HospitalInspections.org

Based on observation, interview and record review, the facility failed to meet the Condition of Participation of Patient's Rights (The Patient's Bill of Rights is a document that outlines what patients can expect when receiving health care) as evidenced by:

1. The facility failed to ensure for two of 30 sampled patients (Patients 25 and 27) the following:

1.a. Patient 25 was provided the Important Message from Medicare (IMM, given to all Medicare [federal health insurance for people at a certain age or with specific medical disabilities] beneficiaries, notifying them of their hospital discharge appeal rights) and the Conditions of Admission (COA - contracts between a patient and a hospital that outline the patient's responsibilities and obligations while receiving treatment) upon admission to the facility.

1.b. Patient 27 was provided the Important Message from Medicare letter (IMM, given to all Medicare [federal health insurance for people at a certain age or with specific medical disabilities] beneficiaries, notifying them of their hospital discharge appeal rights) upon admission to the facility.

These deficient practices resulted in Patients 25 and 27 to not be informed of their rights as a patient, which may result in Patients 25 and 27's inability to effectively make decisions regarding their care or treatment. (Refer to A-0117)

2. The facility failed to ensure one of 30 sampled patients (Patient 5), was given the opportunity to actively participate in the development of his treatment plan, in accordance with the facility's policy and procedure regarding Patient Rights (document that outlines what patients can expect when receiving health care) and Responsibilities, when Patient 5 was not provided with information regarding health status, diagnosis, course of treatment and procedures, and prospects of recovery during the patient's (Patient 5) visit in the Emergency Department (ED, a specialized medical facility within a hospital that provides immediate care to patients with acute illnesses or injuries requiring urgent medical attention).

This deficient practice had violated Patient 5's right to receive effective communication and to be informed, as well as actively participate in the development of the treatment plan. Additionally, this deficient practice had the potential to result in compromised care and emotional harm for Patient 5. (Refer to A-0130)

3. The facility failed to ensure for one of 30 sampled patients (Patient 30), Patient 30 was provided a copy of an "Informed Consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered): Image Guided Left Upper Arm Fistulogram with Possible Intervention (test to check the blood flow of a connected vein and artery used for hemodialysis [a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed])," in the patient's (Patient 30) preferred language. Patient 30's preferred language was Spanish.

This deficient practice resulted in Patient 30 and/or the patient's representative not able to exercise the right to make informed decisions regarding Patient 30's care as well as to understand the risks involved, which may result in emotional or mental distress. (Refer to A-0131)

4. The facility failed to ensure for four of 30 sampled patients (Patients 25, 26, 27, and 28), Patients 25, 26, 27, and 28 and/or the patients' representative received information about an Advance Directive (AD, legal document a patient makes in case they are no longer able to communicate their instructions for care) in accordance with the facility's policy and procedure regarding Advance Directives.

This deficient practice resulted in Patients 25, 26, 27, and 28 and/or the patients' representative to not be informed of the process to make decisions on their care if they are no longer able to, which could negatively affect their rights and wishes for treatment when they receive medical care that they may not want. (Refer to A-0132)

5. The facility failed to ensure safe care was provided when:

5.a. For three of three medication rooms (MR) observed (MR 1, MR 2, and MR 3), the intravenous (IV-fluids given through the vein to restore and maintain electrolytes, salt, and sugar levels in the body) medications and medical supplies (equipment used for giving medications) were kept in unlocked cabinets and were accessible to non-licensed staff (staff with no permission to give medications and assess the patients).

This deficient practice resulted in non-licensed staff having access to medications, needles used for injecting medications and syringes (small tube used with a needle for injecting medications) that could be used for inappropriate purposes. (Refer to A-0142)

5.b. Patient 25 was not wearing an identification arm band (facility armband that contains information such as name, date of birth and medical record number) in accordance with the facility's policy and procedure regarding Patient Identification.

This deficient practice resulted in Patient 25 to not be accurately identified and had the potential for the patient's safety, while in the facility, be jeopardized such as with medication errors, etc. due to lack of proper identification. (Refer to A-0142)

6. The facility failed to ensure for one of 30 sampled patients (Patient 30), Patient 30's personal privacy was respected when, Patient 30 and/or the patient's representative was not informed of Patient 30 being placed on Video Monitoring (audio/visual monitor with someone watching to alert staff and redirect patients who are at risk for falling or removing important equipment).

This deficient practice resulted in Patient 30's rights to personal privacy violated which could have a negative impact on Patient 30's emotional status and dignity. (Refer to A-0143)

7. The facility failed to ensure completion of Abuse (intentional maltreatment of an individual that may cause physical or psychological injury) training for one of five sampled staff members (Registered Nurses [RN] 15), in accordance with the facility's policies and procedures regarding abuse.

This deficient practice had the potential for staff not to be informed of abuse, neglect (the negligent failure of the caretaker to provide the necessary care and assistance to ensure the person's health and safety), related reporting requirements, including prevention, intervention, and detection, which could potentially compromise patient safety. (Refer to A-0145)

8. The facility failed to ensure for three of 30 sampled patients (Patients 24, 25 and 30), Patients 24, 25, and 30 were free from restraint (physical device that prevents a person from freely moving), in accordance with the facility's policy and procedure regarding restraints use, when the patients' (Patient 24, 25 and 30) all 4 side rails were raised without a physician order.

This deficient practice resulted in inappropriate, unnecessary, and prolonged use of restraints, and had violated Patients 24, 25, and 30's rights. In addition, this deficient practice had the potential for Patients 24, 25, and 30 to suffer from physical harm such as strangulation (obstruction of blood vessels and/or airflow in the neck resulting in asphyxia [lack of oxygen]), skin tear, loss of consciousness, broken skull, bleeding in the brain, etc., due to lack of proper monitoring in relation to restraints use. (Refer to A-0154)

9. The facility failed to ensure nursing staff initiated and developed a restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) upon restraints initiation, in accordance with the facility's policy and procedure regarding restraints, for one of 30 sampled patients (Patient 21), when the restraint was initiated on 9/13/2024.

This deficient practice had the potential to result in unnecessary restraints use for Patient 21 as there was no care plan developed for nursing staff to monitor progress and evaluate restraints use. This deficient practice also had the potential to result in complications of restraints use such as skin integrity issues (a break in the skin), etc. (Refer to A-0166)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe setting, potentially placing patients at risk for a delay in care and treatments and/or death.

Based on interview and record review, the facility failed to ensure for two of 30 sampled patients (Patients 25 and 27) the following:

1. Patient 25 was provided the Important Message from Medicare (IMM, given to all Medicare [federal health insurance for people at a certain age or with specific medical disabilities] beneficiaries, notifying them of their hospital discharge appeal rights) and the Conditions of Admission (COA - contracts between a patient and a hospital that outline the patient's responsibilities and obligations while receiving treatment) upon admission to the facility.

