HospitalInspections.org

Based on observation, interview, and record review, the facility failed to meet the Condition of Participation for Nursing Services as evidenced by:

1.The facility failed to develop an individualized nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for two of 32 sampled patients (Patient 7 admitted for acute pain and Patient 8 was admitted for altered mental status) for appropriate care.

This deficient practice had the potential result in Patient 7 and Patient 8 not receiving the right level of care and not meeting the needs for the identified patient's concerns. (Refer to A-0396).



2. The facility ' s failure to:

A. Ensure two of 32 sampled patients (Patients 3 and Patient 5) intravenous (IV) (administering fluids, medication and nutrients directly into the veins) dressing site was labeled with a date, time and initial written by the nurse on the patients ' dressing per the facility policy and procedure.



This deficient practice had the potential to result in Patient 3 and Patient 5 at risk for infection due to a dirty or compromised (unsafe) dressing. (Refer to A-0398).



B. Document two of 32 sampled patients (Patient 6 and Patient 7) actual time for pain reassessment in medical record.



This deficient practice had the potential result in Patient 6 and Patient 7 ' s pain level was not reassessed and without time recorded when pain reassessment was done in the medical record per hospital policy. (Refer to A-0398).





3. The facility nursing staff failed to ensure correct IV (intravenous into the vein) fluid was administered not the discontinued Magnesium Sulfate (medication used for treating high blood pressure caused by pregnancy and involuntary muscle movements from temporary abnormal brain activities caused by high blood pressure) for one of 32 sampled patients (Patient 1).



This deficient practice had cause Patient 1's to receive the discontinued Magnesium Sulfate (medication for managing preeclampsia) IV instead of the new order medication Dextrose 5% Lactate Ringers (D5LR- sterile, nonpyrogenic solution used for intravenous fluid and electrolyte replenishment and caloric supply) IV and Patient 1 may potentially be at risk to experience side effect from Magnesia Sulfate including low blood pressure, muscle weakness, and drowsiness/lethargy, etc. (Refer to A-0405).



The cumulative effect of these deficient practices resulted in the facility ' s inability to provide quality health care in a safe environment.

Based on observation, interview, and record review, the facility failed to follow and implement the facility's falls prevention policy for one of 32 sampled patients (Patient 3). This deficient practice placed patients at risk for falls and injury.

Findings:

During a review of Patient 3 ' s "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/3/2025 at 9:29 p.m., indicated, the H&P indicated Patient 3 ' s was admitted on 7/3/2025 due to Sepsis (a body ' s overwhelming and life-threatening response to infection), diabetes mellitus (a group of diseases that result in too much sugar in the blood), and diabetic foot infection (a serious complication of diabetes, often stemming from poorly managed or undetected foot ulcers).

During a concurrent observation and interview on 7/8/2025 at 10:30 a.m. with Accreditation and Licensing Coordinator (AL) and Clinical Director (CD3). Patient 3 was observed with both feet were wrapped with dressing. Patient 3 did not have a fall risk wristband on neither left nor right wrist. CD3 stated that if Patient 3 is identified as a fall risk, he should have a yellow color fall risk wristband. CD3 agreed Patient 3 did not have a fall risk wristband on. CD3 further stated she needed to check on the patient ' s record if patient is identified with fall risk.

During an interview and record review on 7/8/2025 at 10:40 a.m., with AL and CD3. CD3 reviewed Patient 3 ' s medical record at nursing station and stated that Patient 3 ' s fall risk is identified as moderate. CD3 stated that the facility is using John Hopkins fall assessment tool (a tool used to assess a patient's risk of falling in a healthcare setting, 0-5 is universal risk, 6-13 is moderate fall risk, and 13 and above is high fall risk). CD3 stated that this patient should have a yellow fall risk wristband and a falling star magnet post on Patient 3 ' s door for staff to identify Patient 3 is a risk for fall.



