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Based on observation, interview, and record review, the facility failed to ensure standards of nursing practice were followed for four (4) of 30 sampled patients (Patient 2, 3, 13, and 15) when:

1. For Patient 2, Registered Nurse (RN) 2 failed to provide instruction and education for Patient 2's visitors about infection control and droplet transmission precaution (isolation precaution for patients known or suspected to be infected with micro-organisms transmitted by droplets greater than or equal to five micrometers...in size, that can be generated by the patient during coughing, sneezing, talking, or the performance of cough inducing procedures) for two visitors observed sitting at Patient 2's bedside without wearing a masks for protection.

2. For Patient 13, RN 3 failed to ensure a STAT order (immediately, should be done without delay) for a MRI (Magnetic Resonance Imaging, a type of diagnostic test that can create detailed images of nearly every structure and organ inside the body) was carried out immediately as ordered for Patient 13.

3. For Patient's 3 and 15, RN failed to address Patient 3 and 15's skin breakdown identified on admission, failed to follow through on Patient 3's wound care consult, and did not document a wound photo weekly, and prior to discharge home per facility policy.

These failures had the potential to expose and spread infection to other staff, patients, and visitors, resulted in an 8-hour delay in the identification of progression of stroke (a condition when blood flow to the brain is interrupted, leading to brain cell damage or death), and potential for delay in implementing wound care treatments necessary to prevent infection, tissue growth and healing.

Findings:

On February 10, 2025, at 8:25 a.m., an unannounced visit was conducted for a complaint validation survey.

1. A tour of the Intensive Care Unit (ICU), was conducted on February 10, 2025, at 9:14 a.m., with the Risk Manager (RM), Director of Women's Services (DWS), and Clinical Supervisor/Charge Nurse (CS/CN). During the tour RN 2 was observed inside Patient 2's room, a droplet precaution room, with two visitors sitting bedside without protective masks on.

On February 10, 2025, at 9:18 a.m., a concurrent interview was conducted with the CS/CN. The CS/CN stated Patient 2 was positive for Influenza B (type of virus causing Influenza "FLU", a contagious respiratory illness) and was on isolation precautions. The
CS/CN further stated, visitors are supposed to wear masks for droplet precaution to protect themselves and the staff, and to prevent flu transmission (spread of infection).

On February 12, 2025, at 9:26 a.m., Patient 2's medical record was reviewed with the Senior Clinical System Analyst (SCSA). Patient 2's record indicated Patient 2 was admitted to the facility on February 8, 2025, for Diabetic Ketoacidosis (DKA, a serious complication of diabetes and can be life-threatening) and Influenza. During a concurrent interview with the SCSA, the SCSA stated, per the facility policy, family should be provided with education regarding use of PPE so they are not spreading potential infection to themselves or others.

A review of the facility policy titled, "Transmission-based Precaution," dated April 14, 2023, indicated, "PURPOSE: To provide guideline to prevent the transmission of infections to patients; reduce patient and interdisciplinary health care staff risk of cross transmission of exogenous organisms by providing an appropriate environment, patient placement, management and care of patients with a known or suspected infection or colonization of an infectious agent...Nursing Responsibility...Provide the patient and family members with information on the type of precautions and why the patient was placed in these precautions...ensure all precautions are followed and appropriate PPE is worn..."

2. On February 11, 2025, Patient 13's medical record was reviewed with the Risk Manager (RM). The "ED Physician Record" indicated, "...presents with altered speech... HTN [hypertension, elevated blood pressure], DM [Diabetes Mellitus, a disorder in which the body does not produce enough or respond normally to insulin {a hormone that regulates blood sugar level}, causing blood sugar levels to be abnormally high]...EMS [Emergency Medical Services] reports pt [patient] was on the phone with her daughter when she had an episode of slurred speech that lasted 3-5 minutes...By the time they arrived the patient symptoms had completely resolved and she was negative on the stroke scale [NIH-National Institutes of Health, helps health care providers assess the severity of stroke]...Reexamination/Reevaluation. Time: 12/15/2024 [December 15, 2024]21:22:00 [9:22 p.m.]. Notes...She was made a code stroke, however, NIHSS [stroke scale] = 0 at this time, so code stroke was cancelled...Patient family arrived and were concerned about her speech. I went back to the bedside to evaluate the patient...her speech remains clear with no facial asymmetry, but due to family concern I did have a stroke code CT [Computed Tomography, non invasive medical examination that uses specialized X-ray equipment to produce cross-sectional images of the body] only called in order to expedite the imaging...High-grade stenosis of the carotid arteries, but no LVO [large vessel obstruction] noted...CT head Noncon [non-contrast] is unremarkable...Given the carotid artery stenosis will admit for further evaluation/management...Impression and Plan...TIA [transient ischemic attack, temporary interruption of blood flow to the brain, causing stroke-like symptoms that typically resolve within 24 hours]. 2. Carotid artery stenosis. Plan. Condition: Stable. Disposition: Patient care transitioned to...NP [Nurse Practitioner]..."