2. Patient 27 was provided the Important Message from Medicare letter (IMM, given to all Medicare [federal health insurance for people at a certain age or with specific medical disabilities] beneficiaries, notifying them of their hospital discharge appeal rights) upon admission to the facility.

These deficient practices resulted in Patients 25 and 27 to not be informed of their rights as a patient, which may result in Patients 25 and 27's inability to effectively make decisions regarding their care or treatment.

Findings:

1. During a review of Patient 25's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 8/30/2024, the H&P indicated, Patient 25 was admitted to the facility after sustaining a ground level fall (an unintentional event that results in the person coming to rest on the ground or another lower level). Patient 25 was found to have multiple left sided rib fractures (breaks in a bone).

The H&P also indicated, Patient 25 had a past medical history of altered mental status (a change in mental function, such as a change in awareness, cognition [thinking and learning], attention, or consciousness), and schizophrenia (a serious mental illness that affects a person's thoughts, feelings, and behaviors).

1.a. During a concurrent interview and record review on 9/19/2024 at 10:50 a.m. with the Director of Telemetry (DIR 5), DIR 5 stated Patient 25's "Conditions of Admission (COA- contracts between a patient and a hospital that outline the patient's responsibilities and obligations while receiving treatment)," for 8/30/2024 at 9:25 p.m., indicated Patient 25 was not able to sign the COA, "due to health condition."

During the same interview and record review on 9/19/2024 at 10:50 a.m. the DIR 5 stated Patient 25's COA for 8/31/2024 at 12:25 p.m. indicated, Patient 25 did not sign the COA and it was documented "nurses were working with PT (patient- Patient 25)."

During an interview on 9/19/2024 at 11:05 a.m. with the Admitting Lead (AD), the AD stated when a patient was admitted to the facility, the admitting personnel would make three attempts to have the COA signed. The AD said when the COA was not signed and the patient was transferred up to their admitting floor, the admitting personnel would follow the patient and would have three more attempts to get the COA signed. The AD stated if the patient was unable to sign the COA due to medical condition, the admitting personnel should contact the patient's representative on the patient's emergency contact list to sign the COA.

During the same interview on 9/19/2024 at 11:05 a.m., the AD stated, since Patient 25 was unable to sign the COA due to medical condition, the next attempt should have been Patient 25's listed emergency contact. The AD said there was no documentation Patient 25's representative was contacted to sign the patient's COA.

During a review of the facility's policy and procedure (P&P) titled, "Conditions of Admission," dated 10/2022, the P&P indicated, "the form must be signed by the patient and/or the patient's legal representative, just prior to each hospitalization." The P&P also indicated "the Patient Financial Services representative will make every effort to obtain consent."

1.b. During a concurrent interview and record review on 9/19/2024 at 11:14 a.m. with the Admitting Lead (AD), the AD stated once the patient was admitted, the IMM (Important Message from Medicare- given to all Medicare [federal health insurance for people at a certain age or with specific medical disabilities] beneficiaries, notifying them of their hospital discharge appeal rights) letter would be given to the patient by the admitting personnel. The AD said Patient 25's record had no documented evidence the IMM letter was provided to the patient (Patient 25).

During a review of the facility's policy and procedure (P&P) titled, "Important Message from Medicare (IMM) Letter - Delivery Process," dated 02/2020, the P&P indicated, "all Medicare inpatients will receive the initial IMM within two days of admission."

2. During a review of Patient 27's "Discharge Summary (a narrative document for communicating clinical information about what happened to the patient in the hospital)," dated 9/18/2024, the summary indicated, Patient 27 was admitted on 9/15/2024 for heart failure (heart is not effectively pumping blood throughout the body) and pneumonia (lung infection). Patient 27 was discharged (released) from the hospital on 9/18/2024 at 1:45 p.m. Patient 27 stayed at the facility for a total of 4 days.

During an interview on 9/18/2024 at 3:44 p.m., with the Director of Patient Access (DPA), the DPA stated when a patient was admitted to the facility, the Patient Access Staff would give the IMM (Important Message from Medicare- given to all Medicare [federal health insurance for people at a certain age or with specific medical disabilities] beneficiaries, notifying them of their hospital discharge appeal rights) letter. The DPA stated another IMM letter should have been given to the patient upon discharge by the Care Coordination team.

During the same interview and record review on 9/18/2024 at 3:44 p.m., the DPA stated Patient 27's record had no documentation the IMM letter was given to Patient 27 on admission. The DPA said Patient 27's IMM letter was received and signed by Patient 27 on 9/18/2024 at 10:00 a.m., on the day the patient was discharged from the facility.

During a review of the facility's policy and procedure (P&P) titled, "Important Message from Medicare (IMM) Letter-Deliver Process," dated 2/2023, the P&P indicated, "All Medicare inpatients will receive the initial IMM within two days of admission and the follow-up IMM prior to discharge as required by CMS (Centers for Medicare and Medicaid Services) ... Hospitals must issue the Important Message for Medicare (IMM):
-Within two days of admission and
-In advance of discharge as possible, but no more than 2 calendar days before the planned date of discharge so that the beneficiary has the opportunity to consider appealing the discharge decision."

Based on observation, interview and record review, the facility failed to ensure one of 30 sampled patients (Patient 5) was given the opportunity to actively participate in the development of his treatment plan, in accordance with the facility's policy and procedure regarding Patient Rights (document that outlines what patients can expect when receiving health care) and Responsibilities, when Patient 5 was not provided with information regarding health status, diagnosis, course of treatment and procedures, and prospects of recovery during the patient's (Patient 5) visit in the Emergency Department (ED, a specialized medical facility within a hospital that provides immediate care to patients with acute illnesses or injuries requiring urgent medical attention).

This deficient practice had violated Patient 5's right to receive effective communication and to be informed, as well as actively participate in the development of the treatment plan. Additionally, this deficient practice had the potential to result in compromised care and emotional harm for Patient 5.

Findings:

During an observation on 9/18/2024 at 12:03 p.m. with the director of Emergency Department (Dir 4), in the Emergency Department (ED, a specialized medical facility within a hospital that provides immediate care to patients with acute illnesses or injuries requiring urgent medical attention), Patient 5 was observed in bed. The patient's (Patient 5) monitor (a monitor refers to a medical device or system used to continuously observe and display a patient's vital signs [consist of temperature, respiratory rate, heart rate, and blood pressure] ) was alarming. Patient 5 stated, "I have been waiting for my nurse for half an hour because the monitor keeps beeping."