During a review of Patient 3's "Adult Assessment Intervention" flowsheet (a form in an electronic medical record that collects all the necessary data and displays it for easier review), dated 7/8/2025, at 8:15 a.m., the flowsheet indicated Patient 3 scored a 8 on the John Hopkins fall assessment tool indicated that Patient 3 is identified as moderate fall risk.



During a review of the facility's policy and procedure (P&P), titled "Falls Prevention and Management in Adult," policy number E.87200.609, last revised date 7/1/25, indicated "Patient will be scored at one of three levels using John Hopkins Fall Assessment: universal, moderate and high ....any patient assess/reassessed to be at risk of fall shall have a basic set of interventions deployed to prevent a fall ...intervention for moderate and high risk included applied fall magnet and apply yellow fall risk wristband."

Based on interview, and record review, the facility failed to develop an individualized nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for two of 32 sampled patients (Patient 7 and Patient 8) for Patient 7 diagnosis of acute pain and Patient 8 diagnosis of altered mental status.

This deficient practice had the potential result in Patient 7 and Patient 8 not receiving the right level of care and not meeting the needs for the identified patient's concerns.





Findings:

During a record review of Patient 7's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/9/2025, indicated Patient 7 was admitted on 7/9/2025 with diagnosis of abdominal pain (pain at abdominal area),Choledocholithiasis (presence of gallstones within the common bile duct), and morbid obesity (a severe and dangerous level of being overweight that significantly and negatively impacts health and shortens the lifespan).

During a concurrent interview and record review on 7/10/2025 at 10:10 a.m., with Clinical Director 1 (CD1). CD 1 stated there was no initial plan of care developed for Patient 7. CD1 further stated that the nurse should have developed an initial plan of care for Patient 7 for acute pain within four to five hours of admission. The primary nurse must develop a plan of care for all actual or potential patient's needs to plan patient care and interventions toward meeting those needs. The primary nurse did not develop a plan of care, and this might potentially cause the patient to not get the appropriate care he needed.

During a record review of Patient 8's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/9/2025 , indicated Patient 8 was admitted on 7/9/2025 with diagnosis of altered mental status (AMS - disruption in how the brain works that causes a change in behavior), febrile (someone is sick and running a temperature), and Tachycardia (a condition where the heart beats faster than normal, typically over 100 beats per minute).

During a concurrent interview and records review on 7/10/2025 at 11:25 a.m., with CD1. CD1 stated the initial plan of care for altered mental status was not develop for Patient 8. CD1 further stated this patient was admitted last night on 7/9/25 before midnight, the primary nurse should have develop an initial plan of care for Patient 8 within four to five hours or at least within her shift. The nurse must develop a plan of care for all actual or potential patient's needs to plan the patient care and interventions toward meeting those needs. The primary nurse did not develop one and this might potentially cause the patient to not get the appropriate care he needs.

During a review of the facility's policy and procedure (P&P) titled, Patient Plan Of Care, policy number E.87200.613, last revised date 1/24/25, indicated, "Each patient will have an individualized plan of care based on needs identified by patient ' s assessment, reassessment, and results of diagnostic testing ....Plan of care is based on patient ' s goals and time frames, settings, and services required to meet those goals ....Upon admission, disciplines will complete an assessment/evaluation of their patient within their scope of practice and initiate or contribute to patient ' s individual plan of care.

Based on observation, interview and record review, the facility failed to



Ensure two of 32 sampled patients (Patients 3 and Patient 5) intravenous (IV) (administering fluids, medication and nutrients directly into the veins) dressing site was labeled with a date, time and initials written by the nurse on the patients ' dressing per the facility policy and procedure.

This deficient practice had the potential to result in Patient 3 and Patient 5 at risk for infection due to a dirty or compromised (unsafe) dressing.

Document two of 32 sampled patients (Patient 6 and Patient 7) actual time for pain reassessment in medical record.



This deficient practice had the potential result in Patient 6 and Patient 7 ' s pain level was not reassessed and without time recorded when pain reassessment was done in the medical record per hospital policy.