Patient 13's ED Encounter "Event Information", Timeline indicated:
* Arrive, December 15, 2024, 8:28 p.m.;
* Triage, December 15, 2024, 8:28 p.m.;
* DR (doctor) Exam, December 15, 2024, 8:30 p.m.; and
* MSE (Medical Screening Examination, the point at which it can be determined whether the individual has an EMC (Emergency Medical Condition) or not, 8:36 p.m.

The facility document titled, "Nursing Note-Text", dated December 15, 2024, at 9:13 p.m., authored by RN 3 was reviewed and indicated, "...Patient [Patient 13] placed in ER 14 [Emergency Room] for stroke like symptom...[Name of Doctor] cancelled code stroke as exam did not warrant response. [Patient 13's family]...patient has facial droop on the left side. I assessed the patient who is found to be confused, alert and oriented to person and place only. I did not see the facial droop reported. Informed [Name of Doctor] of the family's concern..."

The facility document titled, "Nursing Note-Text", dated December 15, 2024, at 11:25 p.m., authored by RN 3, was reviewed and indicated "...patient (sic) is in no acute distress...Neuro check revealed patient is no longer speaking when asked orientation questions. She is not alert but not oriented to time, place, situation, and person...Informed provider via tiger text [communication app]..."

On February 11, 2025, at 10:33 a.m., a concurrent record review and interview was conducted with the Stroke Program Manager (SPM) regarding RN 3's action/inaction of an MRI (magnetic resonance imaging-a medical examination performed using magnetic resonance imaging) STAT (immediately) order placed by the provider on December 16, 2024, at 00:07 a.m. The SPM stated the provider ordered the MRI STAT and the MRI result was completed on December 16, 2024, at 8:34 a.m., 8 hours after the order was placed. Reviewed with SPM MRI brain result that indicated, acute infarction anterior R-MCA (Right-Middle Carotid Artery, an artery in the brain) infarct and infarct r-occipital lobe (back portion of the brain).The SPM stated somebody should have called the on-call tech in. The SPM stated, she believed there should be an urgency in doing the MRI. "I am not sure who is responsible for calling the person on-call". The SPM stated, they should have done the MRI Stat as ordered because of worsening of symptoms. They should look for any changes. Patient 13 had a known stenosis of the Carotid Artery, they should be looking for a possible occlusion that may necessitate an immediate intervention.

On February 11, 2025, at 10:56 a.m., a concurrent interview and record review was conducted with the Director of Radiology (DOR). The DOR stated physician's order automatically print out in the Radiology printer but after 11:30 p.m., staff are only on-call. Staff are off the property and only the XRAY Tech are in-house. The DOR stated they usually had to wait for the MRI screening to be completed by the nursing staff and it is available in Powerchart for nurses access. The DOR stated they do not need to remind the nurses. They can see it under their "to do/task list". If MRI screening is completed, XRAY Tech can view it and if there is no contra-indication, they will call the on-call MRI tech who are expected to respond within 30-45 minutes. "Policy and Procedure" for "Scope of Service" was reviewed with DOR that indicated, "Inpatient STAT orders have a response time of 60 minutes". The DOR stated, for this stroke patient (Patient 13), the MRI should have been done STAT as ordered".

A review of the facility policy titled, "SCOPE OF SERVICE. Title: Imaging", dated September 24, 2020, indicated, "SCOPE OF SERVICE...define the Scope of Service...to specify their roles...acting in the best interest of the patient...Preparation of patients for their exams in the Imaging department...Coordinate with nurse provider to arrange the transport of patients to and from Imaging department to complete ordered exams...Use independent judgement and systematic problem solving methods to produce high quality diagnostic information and optimize patient care...Continuity of patient care through different settings...Goals...The Department of Imaging is accountable to the Medical Staff for: The safe delivery of radiological procedures to patients...Trauma ED orders have priority response of 30 minutes. Inpatients STAT orders have a response time of 60 minutes..."