During a concurrent observation and interview on 9/18/2024 at 12:03 p.m. with Patient 5 and the Director 4 (Dir 4), Patient 5 stated that during the entire ED visit (on 9/18/2024), the staff did not introduce themselves and did not provide explanations about the procedures they were performing, what was happening, or the plan of care.

During an interview on 9/18/2024 at 12:03 p.m. with the Director 4 (Dir 4), Dir 4 stated that ED nurses and other healthcare personnel should introduce themselves and provide explanations of the procedures. Dir 4 further stated that the assigned registered nurse (RN) should keep patients informed about their care and treatment, as "this is the standard of care we provide in the Emergency Department."

During a review of Patient 5's "HPI (History of Present Illness)-ED (Emergency Department General)," dated 9/18/2024, the HPI indicated, Patient 5 was seen in the ED for weakness and near syncope episode (feeling like one was going to pass out but without actual loss of consciousness).

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibilities," (no date), the policy indicated, "Each patient is entitled to compassionate and professionally competent care delivered with respect for each individual. 4. Patient has the right to know the name of the licensed health care professional acting within the scope of practice, with primary responsibility for coordinating care ... 5. Receive information about your health status, diagnosis, course of treatment, prospects for recovery and outcomes of care ...5. The right to effective communication and to participate in the development of the plan of care. 10. The Right to appropriate assessment and management of pain, information about pain, pain relief measures and to participate in pain management decisions.

Based on observation, interview, and record review, the facility failed to ensure for one of 30 sampled patients (Patient 30), Patient 30 was provided a copy of an "Informed Consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered): Image Guided Left Upper Arm Fistulogram with Possible Intervention (test to check the blood flow of a connected vein and artery used for hemodialysis [a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed])," in the patient's (Patient 30) preferred language. Patient 30's preferred language was Spanish.

This deficient practice resulted in Patient 30 and/or the patient's representative not able to exercise the right to make informed decisions regarding Patient 30's care as well as to understand the risks involved, which may result in emotional or mental distress.

Findings:

During a review of Patient 30's "History and Physical" (H&P, a formal and complete assessment of the patient and the problem), dated 7/25/2024, the "H&P" indicated Patient 30 had a history of dementia (problems with the brain related to memory, reasoning, and thinking) and End Stage Renal Disease (irreversible kidney failure) on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed).

During a review of Patient 30's "Face sheet (front page of the chart that contains a summary of basic information about the patient)," the Face sheet indicated Patient 30's preferred language was Spanish.

During a concurrent interview and record review on 9/19/2024 at 3:00 p.m. with the Director of Medical-Surgical (DIR 6), DIR 6 verified, Patient 30's "Informed Consent: Image Guided Left Upper Arm Fistulogram with Possible Intervention (test to check the blood flow of a connected vein and artery used for hemodialysis)," dated 8/6/2024, was in English version. The consent indicated Patient 30's representative gave a telephone consent and was witnessed by two nurses. DIR 6 stated it was unknown if Patient 30's representative, who signed the informed consent, preferred language was English. DIR 6 stated Patient 30's informed consent did not indicate if an interpreter was used in accordance with Patient 30's preferred language. DIR 6 stated Patient 30's consent should have been in the patient's preferred language (Spanish).

During a review of the facility's policy & procedure (P&P) titled, "Limited English Proficiency (LEP): Language Access for Patient and Companions," dated 4/2/2023, the P&P indicated, "Interpreter services will be provided for any patient who has Limited English Proficiency. Interpreter Services, including a Qualified Medical Interpreter when needed to provide meaningful, equitable access to the Facility's services, are required for patient assessment, consent, education and discharge, including but not limited to the following topics ... Obtaining informed consent or permission for treatment."

During a review of the facility's policy & procedure (P&P) titled, "Informed Consent for Operations, Diagnostic or Therapeutic Procedure," dated 8/2027, the P&P indicated, "Securing Consent when Communication Barriers Exist: When interpreters are used for the purpose of obtaining and documenting Informed Consent, the person's name, position and interpreter number, or when appropriate, relationship to the patient will be documented in the patient's medical record. If the patient declines the Medical Center provided interpretation services, this will be documented by Medical Center Staff."

Based on interview and record review, the facility failed to ensure for four of 30 sampled patients (Patients 25, 26, 27, and 28), Patients 25, 26, 27, and 28 and/or the patients' representative received information about an Advance Directive (AD, legal document a patient makes in case they are no longer able to communicate their instructions for care) in accordance with the facility's policy and procedure regarding Advance Directives.

This deficient practice resulted in Patients 25, 26, 27, and 28 and/or the patients' representative to not be informed of the process to make decisions on their care if they are no longer able to, which could negatively affect their rights and wishes for treatment when they receive medical care that they may not want.

Findings:

1. During a review of Patient 25's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 8/30/2024, the H&P indicated, Patient 25 was admitted to the facility after sustaining a ground level fall (an unintentional event that results in the person coming to rest on the ground or another lower level). Patient 25 was found to have multiple left sided rib fractures (breaks in a bone). Patient 25 had a past medical history of altered mental status (a change in mental function, such as a change in awareness, cognition [thinking and learning], attention, or consciousness), and schizophrenia (a serious mental illness that affects a person's thoughts, feelings, and behaviors).

During a concurrent interview and record review on 9/19/2024 at 10:37 a.m. with the Director of Telemetry (DIR 5), Patient 25's "Advance Directive," dated 8/30/24 indicated Patient 25 did not have an Advance Directive (AD, legal document a patient makes in case they are no longer able to communicate their instructions for care). DIR 5 stated if a patient does not have an AD, a social work consult would be ordered for the SW to provide AD information to the patient and/or patient's representative.

During the same interview and record review on 9/19/2024 at 10:37 a.m., DIR 5 stated Patient 25's record did not have a SW consult ordered for AD follow-up.

During an interview on 9/18/2024 at 3:14 p.m., with the Social Work Services (SW), the SW stated the expectation was for the nurse to inform the SW department that a patient needed consultation for AD. The SW said they (Social Work Department) provide education to the patient and/or the patient's representative regarding AD.

During a review of the facility's policy and procedure (P&P) titled, "Advanced Directives," dated 08/2024, the P&P indicated the following:

- "At the time of registration for admission, Access Care personnel give patient/surrogate a copy of the Advance Health Care Directive instructions, the (AHCD) form and the brochure "Your Right to make decision about medical treatment."

-If a "patient states, "I do not have an Advance Directive, but interested in executing one," the patient's face sheet is to be flagged to alert Social Services to follow up with the patient and provide information on the process.

- "For patients who might not have asked at admission or were non-responsive ... "if no, provide information/education on Advanced Directives (i.e. Brochure: About Advance Directives). Document all interventions on referral form and in medical record."