Finding:

1. A. During a review of Patient 3 ' s "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/3/2025 at 9:29 p.m., indicated Patient 3was admitted on 7/3/2025 with diagnosis of sepsis (a body ' s overwhelming and life-threatening response to infection), diabetes mellitus (a group of diseases that result in too much sugar in the blood), and diabetic foot infection (a serious complication of diabetes, often stemming from poorly managed or undetected foot ulcers).

During a concurrent observation and interview on 7/8/2025 at 10:30 a.m. with Accreditation and Licensing Coordinator (ALC) and Clinical Director (CD3), Patient 3 was observed with a peripheral intravenous (PIV) saline lock (access in a vein use to administer medication or withdraw blood) in patient ' s left middle forearm and the PIV dressing site was observed to be blank with no date, time and nurse ' s initials written on it. CD3 stated all nurses are expected to label the date, time and nurse ' s initials after intravenous (IV- administering fluids, medication and nutrients directly into the veins) inserted or dressing changed. The CD3 stated without labeling the date and time, it could compromise the IV site for risk of infection.

During a review of the facility's policy and procedure (P&P) titled, Intravenous (IV) Therapy for Adult and Pediatrics-Peripheral and Central, policy number E.87200.307, last revised date 7/3/2024, indicated all IV sites will be change only as clinically warranted(required)based on integrity (strength) and patency(being open) of the site and labeled with initiation (start) date and time.

B. During a review of Patient 5 ' s "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/7/2025 at 11:41 a.m., indicated Patient 5 ' s was admitted on 7/7/2025 with diagnosis of Pneumonia (lung infection), diabetes mellitus (a group of diseases that result in too much sugar in the blood), and end stage renal disease (ESRD, a stage where the kidneys can no longer support the body's needs for waste removal and fluid balance).

During a concurrent observation and interview on 7/8/2025 at 10:45 a.m. with Accreditation and Licensing Coordinator (ALC) and Clinical Director 1 (CD1), Patient 5 was observed with a peripheral intravenous (PIV- a thin, flexible tube inserted into a peripheral vein (like those in the hand, arm, or foot) to deliver fluids, medications, or blood products) saline lock (access in a vein use to administer medication or withdraw blood) in patient ' s right wrist and the PIV dressing site was observed to be blank with no date, time, and nurse ' s initials written on it. CD1 stated all nurses are expected to label with the date, time and nurse ' s initial after IV inserted or dressing changed. The CD1 stated without labeling the date and time, it could compromise the IV site for risk of infection.

During a review of the facility's policy and procedure (P&P) titled, Intravenous (IV) Therapy for Adult and Pediatrics-Peripheral and Central, policy number E.87200.307, last revised date 7/3/2024, indicated all IV sites will be change only as clinically warranted(required)based on integrity (strength) and patency(being open) of the site and labeled with initiation (start) date and time.



2. A. During a record review of Patient 6's "Office visit" (a physician or other qualified provider, where a patient seeks evaluation, diagnosis, treatment, or management of a specific health concern or condition)," dated 5/30/2025, indicated Patient 6 planned to schedule left robotic assisted total knee arthroplasty (a surgical procedure that uses robotic technology to enhance the precision and accuracy of knee replacement surgery).

During a record review of Patient 6's "Facesheet Report (summary of a patient ' s information), indicated Patient 6 was admitted on 7/9/2025 at 5:27 a.m., with diagnosis of left Robotic-assisted total knee arthroplasty for surgery of degrative arthritis of left knee (a condition where the cartilage in the knee joint gradually wears away, leading to pain, stiffness, and decreased mobility).

During a review of Patient 6's " Flowsheet" (a form in an electronic medical record that collects all the necessary data and displays it for easier review), indicated Patient 6 ' s pain level (scale use to rate pain intensity (strength) from 0 to 10 , where 0 is no pain and 10 is worst pain) as follows:

On 7/9/2025, at 11:39 p.m., Patient 6 ' s pain level is 9 at left knee; nursing staff indicated single medication modality (method of treatment).

