HospitalInspections.org

Based on interview and record review the hospital failed to follow their policy and procedure (P&P) titled, "Swing Bed Program" for one of 26 sampled patients (Patient (Pt) 16)) when nurses did not assess and develop a care plan for PTSD [Post traumatic Stress Disorder - a mental health condition that can develop in people who have experience a life-threatening event], and Night Terrors [a sleep disorder in which a person quickly awakens from sleep in a terrified state]..

This failure had the potential to result in PTSD symptoms of night terrors to go unaddressed.

Findings:

During a concurrent interview and record review on 5/29/24, at 10:15 a.m., with the Risk Quality Specialist (RQS) and Clinical Informatics Nurse (CIN), Pt 16's electronic health record (EHR- digital collection of medical information) was reviewed. Pt 16's "History and Physical (H&P - the formal document that physicians produce through interview with the patient, physical exam, and the summary of testing either obtained or pending)", dated 5/21/24, and "Order Plans [Nursing Care Plan]", undated dated, were reviewed Pt 16's H&P indicated Pt 16 was brought to the hospital "PMhx [Past Medical History] of HTN [Hypertension - high blood pressure], Atrial Fibrillation [a heart condition that causes an irregular and often rapid heartbeat], PTSD [Post traumatic Stress Disorder - a mental health condition that can develop in people who have experience a life-threatening event], Night Terrors [a sleep disorder in which a person quickly awakens from sleep in a terrified state] who is admitted to Swing Bed for trach [tracheotomy - a opening through the neck into the windpipe to allow air to fill the lungs] care, PEG [percutaneous endoscopic gastrostomy - a tube through the abdomen to the stomach for feeding] tube feeds, and rehabilitation after an acute hospitalization ... after having an accident on his motorcycle which led to Cardiac Arrest, with multiple ... Injuries ... During his hospitalization ... pt suffered a vent [ventilator - breathing machine] associated pneumonia [infection of the lungs] and was not able to be weaned from the Vent and had to have a trach placed. ... He is a Veteran and has a history of PTSD and Night Terror - recommends that staff not try to wake him up in the dark when he is having a terror episode, they should turn on the light and call his name from a distance. Says the Night Terror are worse anytime he is stressed or sleep deprived. ...". RQS stated, Pt 16's care plan addressed issues for self-care deficit, skin integrity, pain management, and discharge readiness as the focused care problems for nursing interventions. RQS stated, nothing was included to address his "night terrors" or PTSD. RQS stated, there should have been a nursing care plan that addresses PTSD and "night terrors". RQS stated, nurses are expected to develop a care plan that matches and guides the care needs of the patient.

During a concurrent observation and interview on 5/30/2024, at 10:00 a.m., with Pt 16, in room 15 A, Pt 16 was observed resting in bed, watching television and in no apparent distress. Pt 16 stated, he has a history of PTSD and "night terrors". Pt 16 stated, he should not have any roommates because he often wakes up in the middle of night yelling out.

During a concurrent interview and record review with Registered Nurse (RN) 1 on 5/30/24, at 10:45 a.m. Pt 16's EHR titled "History and Physical", dated 5/21/24, and "Order Plans [Nursing Care Plan]", undated dated, were reviewed.. RN 1 stated, she was not aware of Pt 16's history of "night terrors". RN 1 stated, the care plan should have include interventions to address Pt 16's history of "night terrors".

During a concurrent interview and record review with Medical/Surgical Unit Manager (MSM) on 5/30/24, at 11:05 a.m., Pt 16's "History and Physical", dated 5/21/24, and "Order Plans [Nursing Care Plan]", undated t , were reviewed. MSM stated, Pt 16 should have a focus intervention to address his past history of PTSD and "night terrors". MSM stated, she expected the nurses to update the care plan to address the needs of the patient. MSM stated, if the care plan is not updated, the care of the patient could suffer.