2. During a review of Patient 26's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/14/2024, the H&P indicated, Patient 26 was admitted to the facility for headache, fatigue (feeling of tiredness or lack of energy that can make it hard to do daily activities) , night sweats and cough for two weeks.

During a concurrent interview and record review on 9/19/2024 at 9:33 a.m. with DIR 5, Patient 25's "Advance Directive (AD, legal document a patient makes in case they are no longer able to communicate their instructions for care) and POLST (Physician's Orders for Life-Sustaining Treatment, a medical order that documents a patient's end-of-life care preferences) Tracking" document, dated 9/14/2024, indicated, Patient 26 did not have an Advance Directive (AD). DIR 5 stated Patient 26's record had no documentation that AD information was provided and discussed with Patient 26 and/or the patient's representative.

During a review of the facility's policy and procedure (P&P) titled, "Advanced Directives," dated 08/2024, the P&P indicated the following:

- "At the time of registration for admission, Access Care personnel give patient/surrogate a copy of the Advance Health Care Directive instructions, the (AHCD) form and the brochure "Your Right to make decision about medical treatment."

-If a "patient states, "I do not have an Advance Directive, but interested in executing one," the patient's face sheet is to be flagged to alert Social Services to follow up with the patient and provide information on the process.

- "For patients who might not have asked at admission or were non-responsive ... "if no, provide information/education on Advanced Directives (i.e. Brochure: About Advance Directives). Document all interventions on referral form and in medical record."

3. During a review of Patient 27's "Discharge Summary (a narrative document for communicating clinical information about what happened to the patient in the hospital)," dated 9/18/2024, the discharge summary indicated Patient 27 was admitted on 9/15/2024 for heart failure (heart is not effectively pumping blood throughout the body) and pneumonia (lung infection).

During a concurrent interview and record review on 9/18/2024 at 2:30 p.m. with the Director of Telemetry 5 (DIR 5), Patient 27's "Advance Directive and POLST (Physician Order for Life Sustaining Treatment) Tracking," dated 9/15/2024 indicated, Patient 27 had no AD. DIR 5 stated if the patient had no AD, the nurse would place an order for a Social Work (SW) consult or Spiritual Care to provide AD information to the patient.

During the same interview and record review on 9/18/2024 at 2:30 p.m., DIR 5 verified Patient 27 had a SW consult on 9/16/2024 at 12:15 a.m. DIR 5 stated Patient 27's record had no documentation of SW discussing the AD to the patient (Patient 27).

During a concurrent interview and record review on 9/18/2024 at 3:14 p.m., with the Social Work Services (SW), the SW stated the main goal of having an AD discussion was to give the patient education about a document stating who makes decisions if the patient cannot make them known. The SW said Patient 27 was seen today (9/18/2024). The SW stated Patient 27's SW consult order was not for AD and so AD was not discussed with Patient 27.

During a review of the facility's policy and procedure (P&P) titled, "Advanced Directives," dated 08/2024, the P&P indicated the following:

- "At the time of registration for admission, Access Care personnel give patient/surrogate a copy of the Advance Health Care Directive instructions, the (AHCD) form and the brochure "Your Right to make decision about medical treatment."

-If a "patient states, "I do not have an Advance Directive, but interested in executing one," the patient's face sheet is to be flagged to alert Social Services to follow up with the patient and provide information on the process.

- "For patients who might not have asked at admission or were non-responsive ... "if no, provide information/education on Advanced Directives (i.e. Brochure: About Advance Directives). Document all interventions on referral form and in medical record."

4. During a review of Patient 28's "Discharge Summary (a narrative document for communicating clinical information about what happened to the patient in the hospital)," dated 9/18/2024, the discharge summary indicated Patient 28 was admitted on 9/15/2024 for Encephalopathy (disease affecting brain function). Patient 28 was discharged (released) from the facility on 9/18/2024.

During a concurrent interview and record review on 9/18/2024 at 1:51 p.m. with DIR 5, Patient 28's "Advance Directive and POLST (Physician Order for Life Sustaining Treatment) Tracking," dated 9/15/2024, was reviewed. The document indicated Patient 28 had no AD.

During the same interview and record review on 9/18/2024 at 1:51 p.m., DIR 5 stated Patient 28 had a Social Work consult on 9/15/2024 at 10:18 p.m. DIR 5 stated Patient 28 was discharged today (9/18/2024) and there was no documentation of a Social Work Consult note.

During an interview on 9/18/2024 at 2:30 p.m., with DIR 5, DIR 5 stated if the patient had no AD, the nurse would place an order for a Social Worker (SW) consult or Spiritual Care to provide AD information to the patient.

During a concurrent interview and record review on 9/18/2024 at 3:14 p.m. with the Social Work Services (SW), the SW verified Patient 28 had a SW consult order on 9/15/2024. The SW stated the "Social Work Risk and Severity Levels" screening, which provided timeframes to see the patient based on specific criteria, was used to prioritize the SW consult orders and when to see the patients.

During the same interview and record review on 9/18/2024 at 3:14 p.m., the SW stated Patient 28's SW consult order was a Level 1 (per the document, Level 1 are patients who depend on help, live alone or have little support, need their care evaluated, need family involvement, and need caregiver help). The SW stated Level 1 patients are seen within 72 hours. The SW stated Patient 28's SW consult was on 9/15/24, and the patient should have been seen. The SW confirmed Patient 28 had not been seen for SW consult to discuss the AD information.

During a review of the facility's policy and procedure (P&P) titled, "Advanced Directives," dated 08/2024, the P&P indicated the following:

- "At the time of registration for admission, Access Care personnel give patient/surrogate a copy of the Advance Health Care Directive instructions, the (AHCD) form and the brochure "Your Right to make decision about medical treatment."

-If a "patient states, "I do not have an Advance Directive, but interested in executing one," the patient's face sheet is to be flagged to alert Social Services to follow up with the patient and provide information on the process.

- "For patients who might not have asked at admission or were non-responsive ... "if no, provide information/education on Advanced Directives (i.e. Brochure: About Advance Directives). Document all interventions on referral form and in medical record."

Based on observation, interview, and record review, the facility failed to ensure safe care was provided when:

1. For three of three medication rooms (MR) observed (MR 1, MR 2, and MR 3), the intravenous (IV-fluids given through the vein to restore and maintain electrolytes, salt, and sugar levels in the body) medications and medical supplies (equipment used for giving medications) were kept in unlocked cabinets and were accessible to non-licensed staff (staff with no permission to give medications and assess the patients).

This deficient practice resulted in non-licensed staff having access to medications, needles used for injecting medications and syringes (small tube used with a needle for injecting medications) that could be used for inappropriate purposes.