On 7/10/2025, at 4:54 a.m., Patient 6 ' s pain level is 7 at left knee; nursing staff indicated single medication modality.

During a review of Patient 6's medication administration record (MAR-record that document all medication given to a patient) indicated:

On 7/9/2025, at 11:39 p.m., Norco 10/325 (hydrocodone and acetaminophen 10/325 milligram (mg-unit of weight), 1 tablet by mouth every 4 hours as needed (PRN) for pain were administered.

On 7/10/2025, at 4:54 a.m., Norco 10/325 (hydrocodone and acetaminophen 10/325 milligram (mg), 1 tablet by mouth every 4 hours as needed (PRN) for pain were administered.

During a concurrent record review and interview of the MAR on 7/10/2025 at 9:40 a.m., with Clinical Director (CD1), CD1 stated there was no pain reassessment documented within one hour after Norco 10/325 was administered on 7/9/25, at 11:39 p.m. and on 7/10/2025 at 4:54 a.m., indicated on Patient 6 ' s medical records. CD1 further stated that the nurse did not reassess Patient 6 ' s pain after administering pain medication within one hour after administration.

During a review of the facility's policy and procedure (P&P) titled, pain management, policy number E.87200.624, last revised date 3/28/24, indicated "reassessment after intervention for pain - If an intervention for pain is provided, response to that intervention should be assessed. Reassessment is recommended to occur within an hour following medications for treatment of pain. Documentation of this reassessment must occur at least at next routine pain assessment or prior to end of shift. Reassessment at a minimum will include intensity of pain or patient's response to intervention. If pain was not relieved to the patient's satisfaction, continue to treat and / or notify physician.

B. During a record review of Patient 7's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/9/2025 at 3:31 a.m., indicated Patient 7 was admitted on 7/9/2025 at 3:15 a.m., with diagnosis of abdominal pain (pain at abdominal area), Choledocholithiasis (presence of gallstones within the common bile duct), and morbid obesity (a severe and dangerous level of being overweight that significantly and negatively impacts health and shortens the lifespan).

During a review of Patient 7's " Flowsheet" (a form in an electronic medical record that collects all the necessary data and displays it for easier review), dated 7/9/2025, at 8:16 a.m., indicated Patient 7 ' s pain level was nine (9) on the abdomen; nursing staff indicated single medication modality. (method of treatment)

During a review of Patient 7's Medication Administration Record (MAR) indicated on 7/9/2025, at 8:31 a.m., Dilaudid 1 milligram (mg – unit of measurement) intravenous (IV - through the vein) was administered for pain.

During a concurrent record review and interview of the MAR on 7/10/2025 at 10:10 a.m., with Clinical Director (CD1), CD1 stated there was no indication a pain reassessment was documented within 1 hour after Dilaudid 1 mg was administered on 7/9/25, at 8:31 a.m., on Patient 7 ' s medical records. CD1 further stated the nurse only documented pain reassessment done four (4) hours after administration of pain medication on 7/9/25, at 12:31 p.m.

During a review of the facility's policy and procedure (P&P) titled, pain management, policy number E.87200.624, last revised date 3/28/24, indicated "reassessment after intervention for pain - If an intervention for pain is provided, response to that intervention should be assessed. Reassessment is recommended to occur within an hour following medications for treatment of pain. Documentation of this reassessment must occur at least at next routine pain assessment or prior to end of shift. Reassessment at a minimum will include intensity of pain or patient's response to intervention. If pain was not relieved to the patient's satisfaction, continue to treat and / or notify physician.

Based on interview and record review, the facility nursing staff failed to ensure correct IV (intravenous into the vein) fluid was administered not the discontinued Magnesium Sulfate (medication used for treating high blood pressure caused by pregnancy and involuntary muscle movements from temporary abnormal brain activities caused by high blood pressure) for one of 32 sampled patients (Patient 1).

