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Based on record review and interview, the hospital failed to ensure that a medical history and physical examination was completed and documented for each patient no more than 30 days before or 24 hours after admission or registration for 1 (Patient #1) of 4 (Patient #1, #2, #3, #4) records reviewed.

Findings:

Review of Patient #1's medical record with S3RN revealed an admission date of 06/07/2023. Further review revealed there was no documentation of a history and physical included in Patient #1's medical record.


In an interview on 10/11/2023 at 10:18 a.m. S3RN verified there was no documentation of a history and physical included in Patient #1's medical record.

Based on record review and interview the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by:
1.) Failure of the RN to document a physical assessment upon admission for 1 (Patient #2) of 4 (Patient #1, #2, #3, #4) medical records reviewed; and
2.) Failure of the dietician to document a nutritional assessment after consultation for 1 (Patient #1) of 3 (Patient #1, #2, #4) medical records reviewed that the nursing nutritional screening triggered a consultation of the dietician.

Findings:

1.) Failure of the RN to document a physical assessment upon admission for 1 (Patient #2) of 4 (Patient #1, #2, #3, #4) medical records reviewed.

Review of the hospital's policy titled "Initial Nursing Assessment" revealed in part, 2) a physical and mental assessment is performed at the time of the interview and is documented on the initial assessment form. Special attention is paid to allergies, medications used, appearance of bruises, lacerations or scars, and risk of suicide.

Review of Patient #2's medical record with S3RN revealed an admission date of 06/08/2023. Review of the initial nursing assessment dated 06/08/2023 completed by S4RN revealed a skin assessment as follows: Turgor: normal; Color: normal; Condition: normal. Further review revealed there was no other documentation of a physical assessment upon admission.

In an interview on 10/10/2023 at 10:24 a.m. S3RN verified there was no other documentation of a physical assessment upon admission included in Patient #2's medical record.

2.) Failure of the dietician to document a nutritional assessment after consultation for 1 (Patient #1) of 3 (Patient #1, #2, #4) medical records reviewed that the nursing nutritional screening triggered a consultation of the dietician.

Review of the hospital's policy titled "Diet Orders" revealed in part, upon admission, the nurse will complete nutritional nursing screening and consult the registered dietician for a nutritional assessment if patient scores a 3 or greater. Registered Dietician shall complete assessment within 72 hours.

Review of Patient #1's medical record with S3RN revealed an admission date of 06/07/2023. Review of the nursing nutritional screening conducted on 06/07/2023 revealed a total score of 4. Further review revealed there was no documentation of a nutritional assessment performed by the dietician in Patient #1's medical record.

In an interview on 10/11/2023 at 1:20 p.m. S3RN verified there was no documentation of a nutritional assessment performed by the dietician in Patient #1's medical record.

Based on record review and interview the hospital failed to ensure all hospital orders were signed, dated, and timed by the physician or licensed practitioner. This deficient practice was evident for 1 (Patient #3) of 4 (Patient #1, #2, #3, #4) medical records reviewed.

Findings:

Review of the hospital's policy titled "Verbal/Phone Orders" revealed in part, all phone orders are to be signed during the next physician or LIP face to face with patient or within 10 days.

Review of Patient #3's medical record with S3RN revealed an admission date of 09/20/2023. Review of the physician's orders revealed the following telephone orders were not signed by the physician:
09/20/2023 at 11:50 p.m.: Give the patient Tylenol and recheck temperature in 30 minutes and call me back with temperature
09/21/2023 at 8:10 a.m.: Test patient for COVID
09/21/2023 at 10:21 a.m.: Send patient to ER for evaluation and treatment
09/21/2023 at 5:15 p.m.: Nystatin (mycostatin) 100,000 units/mL suspension. Take 6mLs (600,000 units total) by mouth 4 times daily for 10 days. Dispense 240mL.
09/25/2023 at 12:50 p.m.: Diflucan 100mg PO every day x 5 days. Nystatin powder 100,000 units/gm topical BID x 5 days.

In an interview on 10/10/2023 at 3:41 p.m.S3RN verified the above stated physician orders were not signed by the physician.

Based on observation and interview the hospital failed to ensure supplies were maintained to ensure an acceptable level of safety and quality. This deficient practice was evidenced by failure to ensure expired supplies were not available for patient use.

Findings:

Review of the hospital's policy titled "Unsafe Equipment / Repair / Product Recall / Warnings / Alerts" revealed in part, Outdated Supplies: 2. When supplies are found to be expired or compromised, they shall be immediately removed from use and immediately replaced with new/sterile items. 3. No item will be processed for reuse once expiration date or compromising event occurs.

Observation of the hospital on 10/09/2023 at 9:55 a.m. - 10:22 a.m. revealed the following supplies were expired that were located in the central supply room:
3 of 3 Mesalt 10 X 10 cm / 4 X 4 in gauze with an expiration date of 08/28/2023; and
7 Isolation gowns with an expiration date of 05/2023.

In an interview during the observation, S3RN verified the above stated supplies were expired.