2. Patient 25 was not wearing an identification arm band (facility armband that contains information such as name, date of birth and medical record number) in accordance with the facility's policy and procedure regarding Patient Identification.

This deficient practice resulted in Patient 25 to not be accurately identified and had the potential for the patient's safety, while in the facility, be jeopardized such as with medication errors, etc. due to lack of proper identification.

Findings:

1.a. During a concurrent observation and interview on 9/17/2024 at 3:32 p.m. with the Director of Telemetry 5 (DIR 5) and the Manager of Telemetry 3 (NM 3), the following were observed in Medication Room (MR 1) 1, located on the 9th floor Telemetry (patients placed on a continuous heart monitor) Unit:

-MR 1 door was opened with a badge access (special card that allows staff to enter rooms) by NM 3. MR 1 was only accessible by using the badge access.

- Inside MR 1 was a medication dispensing machine, a cabinet for IV Fluid medications such as Normal Saline (NS - used to restore salt and electrolyte levels in the body) and Dextrose (used to restore and maintain sugar levels in the body), a supply storage cabinet, a linen cart storage and a general supplies cart (basic equipment used by non-licensed staff such as cream, socks, buckets) for patient care.

- The storage cabinet that contained IV fluid medications (NS and Dextrose), needles, syringes, and IV fluid tubing (tubes used specifically for giving IV Fluids) was unlocked with the cabinet doors partially open.

NM 3 stated MR 1 was the medication room, supply room, and linen room of the unit and it is accessible to the all the staff.

NM 3 stated when a non-licensed staff member needed to enter the medication room to get blankets, towels, gowns, and general patient care supplies, a licensed staff member would accompany them (non-licensed staff). NM 3 stated a licensed staff needed to be in the room with a non-licensed staff because the room was shared with the medication dispensing machine and storage cabinets for the IV Fluids and medical supplies.

During a concurrent observation and interview on 9/17/2024 at 3:35 p.m. with DIR 5 and NM 3, inside MR 1, Environmental Services 1 (EVS 1, unlicensed staff who cleans the patient's rooms) was observed to enter the room 9MR 1) alone, without a licensed staff. EVS 1 stated she (EVS 1) needed to get blankets from the linen cart. EVS 1 stated she got into the room using her badge access and she (EVS 1) did not need anyone else to come in with her (EVS 1). DIR 5 stated medication supplies such as needles should follow the same concept as IV fluids and should be locked.

During an observation on 9/17/2024 at 3:38 p.m., EVS 2 was observed to enter MR 1 alone and was not accompanied by licensed staff. EVS 2 retrieved blankets from the linen cart.

During a review of the facility's Policy and Procedure (P&P) titled, "Safe Handling of Medications," dated 2/2027, the P&P indicated, "Drug Storage and Security: Medications will be stored properly and safely ...Lockable medication carts are used to store unit-of-use medications in the patient medication dose system. These carts will be locked when not attended. Medication rooms on nursing units used for storage of floor stock medications will remain locked. Access shall be limited to licensed nursing personnel."


1.b. During a concurrent observation and interview on 9/18/2024 at 10:07 a.m. with the Director of Telemetry 5 (DIR 5), the following were observed in Medication Room (MR 2) 2, located on the 6th floor East Telemetry Unit:

- MR 2 door was opened with a badge access by DIR 5.

-Inside MR 2 was a medication dispensing machine, a cabinet for IV (Intravenous, into the vein) Fluid medications, a supply storage cabinet, a linen cart storage and a general supplies cart for patient care.

-The cabinet that contained IV fluids such as NS (Normal Saline, used to restore salt and electrolyte levels in the body), Dextrose (used to restore and maintain sugar levels in the body), Lactated Ringers (LR - used to restore electrolytes) and medical supplies had a padlock on one side of the cabinet door and was not used to lock the cabinet.

DIR 5 stated MR 2 was the medication room, supply room, and linen room of the unit and it is accessible to all the staff.

DIR 5 stated IV fluids were considered medications and could be used inappropriately by anyone with access by unlicensed staff.

During a review of the facility's Policy and Procedure (P&P) titled, "Safe Handling of Medications," dated 2/2027, the P&P indicated, "Drug Storage and Security: Medications will be stored properly and safely ...Lockable medication carts are used to store unit-of-use medications in the patient medication dose system. These carts will be locked when not attended. Medication rooms on nursing units used for storage of floor stock medications will remain locked. Access shall be limited to licensed nursing personnel."


1.c. During a concurrent observation and interview on 9/18/2024 at 10:45 a.m. with the Director of Telemetry 5 (DIR 5), the following were observed in Medication Room (MR 3) 3, located on the 6th floor West Telemetry Unit:

- MR 3 door was opened with a badge access by DIR 5.

-Inside MR 3 was a medication dispensing machine, a cabinet for IV (Intravenous, into the vein) Fluid medications such as NS (Normal Saline, used to restore salt and electrolyte levels in the body), a supply storage cabinet, a linen cart storage and a general supplies cart for patient care.
- IV Fluids such as NS were in an open cabinet that was not locked.

During a review of the facility's Policy and Procedure (P&P) titled, "Safe Handling of Medications," dated 2/2027, the P&P indicated, "Drug Storage and Security: Medications will be stored properly and safely ...Lockable medication carts are used to store unit-of-use medications in the patient medication dose system. These carts will be locked when not attended. Medication rooms on nursing units used for storage of floor stock medications will remain locked. Access shall be limited to licensed nursing personnel."

2. During a review of Patient 25's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 8/30/2024, the H&P indicated, Patient 25 was admitted to the facility after sustaining a ground level fall (an unintentional event that results in the person coming to rest on the ground or another lower level). Patient 25 was found to have multiple left sided rib fractures (breaks in a bone). Patient 25 has a past medical history of altered mental status (a change in mental function, such as a change in awareness, cognition [thinking and learning], attention, or consciousness), and schizophrenia (a serious mental illness that affects a person's thoughts, feelings, and behaviors).

During a concurrent observation and interview on 9/18/2024 at 10:53 a.m. with Director of Telemetry (DIR 5), Patient 25 was observed lying in bed, awake, and disoriented (a mental state marked by confusion about time, place, or who one is). Patient 25's identification arm band was attached to the bedside rail and not attached to Patient 25. DIR 5 stated Patient 25's identification band should be attached to Patient 25. DIR 5 stated the risk of not having the identification band attached would be the possibility of falsely identifying a patient.

During a review of the facility's policy and procedure (P&P) titled, "Patient Identification," dated 12/2022, the P&P indicated, "hospital identification bands are to be placed on the wrist of the patient."