A review of the facility policy titled, "POLICY AND PROCEDURE. Title: Code Stroke Activation and Stroke Patient Management," dated January 23, 2025, indicated, "PURPOSE...To outline the standard of care provided to all patients...Code Stroke Team Members include...ED Staff Nurse caring for the patient...The Code Stroke Team is expected to respond immediately...ROLES AND RESPONSIBILITIES...ED or ICU RN...Accompanies the patient to Imaging...Facilitates the completion of all patient testing..."

3a. On February 12, 2025, at 10:18 a.m., a concurrent interview and record review was conducted with the SCSA. Patient 3's record indicated Patient 3 was admitted for encephalopathy (a broad range of brain disorders that can affect brain structure, function, or consciousness) and some respiratory symptoms. Past Medical History (PMHX) included ESRD (End Stage Renal Disease, kidneys have permanently lost most of their function and can no longer filter waste products from the blood) SP (status post) Kidney transplant, CVA (Cerebrovascular Accident, stroke, a condition that occur when blood flow to the brain is interrupted) with residual right side deficit, bedridden for the last 3 years.

Further record review indicated "Body Systems Assessment" that indicated, pressure injury was identified on January 24, and 25, 2025, as "present on admission" (Unstageable Pressure Injury {PI} to the Left Heel, Unstageable PI to the right ischium {lower and back part of the hip bone}, and Stage 3 PI to the coccyx {tailbone}). The SCSA was unable to provide documented evidence the skin assessment was done initially on admission on January 22, 2025, and no intervention was in place to address the skin breakdown until January 26, 2025, four days after Patient 3's admission. SCSA stated admission skin assessment is important to identify skin condition when patient is initially admitted to the facility so they can track it throughout their stay and monitor changes and progress. SCSA stated this is also to determine if wound is facility development and to have interventions in place as early as they are identified to prevent development of infection.

3b. On February 12, 2025, at 8:55 a.m., a concurrent interview and record review was conducted with SCSA. Patient 15 was admitted to the facility on December 6, 2024, for Influenza. PMHX included CVA with right hemiplegia (weakness), HTN, chronic bedridden, dysphagia (difficulty in swallowing) s/p PEG Tube (percutaneous endoscopic gastrostomy, placement of a feeding tube through the skin and the stomach wall). Record indicated patient was admitted with pressure ulcers in multiple parts of his body. The SCSA stated there was no documented evidence Patient 15's skin breakdown was reassessed and photos-documented throughout his stay. SCSA stated weekly photo-documentation was important to document progress of healing or deterioration to determine if treatment was working or needed to be changed.

On February 12, 2025, at 9:43 a.m., RN 5 (Wound Care Nurse) was interviewed. RN 5 stated they should have taken a wound photo every week and before the day of discharge according to their policy to monitor progress of the wound, and if treatment needed to be changed.

A review of the facility policy and procedure titled, "Pressure Injuries: Assessment, Documentation and Treatment Guidelines," dated September 26, 2024, indicated, "POLICY...Patients will be assessed for pressure injury...This assessment will create a baseline for further skin and/or wound care, and minimize and/or prevent any further deterioration of tissue...PROCEDURE...Documentation in Medical Record...Photograph and measure all pressure injuries on admission...weekly or completed on admission or discharge..."

Based on observation, interview and record review, the facility failed to ensure the facility's policy and procedures (P&P) were followed for five of 30 sample patients (Patients 16, 17, 22, 23, and 29) when:

1. For Patients 16, 22, and 23, fall risk assessments were not completed;

2. For Patients 17, and 29, no medication reconciliation was completed;

3. For Patient 17, no pain reassessment was completed; and

4. The pediatric crash cart was missing a medication drawer lock.

These failures had the potential to jeopardize the health and safety of the patients.

Findings:

1a. On February 10, 2025, at 9:05 a.m., a review of Patient 16's record was conducted with the Clinical Effectiveness Coordinator (CEC) and the Director of Quality (DOQ).

On February 11, 2025, at 9:07 a.m., a review of the facility document titled, "Face Sheet," dated February 9, 2025, at 8:22 p.m., indicated Patient 16 was admitted to the facility with a diagnosis of Infectious Enteritis (inflammation of the intestines).

On February 11, 2025, at 9:15 a.m., a review of the facility document titled, "History and Physical (H&P)," dated February 9, 2025, at 8:23 p.m., indicated Patient 16 had no previous medical history.

On February 11, 2025, at 9:20 a.m., a review of the facility undated document titled, "KINDER I Tool for Emergency Department Falls Risk Assessment," indicated no documentation in boxes titled, "...Presented to ED [Emergency Department] Because of Falls...Altered Mental Status...Impaired Mobility...Nurse Judgment..."