This deficient practice had cause Patient 1's to receive the discontinued Magnesium Sulfate (medication for managing preeclampsia) IV instead of the new order medication Dextrose 5% Lactate Ringers (D5LR- sterile, nonpyrogenic solution used for intravenous fluid and electrolyte replenishment and caloric supply) IV and Patient 1 may potentially be at risk to experience side effect from Magnesia Sulfate including low blood pressure, muscle weakness, and drowsiness/lethargy, etc.

This deficient practice had the potential to cause Patient 1 to not receive the right medication on time and potentially lead to other complications.





Finding:

During a record review of Patient 1's "History & Physical" (H&P, a formal and complete assessment of the patient and the problem), dated 7/14/2024 , indicated Patient 1 was admitted on 7/14/2024 with diagnosis of labor induction (the process of artificially starting labor using medical methods, either to initiate contractions or to make them stronger) and advanced maternal age in multigravida (pregnancies in women aged 35 or older who have had at least one previous pregnancy).

During a record review of Patient 1's Intrapartum Progress note (clinical documentation used during labor and delivery to record a woman's progress and the status of both the mother and fetus), dated 7/15/2024 at 8:04 a.m., indicated Patient 1 ' s had severe pre-eclampsia (a pregnancy complication characterized by new-onset high blood pressure ) and Patient 1 ' s blood pressure (BP) 142/77 was recorded on 7/14/24 at 6:58 p.m., and provider (Medical Doctor) ordered Magnesium Sulfate (is a key medication for managing preeclampsia)(high blood pressure during pregnancy) intravenous (IV) loading dose 4 grams and 1 gram per hour.

During a record review of Patient 1's Vaginal Delivery Procedure note (clinical documentation used during labor and delivery to record giving birth to a baby through the birth canal), dated 7/15/2024 at 1:20 p.m., indicated Patient 1 had delivered a baby girl with vacuum assisted during a prolonged second stage of labor, (Vacuum cup is attached to the baby ' s head to assist with delivery) estimated blood loss 400 milliliter (ml-measurement of unit of volume) with complications of preeclampsia.

During a record review of Patient 1's Maternal Assessment/Intervention Note (clinical documentation for nursing assessment and intervention), dated 7/16/2024 at 12:42 p.m., indicated Registered Nurse (RN7) stopped Magnesium Sulfate Intravenous (IV) administration.

During a record review of Patient 1's Medication Administration Record (MAR-record that document all medication given to a patient), indicated Dextrose 5% Lactate Ringers (D5LR- sterile, nonpyrogenic solution used for intravenous fluid and electrolyte replenishment and caloric supply) IV bolus (rapid intravenous administration of a single, concentrated dose of medication or fluid directly into a vein)was started on 7/16/24 at 2:54 p.m. and ended 3:04 p.m.

During a record review of Patient 1 ' s Adult Rapid Response Team Record (a hospital- based team that provide immediate critical care to patients ' condition is worsening), indicated on 7/16/2024 at 3:38p.m. Patient 1 complain of shortness of breath and the Rapid Response Team was called. The assessment section indicated Patient 1 was little anxious (worried), tachypneic (abnormal, rapid shallow breathing and the Magnesium infusion completed around 1:00p.m.

During a concurrent record review and interview on 7/9/2025 at 11:10 a.m., with Clinical Director 4 (CD4). CD 4 stated that Patient 1 was a postpartum (period after childbirth up to six weeks) patient with severe preeclampsia and the Magnesium Sulfate usually will be continue for 24 hours after delivery. On 7/16/25, physician verbally ordered at bedside to discontinue the Magnesium Sulfate and started D5LR IV bolus. Registered Nurse (RN7) stopped Magnesium Sulfate on 7/16/24 at 12:42 p.m., however RN7 did not discarded the discontinue Magnesium Sulfate bag or the IV tubing and left the Magnesium Sulfate on the IV pump. RN7 supposed to start the D5LR on 7/16/24 at 2:54p.m., but she connected the wrong IV tubing with the Magnesium Sulfate instead of the D5LR IV bolus. The infusing Magnesium Sulfate was stopped at 3:04 p.m, 10 minutes after it was started. At 3:38p.m. on 7/16/2024, Patient 1 walked to the restroom and started to feel short of breath. CD4 stated RN7 should have discarded all discontinued medication and should not leave it in the room. CD4 stated discussed with RN7 regarding the Magnesium Sulfate bag or IV tubing left on the IV pump and connecting the wrong tubing with the Magnesium Sulfate instead of the D5LR IV bolus.