Based on observation, interview and record review, the facility failed to ensure for one of 30 sampled patients (Patient 30), Patient 30's personal privacy was respected when, Patient 30 and/or the patient's representative was not informed of Patient 30 being placed on Video Monitoring (audio/visual monitor with someone watching to alert staff and redirect patients who are at risk for falling or removing important equipment).

This deficient practice resulted in Patient 30's rights to personal privacy violated which could have a negative impact on Patient 30's emotional status and dignity.

Findings:

During a review of Patient 30's "Face Sheet (record containing basic patient information including admitting date and reason for admission), the face sheet indicated Patient 30 was admitted on 7/24/2024 for a Subdural Hematoma (bleeding between the brain and the skull).

During a concurrent observation and interview on 9/18/2024 at 11:30 a.m. with Registered Nurse 2 (RN 2), inside Patient 30's room, Patient 30 was observed in bed, asleep. A rolling video monitor was on the corner of the room, by the side of the patient's bed. Patient 30 woke up and was able to state her name, where she was, and that she was sick. Patient 30 stated she did not know she was being monitored by the camera. RN 2 stated Patient 30 had the "Virtual Companion (Video Monitoring)" because she fell at home and ended up in the hospital.

During a concurrent interview and record review on 9/19/2024 at 3:00 p.m. with the Director of Medical-Surgical (DIR 6), Patient 30's "Neurological Assessment Flowsheet," dated 9/18/2024, was reviewed. The documentation indicated Patient 30 obeyed commands, was awake, alert, had short term memory, and unsteady gait. DIR 6 stated the "Virtual Companion (video monitoring)" was used for patients who have fallen or were at risk for falls (an unintentional event that results in the person coming to rest on the ground or another lower level).

During the same interview and record review on 9/19/2024 at 3:00 p.m., DIR 6 stated Patient 30's record did not have documentation that Patient 30 and/or the patient's representative was informed about the patient's video monitoring. DIR 6 stated Patient 30 and/or the patient's family/representative should have been informed of Patient 30's video monitoring.

During a review of the facility's policy and procedure (P&P) titled, "Video Monitoring of Patients with a Virtual Companion (VCompanion)," dated 8/2024, the P&P indicated, "Document in the electronic health record (EHR, digital version of the paper chart) necessary patient education, details include: notification of patient and/or patient representative that video monitoring will be or is currently implemented to enhance patient safety."

Based on interview and record review, the facility failed to ensure completion of Abuse (intentional maltreatment of an individual that may cause physical or psychological injury) training for one of five sampled staff members (Registered Nurses [RN] 15), in accordance with the facility's policies and procedures regarding abuse.

This deficient practice had the potential for staff not to be informed of abuse, neglect (the negligent failure of the caretaker to provide the necessary care and assistance to ensure the person's health and safety), related reporting requirements, including prevention, intervention, and detection, which could potentially compromise patient safety.

Findings:

During a review of Registered Nurse (RN 15)'s contract with the facility titled, "[contract company] Client Work Order (contract)," undated, the contract indicated, RN 15 was contracted to work at the facility as a Registered Nurse at Labor and Delivery (hospital unit specialized in taking care of mothers and newborns before, during and after the birth) from 8/7/2023 to 8/3/2024.

During an interview on 9/20/2024 at 10:10 a.m. with the Director of Education (DIR 7), DIR 7 stated abuse (intentional maltreatment of an individual that may cause physical or psychological injury) training was provided in the new employee orientation. DIR 7 stated it was required for all staff working at the facility to ensure the staff would know how to identify abuse and report any abuse to keep patients safe.

During a concurrent interview and record review on 9/20/2024 at 10:42 a.m. with DIR 7, Registered Nurse (RN 15)'s personnel record, undated, was reviewed. The personnel recorded indicated the facility's abuse training titled, "2024 Elsevier Regulatory Refresher: Clinical Nursing Personnel," was "In progress/ past due." DIR 7 stated that training was online for the facility's abuse training. DIR 7 stated the training was assigned to RN 15 on 7/1/2024 but RN 17 never completed the abuse training. DIR 7 stated the training was mandatory for all staff including contracted staff.
During an interview on 9/20/2024 at 11:46 a.m. with the Director of Maternal (mother) Child Health (DIR 1), DIR 1 stated she (DIR 1) was not aware RN 15 did not complete the abuse training. DIR 1 stated, "this was an opportunity of improvement and would make sure all staff complete the required training moving forward."

During a concurrent interview and record review on 9/20/2024 at 1:57 p.m. with the Interim Chief Nursing Officer (CNO), the facility's policy and procedure (P&P) titled, "Abuse: Identification and Mandatory Reporting and Abuse Prohibition," dated 2/2020, was reviewed. The P&P indicated, "every health associate employed in a healthcare facility who has knowledge of or observes a patient whom they know or reasonably suspect is suffering from a wound or injury which is a result of assaultive or abusive conduct is required to make a report ...it is the responsibility of all health practitioners to report suspected abuse." CNO stated, the facility would comply with all regulatory requirements, and it was mandatory for all staff to complete all required abuse training so that staff would recognize signs of abuse and report abuse to ensure patients' safety.

During a review of the facility's policy and procedure (P&P) titled, "Employee Orientation," [the facility] requires employee orientation within the employee's first thirty (30) calendar days of employment for all newly hired employees ... The employee orientation program may convey information on, but not limited to, the following: Patient Safety, Employee Safety, Injury Prevention and Reporting, Other policies to which the individual is subject, other information as required by applicable law and regulations ... all [facility] employees, physicians, contractors, students, and volunteers are subject to the requirements of this policy."

Based on observation, interview, and record review, the facility failed to ensure for three of 30 sampled patients (Patients 24, 25 and 30), Patients 24, 25, and 30 were free from restraint (physical device that prevents a person from freely moving), in accordance with the facility's policy and procedure regarding restraints use, when the patients' (Patient 24, 25 and 30) all 4 side rails were raised without a physician order.

This deficient practice resulted in inappropriate, unnecessary, and prolonged use of restraints, and had violated Patients 24, 25, and 30's rights. In addition, this deficient practice had the potential for Patients 24, 25, and 30 to suffer from physical harm such as strangulation (obstruction of blood vessels and/or airflow in the neck resulting in asphyxia [lack of oxygen]), skin tear, loss of consciousness, broken skull, bleeding in the brain, etc., due to lack of proper monitoring in relation to restraints use.

Findings:

1. During a review of Patient 24's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 6/26/2024, the H&P indicated, Patient 24 was admitted to the facility after being assaulted (physically attacked). Patient 24 was found to have blunt head trauma (hit to head with violent force) with intracranial hemorrhage (brain bleed), scattered subarachnoid hemorrhage (blood in between brain and brain covering membrane) and left anterior frontal subdural hematoma (pooling of blood in between the brain and skull).