On February 11, 2025, at 9:25 a.m., an interview with the DOQ was conducted. The DOQ stated, "The KINDER I fall assessment should have been completed in full per facility policy..."

1b. On February 11, 2025, at 9:05 a.m., a review of Patient 22's record was conducted with the Clinical Effectiveness Coordinator (CEC) and the Director of Quality (DOQ).

On February 11, 2025, at 9:45 a.m., a review of the facility document titled, "Face Sheet," dated December 27, 2024, at 3:41 p.m., indicated, Patient 22 was admitted to the facility with a diagnosis of COPD (Chronic Obstructive Pulmonary Disease- a condition involving constriction of the airways) exacerbation (sudden worsening).

On February 11, 2025, at 9:48 a.m., a review of the facility document titled, "H&P," dated December 27, 2024, at 3:31 p.m., indicated Patient 22 had a medical history of Hypertension (HTN-elevated blood pressure), and COPD.

On February 11, 2025, at 9:50 a.m., a review of Patient 22's record did not show any record of a KINDER I fall assessment completed by a registered nurse in the emergency room.

On February 11, 2025, at 9:55 a.m., an interview with the DOQ was conducted. The DOQ stated, "There was no KINDER I fall assessment completed for Patient 22 while in the emergency room...It should have been completed in the emergency room..."

1c. On February 11, 2025, at 9:05 a.m., a review of Patient 23's record was conducted with the Clinical Effectiveness Coordinator (CEC) and the Director of Quality (DOQ).

On February 11, 2025, at 10:02 a.m., a review of the facility document titled, "Face Sheet," dated January 26, 2025, at 6:05 p.m., indicated Patient 23 was seen in the Emergency room for fever, chills, and body aches.

On February 11, 2025, at 10:05 a.m., a review of the facility document titled, "ED Physician Record," dated January 26, 2025, at 7:13 p.m., indicated, Patient 23 had no previous medical history.

On February 11, 2025, at 10:07 a.m., a review of the facility undated document titled, "KINDER I Tool for Emergency Department Falls Risk Assessment," indicated no documentation in boxes titled, "...Presented to ED Because of Falls...Altered Mental Status...Impaired Mobility...Nurse Judgment..."

On February 11, 2025, at 10:10 a.m., an interview with the DOQ was conducted. The DOQ stated, "The KINDER I fall assessment should have been completed in full per facility policy..."

On February 11, 2025, at 9:30 a.m., a review of the P&P titled, "Fall Prevention," dated June 17, 2024, indicated, "...Upon admission, all patients will be assessed for fall risk using an age appropriate, evidence-based tool by a qualified professional...For adult patient in the emergency department, a registered nurse (RN) will use the KINDER I tool...The KINDER I tool will be completed at triage and as warranted by clinical judgement..."

2a. On February 11, 2025, at 9:05 a.m., a review of Patient 17's record was conducted with the Clinical Effectiveness Coordinator (CEC) and the Director of Quality (DOQ).

On February 11, 2025, at 10:02 a.m., a review of the facility document titled, "Face Sheet," dated February 9, 2025, at 10:54 a.m., indicated Patient 17 was admitted to the facility with a diagnosis of a small bowel obstruction (blockage in the small intestine).

On February 11, 2025, at 10:07 a.m., a review of the facility document titled, "ED Physician Record," dated January 26, 2025, at 7:13 p.m., indicated, Patient 17 had a medical history of schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior), HTN, and transient ischemic attack (a temporary disruption of blood flow to the brain).

On February 11, 2025, at 10:10 a.m., a review of the facility document titled, "Orders," no date, indicated, "...Reconciliation Status...! Med History...! Admission..." The document further indicated no medication reconciliation history for Patient 17.

On February 11, 2025, at 10:15 a.m., an interview with the DOQ was conducted. The DOQ stated, "The medication reconciliation should have been completed by the physician within twenty four hours of admission per policy...the medication reconciliation is the responsibility of the physician..."

2b. On February 11, 2025, at 9:05 a.m., a review of Patient 29's record was conducted with the Clinical Effectiveness Coordinator (CEC) and the Director of Quality (DOQ).

On February 11, 2025, at 10:22 a.m., a review of the facility document titled, "Face Sheet,", dated February 10, 2025, at 11:09 a.m., indicated Patient 29 was admitted to the facility with diagnosis Acute Respiratory Failure."

On February 12, 2025, at 8:45 a.m., a review of the facility document titled, "H&P," dated February 10, 2025, at 1:39 p.m., indicated Patient 29 had a medical history of HTN, Congestive heart failure (a condition where the heart can't pump blood efficiently), and Bone cancer.