During a concurrent interview and record review with the Assistant Patient Care Executive (APCE), on 5/31/24, at 10:00 a.m., Pt 16's "Nursing Care Plan" undated, was reviewed. The APCE stated, the nursing care plan should have been updated to address Pt 16's needs. The APCE stated, the nursing care plan should address the patient's care needs to provide safe quality care. The APCE stated, nurses are expected to follow the policy to develop. document and updating the care plan to meet the patient's care needs.

During a review of the facility position description titled, "RN [Registered Nurse] Job Summary", dated 2/3/2024, indicated, " ... Collects relevant data pertinent to the patient's health or situation. Analyzes the assessment data in determining diagnosis and care issues. Develops a plan that prescribes interventions to attain outcomes. Implements the plan, coordinates care delivery, and employs strategies to promote health and a safe environment. Evaluates progress toward attaining outcomes. Identifies outcomes for the patient or the patient's situation ... "

During a review of the facility P&P titled, "Swing Bed Program", dated 9/21/2021, the P&P indicated, " ... D. Comprehensive Care Plan: ... 1. The comprehensive care plan is developed by the Interdisciplinary team. ...2. The comprehensive care plan must include measurable objectives and time frames to meet these needs: ... a. Be developed within 7 days after completion of the comprehensive assessment. ... b. Describe services that will be furnished to maintain or help the patient achieve their highest level of functioning. ... "

During a review of a professional reference titled, "Lippincott Manual of Nursing Practice 10th Edition," dated 2014, page 16-17 indicated, " Standards of practice General Principles... 1. The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable ...b. These standards provide patients with a means of measuring the quality of care they receive ...5. A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation ... Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record ... Failure to formulate or follow the nursing care plan ..."

Based on interview and record review the hospital failed to follow their policy and procedure (P&P) titled "Pain Management Guidelines" for one of 21 sampled patients (Patient (Pt) 15) when nurses did not attempt interventions to relieve the assessed pain.

This failure had the potential to leave patients with uncontrolled pain.

Findings:

During a review of Pt 15's,"History & Physical [H&P (H&P -- the formal document that physicians produce through interview with the patient, physical exam, and the summary of testing either obtained or pending)] Examination", dated 5/14/24, the "H&P Examination" indicated, Pt 15 was admitted on 5/14/24, " ... with morbid obesity, HTN [hypertension - high blood pressure], A-Fib [Atrial Fibrillation -- a heart condition that causes an irregular and often rapid heartbeat], on Coumadin [Warfarin] [a medication that prevents blood from forming clots], type 2 diabetes mellitus [chronic disease that occurs when the body does not produce enough insulin or cannot effectively use the insulin it produces], HX [history] of CVA [cerebrovascular Accident - brain attack], admitted ... with right-sided facial droop speech [a condition that occurs when the facial muscles are not working properly] difficulty, weakness in the right lower extremity. ... She was accepted to our swing bed for rehab [rehabilitation]. ..."

During a concurrent interview and record review on 5/29/24, at 1:22 p.m., with the Risk Quality Specialist (RQS) and Clinical Informatics Nurse (CIN), Pt 15's electronic health record (EHR- digital collection of medical information), Pt 15's "H&P Examination", dated 5/14/24, "Pain Monitoring Flowsheet [PMF]", and "Medication Administration Records" for 5/14 admission were reviewed. The RQS stated, Pt15 had an order for acetaminophen-hydrocodone (an opioid pain medication) 7.5 mg (unit of measurement- milligrams) every four hours as need for severe pain of 7 out of 10 (Pain management scales utilizing the 0-10 descriptors, will be assessed as a pain rating of 0=no pain, 1-3=mild pain, 4-6=moderate pain and 7-10=severe pain). The PMF indicated, Pt 15 reported pain intensity level of 8 on 5/27/2024 at 9:27 a.m., a level of 8 on 5/28/2024 at 7:44 a.m. and a level of 8 on 5/29/2024 at 8:45 a.m. when vital signs [measurements of the body's most basic functions] were recorded. The PMF indicated, no interventions for those pain assessments were recorded by the nurse. The RQS validated no pain interventions or medications were documented for those pain assessments.