During a concurrent observation and interview on 9/18/2024 at 11:10 a.m. with Registered Nurse 1 (RN 1), Patient 24 was observed lying in bed, asleep, with all four side rails of the bed raised. RN 1 stated Patient 24 did not have a current order for restraints. RN 1 stated Patient 24's all four side rails were for safety to prevent Patient 24 from falling. RN 1 stated she was aware that when all four side rails were raised, it was a form of restraint (physical device that prevents a person from freely moving).

During a review of Patient 24's "Nursing Assessment Flowsheet," dated 9/18/2024, the flowsheet indicated the following:

- at 8:00 a.m., Patient 24 was disoriented, converses, and obeys commands appropriately.

- at 10:00 a.m., Patient 24's activity status included "total assistance" and to have "side rails up x (times) 2 (two side rails raised)."

During an interview on 9/19/2024 at 3:18 p.m. with the Interim Director of Medical-Surgical (DIR 6), DIR 6 stated the risk of having all four side rails up was that patients can attempt to get out of bed then trip and fall (an unintentional event that results in the person coming to rest on the ground or another lower level).

During a review of the facility's policy and procedure (P&P) titled, "Restraint Use," dated 06/2022, the P&P indicated, "full side rails/4 split rails" is a restraint type.

During a review of the facility's policy and procedure (P&P) titled, "Restraint Use," dated 06/2025, the P&P indicated, a "Restraint is any physical, manual or mechanical method that involuntarily restricts a person's freedom of movement, physical activity, or normal access to their body...The rationale that the patient should be restrained because they might fall is an inadequate basis for using a restraint ...Side rails are considered a restraint when all rails are used to restrict the patient to the bed."

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibilities," dated 06/2024, the P&P indicated, a patient's rights is to "be free from restraints and seclusion (involuntary confinement of patient alone in a room or area from which the patient is physically prevented from leaving) of any form used as a means of ... convenience or retaliation by staff."

2. During a review of Patient 25's "History and Physical (H&P)," dated 8/30/2024, the H&P indicated, Patient 25 was admitted to the facility after sustaining a ground level fall (an unintentional event that results in the person coming to rest on the ground or another lower level). Patient 25 was found to have multiple left sided rib fractures (breaks in a bone). Patient 25 has a past medical history of altered mental status (a change in mental function, such as a change in awareness, cognition [learning and thinking], attention, or consciousness), and schizophrenia (a serious mental illness that affects a person's thoughts, feelings, and behaviors).

During a concurrent observation and interview on 9/18/2024 at 10:53 a.m. with Registered Nurse 3 (RN 3) and the Director of Telemetry (DIR 5), Patient 25 was observed lying in bed, awake, and was disoriented (a mental state marked by confusion about time, place, or who one is). Patient 25's all four bedside rails were raised. RN 3 stated all four side rails were up to prevent Patient 25 from standing and falling. The DIR 5 stated putting all four side rails up on Patient 25's bed was a form of restraint (physical device that prevents a person from freely moving). RN 3 stated Patient 25 did not have a current order for restraints.

During a review of Patient 25's "Nursing Assessments Flowsheet," dated 9/18/2024, the flowsheet indicated the following:

-At 7:00 a.m., Patient 25 was documented to have a GCS (Glasgow Coma Scale, a tool used to measure a patient's level of consciousness) of 15 (the highest GCS score which indicates that the person is fully awake, responsive, and has no problems with their memory or thinking ability), oriented and converses and obeys commands appropriately.

-At 10:00 a.m., Patient 25 was documented to have an activity status of "maximum assistance" and to have "side rails up x (times) 2 (two side rails are raised)."

During an interview on 9/19/2024 at 3:18 p.m. with the Interim Director of Medical-Surgical (DIR 6), DIR 6 stated the risk of having all four side rails up was that patients can attempt to get out of bed then trip and fall.

During a review of the facility's policy and procedure (P&P) titled, "Restraint Use," dated 06/2022, the P&P indicated, "full side rails/4 split rails" is a restraint type.

During a review of the facility's policy and procedure (P&P) titled, "Restraint Use," dated 06/2025, the P&P indicated, a "Restraint is any physical, manual or mechanical method that involuntarily restricts a person's freedom of movement, physical activity, or normal access to their body...The rationale that the patient should be restrained because they might fall is an inadequate basis for using a restraint...Side rails are considered a restraint when all rails are used to restrict the patient to the bed."

During a review of the facility's policy and procedure titled, "Patient Rights and Responsibilities," dated 06/2024, the P&P indicated, a patient's rights is to "be free from restraints and seclusion (involuntary confinement of patient alone in a room or area from which the patient is physically prevented from leaving) of any form used as a means of ... convenience or retaliation by staff."

3. During a concurrent observation and interview on 9/18/2024 at 11:30 a.m. with Registered Nurse 2 (RN 2), Patient 30 was observed in bed, asleep with all four side rails of the bed raised. RN 2 stated all four side rails were up because she (Patient 30) tried to get out of bed on her own. RN 2 stated she (Patient 30) needed assistance with getting out of bed because she (Patient 30) fell at home and was then admitted to the facility. RN 2 stated Patient 30 did not have an order for restraints (physical device that prevents a person from freely moving). RN 2 said using all four side rails meant Patient 30 was restrained.

During a review of Patient 30's "Face sheet (record containing basic patient information including admitting date and reason for admission)," the Face Sheet indicated Patient 30 was admitted to the facility on 7/24/2024 for a Subdural Hematoma (bleeding between the brain and the skull that can occur from a fall [(an unintentional event that results in the person coming to rest on the ground or another lower level] or hit to the head).

During a concurrent interview and record review on 9/19/2024 at 3:00 p.m. with the Director of Medical-Surgical (DIR 6), DIR 6 stated Patient 30's "Neurological Assessment Flowsheet," dated 9/18/2024, indicated Patient 30 follows command, awake, alert, had short term memory (the ability to hold and recall information for a short period of time, typically seconds), and had an unsteady gait (an abnormal or uncoordinated walking pattern). DIR 6 stated the patient could be hurt and tripped when the patient tried to get out of bed when all 4 siderails were raised.

During a review of the facility's policy and procedure (P&P) titled, "Restraint Use," dated 06/2022, the P&P indicated, "full side rails/4 split rails" is a restraint type.


During a review of the facility's policy and procedure (P&P) titled, "Restraint Use," dated 06/2025, the P&P indicated, a "Restraint is any physical, manual or mechanical method that involuntarily restricts a person's freedom of movement, physical activity, or normal access to their body...The rationale that the patient should be restrained because they might fall is an inadequate basis for using a restraint...Side rails are considered a restraint when all rails are used to restrict the patient to the bed."