On February 11, 2025, at 10:25 a.m., a review of the facility document titled, "Orders," no date, indicated, "Reconciliation Status...! Med History...! Admission..." The document further indicated no medication reconciliation history for Patient 29.

On February 11, 2025, at 10:28 a.m., an interview with the DOQ was conducted. The DOQ stated, "The medication reconciliation should have been completed by the physician within twenty four hours of admission per policy...the medication reconciliation is the responsibility of the physician..."

On February 11, 2025, at 10:30 a.m., a review of the P&P titled, "Medication Reconciliation Across the Continuum of Care," dated September 24, 2020, indicated, "...It is the policy to reconcile patient's medication at the time of admission, intradepartmental transfer, and at discharge or transfer to another facility...The admitting/ordering physician compares the home medications list with the medication(s) ordered for treatment during the hospital stay, reconciles the two lists and authenticates the medication order(s) within 24 hours of admission..."

3. On February 11, 2025, at 9:05 a.m., a review of Patient 17's record was conducted with the Clinical Effectiveness Coordinator (CEC) and the Director of Quality (DOQ).

On February 11, 2025, at 10:02 a.m., a review of the facility document titled, "Face Sheet," dated February 9, 2025, at 10:54 a.m., indicated Patient 17 was admitted to the facility with a diagnosis of a small bowel obstruction (blockage in the small intestine).

On February 11, 2025, at 10:07 a.m., a review of the facility document titled, "ED Physician Record," dated January 26, 2025, at 7:13 p.m., indicated, Patient 17 had a medical history of schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior), HTN, and transient ischemic attack (a temporary disruption of blood flow to the brain).

On February 11, 2025, at 10:10 a.m., a review of the facility document titled, "Orders," dated February 9, 2025, at 11:02 p.m., indicated, Patient 17 had an order for "...Morphine...Order Details: 2 mg [milligrams]...IV [intravenous-in the vein] Push...q4H [every four hours]...PRN [as needed]...Pain 7-10..."

On February 11, 2025, at 10:20 a.m., a review of the facility document titled, "Medication Administration Record," dated February 10, 2025, at 3:54 p.m., indicated morphine 2 mg IV was administered by Registered Nurse (RN) 1.

On February 11, 2025, at 10:15 a.m., a review of the facility document titled, "Pain Assessment," dated February 10, 2025, at 3:15 p.m., indicated pain level of 6/10. The document further indicated pain reassessment was completed on February 10, 2025, at 6:38 p.m., with a pain level of 0/10.

On February 12, 2025, 11:10 a.m., an interview of the DOQ was conducted. The DOQ stated, "...PRN pain reassessment should have been completed within 60 minutes after administration..."

On February 12, 2025, at 11:20 a.m., a review of the P&P titled, "Medication Ordering and Administration," dated December 16, 2022, indicated, "...Administered PRN medications must be documented in the medical record along with the indication for administration and patient response. Assessment of patient response to the medication must occur within one hour following the administration..."

4. On February 10, 2025, at 9:08 a.m., a tour of the emergency room was conducted with Director of Women's Services (DWS), Interim Director of Patient Experience (IDPE) and the Director of Emergency Room (DER).

On February 10, 2025, at 9:25 a.m., during the tour of the ED, the Pediatric crash cart was observed with no red lock on the top drawer which contained emergency medications.

On February 10, 2025, at 9:30 a.m., a review of the facility document titled, "Code Cart Checklist (Pediatric)," was conducted with the DER. The document indicated, "...Month/Year...February...2025...Unit...ED...Day...10...Lock#[number]...13899304...Signature...[unknown signature]...Action Required..." There was no documentation under "...Action required..." indicating any action was taken to replace missing lock on medication drawer.

On February 10, 2025, at 9:35 a.m., an interview with the DER was conducted. The DER stated the lock was missing on the pediatric crash cart.

On February 11, 2025, at 3 p.m., an interview with the DOQ was conducted. The DOQ stated, "...The Emergency room staff should have notified pharmacy to replace the lock. The drawer ideally would get a new lock placed on the crash cart..."

On February 11, 2025, at 3:30 p.m., a review of the facility P&P titled, "Emergency Drugs/Supplies," dated December 16, 2022, indicated, "...Emergency medications must be checked by a pharmacist before the cart is sealed...Code Cart trays will be placed into the medication drawers of the carts...a pharmacist will affix a plastic tamperproof lock ensuring that the Code Cart is complete and secure...Department, units and users will notify pharmacy when...The container is opened or the seal is broken..."