During a concurrent interview and record review on 5/30/24, at 10:45 a.m., with Registered Nurse (RN) 1,Pt 15's EHR, "H&P Examination", "Pain Monitoring Flowsheet [PMF]", and "Medication Administration Records", for 5/14/2024 admission were reviewed. RN 1 stated, the pain assessments in the record for Pt 15 on 5/27/2024 at 9:27 a.m., 5/28/2024 at 7:44 a.m. and 5/29/2024 at 8:45 a.m. were done when vitals signs were taken by staff helping the Registered Nurse for the patient. RN 1 stated, the reported pain by Pt 15 should have been reported to the nurse for follow up but nothing is documented in the chart as to why the pain was not addressed with interventions or pain medications.

During a concurrent interview and record review on 5/30/24, at 11:05 a.m., with Medical/Surgical Unit Manager (MSM). Pt 15's EHR, "H&P Examination", "Pain Monitoring Flowsheet [PMF]", and "Medication Administration Records", for 5/14/2024 admission, were reviewed MSM stated, nurses should have addressed Pt 15's pain and charted the follow up in the medical chart. MSM stated, the CNA recorded the pain and there was no follow up charted about the pain interventions used or reassessment of pain by the nurses. . MSM stated, t staff should have reported any concerns the patients have to the nurse and a follow up on those concerns should have occurred in a timely manner.

During an interview on 5/31/24, at 10:00 a.m., with the Assistant Patient Care Executive (APCE), . The APCE stated, nurses are expected to treat pain and document the interventions and reassessment in the chart. The APCE stated, the expectation of the CNAs is to report any concerns from the patients to the nurses and the nurses should follow up and make sure patients are treated in a timely manner.

During a review of the facility P&P titled, "Pain Assessment & Management", dated 9/20/2023, the P&P indicated, " ... Pain is assessed in all patients. The organization will address the appropriateness and effectiveness of pain management. ... It is the responsibility of all clinical staff to assess and periodically reassess the patient for pain and relief from pain including the Intensity and quality (i.e., character, frequency, location and duration of pain), and responses to treatment ... Intensity ratings will be categorized as mild 1-3; moderate 4-6; severe 7-10. Any rating of 5 or greater requires an intervention. ... All patients will undergo reassessment of pain every shift with vital signs, after every pain control mechanism employed by patient care providers, and prn [as needed] ... Documentation: ... a. Initial assessment of patient pain will be documented in the Electronic Health Record (EHR) and electronic Medication Administration system ... Electronic documentation of pain medication administered with pain related comment and reassessment. ..."

During a review of the California Board of Registered Nursing Professional Reference titled, "California Code of Regulations" undated, (https://rn.ca.gov) indicated, "... A registered nurse shall directly provide ... Ongoing patient assessments as defined in the Business and Professions Code, Section 2725(d). Such assessments shall be performed, and the findings documented in the patient ' s medical record, for each shift and upon receipt of the patient when he/she is transferred to another patient care area ... RN is accountable for an ongoing comprehensive assessment that includes data collection, analysis, and drawing conclusions/making judgments in order to ... formulate diagnoses and update diagnoses formulate or change the plan of care ... decide on specific activities to implement the plan of care (immediate and long-term) ... prioritize and coordinate delivery of care delegate to nursing care competent staff to deliver required care ... anticipate discharge planning/teaching needs... advocate for the patient as needed ... RN uses scientific knowledge and experience to make clinical judgments about observed abnormalities and changes based on a series of complex, independent and collaborative decision making activities ... RN is responsible/accountable to see actual and potential patient needs/health problems are addressed and get recorded on the plan of care ... "