN 1's competency titled Emergency Department Registered Nurse Clinical Skills Checklist for Orientation was created for the RN's competencies and based on an RN's skills and scope of practice. The Clinical Educator reviewed the checklist and verified the LVN, based on their scope of practice could not assess the patient and assign the patient with the ESI level.

2/9/24 at 1435 hours, the CNO was made aware of the findings.

Based on interview and record review, the hospital failed to ensure the nursing staff adhered to the hospital's P&Ps and implemented the physicians' orders for two of seven sampled patients (Patients 1 and 2) as evidenced by:

1. For Patient 1, the nursing staff failed to ensure the patient was continuously monitored for the pulse oximetry levels as per the physician's order.

2. For Patient 2, the nursing staff failed to ensure the patient was assessed consistently by the hemodialysis nurse during the hemodialysis treatment as per the hospital's P&P.

These failures had the potential to result in poor health outcomes for the patients in the hospital.

Findings:

1. Review of the hospital's P&P titled Physician's Orders dated 3/2/23, showed the following:

- The purpose of the P&P is to establish a practice and inform licensed healthcare professionals with the methodology involved in acknowledgment, coordination, and implementation of the diagnostic and therapeutic orders of medical staff members.

Review of Patient 1's medical record was initiated on 2/7/24. Patient 1's medical record showed the patient was admitted to the hospital on 2/3/24.

Review of the H&P examination dated 2/4/24 at 0800 hours, showed Patient 1 had a chief complaint of shortness of breath. The patient was admitted to the telemetry unit.

Review of Patient 1's physician's order dated 2/3/24 at 2019 hours, showed to start the continuous pulse oximetry for the patient on 2/3/14 at 2020 hours. On 2/7/24 at 0800 hours, this physician's order was discontinued.

Review of Patient 1's Tabular Trends did not show Patient 1 was monitored continuously for the pulse oximetry levels as per the physician's order. The oxygen saturation level column of the Tabular Trends did not show the numeric values of the patient's oxygen saturation levels. For example:

- On 2/5/24 from 1400 hours to 2030 hours (approximately seven hours),
- On 2/6/24 from 2200 hours to 2330 hours (approximately two hours),
- On 2/7/24 from 0000 hours to 0730 hours (approximately eight hours).

On 2/7/24 at 0950 hours, an interview and concurrent review of Patient 1's medical record was conducted with Monitor Technicians 1 and 2. Monitor Technicians 1 and 2 acknowledged the documentation on the Tabular Trends for Patient 1 as described above. Monitor Technicians 1 and 2 were asked about the reason why there were no documentation of Patient 1's oxygen saturation level. Monitor Technician 1 stated there were no documentation of Patient 1's oxygen saturation level because the patient was in room air (patient had no oxygen supplement) and the patient was not connected to a pulse oximetry. Monitor Technicians 1 and 2 was asked how the monitor technicians would know if the patient needed continuous monitoring of oxygen saturation levels. Monitor Technician 1 stated the nurse would inform the monitoring technician if the patient needed continuous oxygen monitoring.

On 2/7/24 at 1321 hours, an interview and concurrent review of Patient 1's medical record was conducted with RN 12 and Nursing Director 1. RN 12 acknowledged the physician's order of continuous pulse oximetry, as described above, for Patient 1. RN 12 was asked about the reason why there was no documentation to show Patient 1 was no longer on a continuous pulse oximetry. RN 12 stated the telemetry unit had a protocol to discontinue a continuous pulse oximetry when a patient was already on a room air. RN 12 stated the RN would follow up about the telemetry unit protocol about discontinuance of a continuous pulse oximetry for a patient as described above.

On 2/8/24 at 0850 hours, a follow-up interview was conducted with Nursing Director 1. Nursing Director stated there was no unit protocol to discontinue a continuous pulse oximetry when a patient was on a room air. The Nursing Director 1 acknowledged the physician's order was required to discontinue the continuous pulse oximetry for Patient 1.

2. Review of the hospital's P&P titled Dialysis Nursing Assessment and Care of the Hemodialysis Patient dated 3/2/23, showed the following:

* Nursing documentation is completed in the attached Hemodialysis Treatment Record for the following initial assessment and commencement of hemodialysis treatment. The following is to be documented every 15 minutes: BP, pulse, BFR, arterial/venous pressure, TMP, UFR, total fluid removed, fluid given, conductivity, and DFR.

* Post Hemodialysis section showed to obtain and document the patient's including weights.

Review of the dialysis supplier's Job Description for the acute dialysis RN (undated) showed the RN's duties and responsibilities include to keep the complete and accurate documentation of all records in a timely manner; and make frequent patient assessments to ensure safety practices.

Review of Patient 2's medical record was initiated on 2/7/24. Patient 2's medical record showed the patient was admitted to the hospital on 2/3/24.

Review of the physician's order dated 2/5/24 at 2323 hours, showed an order to administer hemodialysis treatments for Patient 2, starting on 2/6/24 at 1200 hours. The duration of the hemodialysis treatment was three hours.

Review of the Pre-Hemodialysis Assessment dated 2/6/24 at 1330 hours, showed Patient 2 was identified using the patient's name and date of birth and a pre-hemodialysis report was received from the nursing staff of the unit.

Review of the Vitals flowsheet dated 2/6/24 from 1330 hours to 1600 hours, did not show Patient 2 was assessed for the BPs and pulse rates every 15 minutes as per the hospital's P&P.

Review of the During Hemodialysis Assessment dated 2/6/24 from 1330 hours to 1600 hours, did not show documented evidence the BFR, arterial/venous pressures, TMP, UFR, total fluid removed, fluid given, onductivity, and DRR were assessed every 15 minutes as per the hospital's P&P.

Review of the Post-Hemodialysis Assessment dated 2/6/24 at 1600 hours, showed Patient 2 was stable. The post treatment report was given the nursing staff. However, there was no documented evidence the patient's weight was assessed after the hemodialysis treatment.

The above flowsheets did not show the start time and completion time of Patient 2's hemodialysis treatment.

Review of the Nursing Note dated 2/6/24 at 1933 hours, showed Patient 2 received the hemodialysis treatment and had the fluid output of two liters.

On 2/7/24 at 1544 hours, an interview and concurrent record review of Patient 2's medical record was conducted with the dialysis supplier's CEO. The dialysis supplier's CEO acknowledged the above findings. The dialysis supplier's CEO confirmed Patient 2 received the hemodialysis treatment on 2/6/24; however, the dialysis supplier's CEO acknowledged the dialysis nurse who provided the hemodialysis treatment to the patient, did not document the start time and completion time of the hemodialysis treatment.

On 2/8/24 at 0900 hours, an interview and concurrent review of Patient 2's medical record review was conducted with Nursing Director 1 and RN 11. Nursing Director 1 and RN 11 acknowledged the above findings.