During a review of the facility's policy and procedure (P&P) titled, Medication Administration in Audits and Pediatrics", policy number E.87200.611, last revised date 9/27/23, indicated "Prior to administration of medication, invasive lines and tubes will be traced to ensure that medication is administered via proper route.

Based on interview and record review, the facility failed ensure for one of 32 sampled patients (Patient 17), had a medical record that was accurately written regarding Patient 17 ' s status of permacath (a thin, flexible tube inserted into a large vein, such as in the neck, guided into a central vein near the heart; also called a central line) presence.

This deficient practice had the potential to result in a lack of accurate information to be utilized detailing Patient 17 ' s care and Permacath status and presence.



Findings:

During a review of Patient 17 ' s "History and Physical (H&P)," dated 3/19/2025, the H&P indicated, Patient 17 was admitted to the facility on 3/18/2025 for hyperkalemia (high potassium levels) with a past medical history of end stage renal disease (ESRD – kidney failure) on hemodialysis (a medical procedure that cleans the blood of a person whose kidneys are not functioning properly).

During a concurrent interview and record review on 7/8/2025 at 3:45 PM with the Clinical Nurse Specialist (CNS 1), Patient 17 ' s infectious disease consultation note on 3/29/2025 was reviewed. The record indicated "The patient developed purulent (containing pus; a thick yellowish or greenish opaque (cloudy) liquid produced in infected tissue) drainage (liquid waste) from his right internal (inside) jugular (of the neck and throat area) Perm-A-Cath (permacath) site on 03/21/2025. The catheter (a thin, flexible tube) has been subsequently (later) removed on 3/21/2025." The CNS 1 stated this record indicated the Infectious Disease Medical Doctor (ID) confirmed the removal of Patient 17 ' s infected permacath to have occurred on 3/21/2025.

During a concurrent interview and record review on 7/9/2025 at 10:40 AM with the Vice President of Regulatory Affairs (VP), Patient 17 ' s "Discharge Summary," dated 3/30/2025 was reviewed. The record indicated on 3/22/2025, Patient 17 had "pus (a thick yellowish or greenish opaque liquid produced in infected tissue) expressing out of prior permacath site, this was removed this Thursday". The VP stated she could not locate a note indicating who had removed Patient 17 ' s infected permacath on the stated date to corroborate (confirm) the information from the "Discharge Summary." The VP also stated all physicians should document any removal of any central line, such as a permacath.

During a concurrent interview and record review on 7/9/2025 at 11:00 AM with the VP, Patient 17 ' s chest x-ray, dated 3/18/2025 was reviewed. The record did not indicate or mention any permacath being present within the findings nor impression. The VP stated this record indicated that Patient 17 was not admitted to the facility with the permacath in place.

During an interview on 7/9/2025 at 11:00 AM with the VP, the VP stated she understood there was a discrepancy (difference) of documentation between Patient 17 ' s chest x-ray result from 3/18/2025, with no mention of the presence of a permacath being in place, and the infectious disease consultation note on 3/29/2025, indicating an infected permacath was removed on 3/21/2025.

During a review of the facility ' s policy and procedure (P&P) titled, "Medical Record Documentation – E.87000.708," dated 4/4/2025, the (P&P) indicated, "Entries in the medical record will be made by health care practitioners and physicians involved in the care and treatment of the patient . . . Entries are to be factual and objective."