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibilities," dated 06/2024, the P&P indicated, a patient's rights is to "be free from restraints and seclusion (involuntary confinement of patient alone in a room or area from which the patient is physically prevented from leaving) of any form used as a means of ... convenience or retaliation by staff."

Based on observation, interview and record review, the facility failed to ensure nursing staff initiated and developed a restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) upon restraints initiation, in accordance with the facility's policy and procedure regarding restraints, for one of 30 sampled patients (Patient 21), when the restraint was initiated on 9/13/2024.

This deficient practice had the potential to result in unnecessary restraints use for Patient 21 as there was no care plan developed for nursing staff to monitor progress and evaluate restraints use. This deficient practice also had the potential to result in complications of restraints use such as skin integrity issues (a break in the skin), etc.

Findings:

During a review of Patient 21's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/10/2024, the H&P indicated, Patient 21 was admitted to the facility with diagnoses including but not limited to severe sepsis (a body's overwhelming and life-threatening response to infection), acute (new onset) hypoxic (lack of oxygen) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood) and pulmonary edema (a condition where too much fluid builds up in the lungs, making it difficult to breathe).

During a concurrent interview and record review on 9/19/2024 at 1:44 p.m. with the Director of Critical Care (specialist hospital wards that provide treatment and monitoring for people who are very ill) (DIR 3), Patient 21's physician order for restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) from 9/13/2024 to 9/17/2024, was reviewed. The physician order indicated Patient 21 required bilateral wrists restraints due to pulling lines and tubes. DIR 3 stated Patient 21 was on bilateral wrists restraints per physician order from 9/13/2024 to 9/17/2024.

During a concurrent interview and record review on 9/19/2024 at 1:47 p.m. with DIR 3, Patient 21's "care plan (provides a framework for evaluating and providing patient care needs related to the nursing process), dated from 9/13/2024 to 9/17/2024, was reviewed. The care plan indicated there was no care plan to address Patient 21 being on bilateral wrist restraints. DIR 3 stated the purpose of care plan was to organize nursing care and to tailor patient's needs. DIR 3 stated the care plan would instruct staff what to do, what to monitor and how to evaluate patient's progress.

During a concurrent interview and record review on 9/19/2024 at 2 p.m. with DIR 3, the facility's policy and procedure (P&P) titled, "Restraints Use," dated 6/2022, was reviewed. The P&P indicated, "define guidelines for appropriate therapeutic and safe use of restraint that preserves that patient's dignity while limiting restraint use to clinically appropriate situations for all patients at [the facility] ... documentation: the plan of care reflects restraints. The patient's response to interventions and less restricted measures attempted." DIR 3 stated there was no care plan developed relating to restraint use for Patient 21. DIR 3 state the staff did not follow facility's policy.

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

1. The facility failed to ensure for two of 30 sampled patients (Patients 6 and 30), nursing care was provided in accordance with accepted standards of nursing practice and the facility's policy and procedure (P&P) when:

1.a. Patient 6's pain was not addressed and evaluated, in accordance with the facility's policy and procedure regarding pain assessment and management.

This deficient practice had the potential for Patient 6 to be uncomfortable due to unrelieved pain and adversely affecting Patient 6's psychological and physiological well-being. (Refer to A-0395)

1.b. Patient 30 was not reassessed, in accordance with the facility's policy and procedure regarding Medication Administration, after administering Seroquel (medication used to balance hormone levels in the brain), ordered as needed (PRN), for agitation (a feeling of irritability or severe restlessness).

This deficient practice had the potential to cause a delay in determining Patient 30's change of condition and/or a delay in the provision of care needed which could worsen the patients' condition. (Refer to A-0395)

1.c. Patient 30's daily weight was not obtained as ordered by the physician.

This deficient practice had the potential to cause a delay in determining Patient 30's change of condition and/or a delay in the provision of care needed which could worsen the patients' condition. (Refer to A-0395)

2. The facility failed to ensure for one of 30 sampled patients (Patient 27), Patient 27's care plan (part of the nursing process, and is a set of goals, assessments, and interventions for each problem) related to pneumonia (lung infection) was developed in accordance with the accepted standards of nursing practice and the facility's policy and procedure regarding care plans.

This deficient practice resulted in Patient 27 not having an individualized goal-oriented plan of care to provide a means for interdisciplinary communication for patient's care. In addition, this deficient practice had the potential for Patient 27's needs and risks to not be addressed. (Refer to A-0396)

3. The facility failed to label the enteral feeding container (a container that holds the liquid food mixture used for enteral feeding [a way to provide nutrition directly into the gut through a feeding tube]) with the date, time hung, and personnel's initials, for one of 30 sampled patients (Patient 12), in accordance with the facility's protocol regarding enteral feeding.

This deficient practice had the potential to place Patient 12 at risk for being administered an expired or contaminated (growing microorganisms, that may cause infections) enteral feeding formula thus, compromising Patient 12's safety and well-being. (Refer to A-0398)

4. The facility failed to label the administration set for Intravenous (IV, into the vein) infusion (a method of putting fluids, including drugs, into the bloodstream) with the date, time hung, and personnel's initials for one of 30 sampled patients (Patient 12), in accordance with the facility's protocol regarding labeling administration set for IV infusions.

This deficient practice had the potential to place Patient 12 at risk for phlebitis (inflammation of the walls of a vein) or contamination (growing microorganisms, that may cause infections) associated with catheter (a device used to draw blood and give treatments) related bloodstream complications. (Refer to A-0398)

5. The facility failed to obtain a renewal order for bilateral (affecting the right and the left sides of the body) wrist restraints (a device, usually a wristlet, anklet, or other type of strap intended for medical purposes and that limits a patient's movements to the extent necessary for treatment, examination, or protection of the patient) for one of 30 sampled patients (Patient 30), in accordance with the facility's policy and procedure regarding restraints use.

This deficient practice had the potential to violate Patient 11's rights to be free from unnecessary restraints when Patient 11 was placed in restraints for 24 hours, without proper authorization by a qualified healthcare professional. (Refer to A-0398)


6. The facility failed to ensure that for one of 30 sampled patients (Patient 5), a call light (a system device used by the patient to call for help) was within the patient's (Patient 5) reach.

This deficient practice had the potential for Patient 5's needs to not be met since Patient 5 was unable to call for help with the call light being out of reach, which may result in a delay from receiving necessary care, potentially exacerbating the patient's (Patient 5) condition and causing unnecessary discomfort to Patient 5.(Refer to A-0398)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality care in a safe environment and potentially putting patients at risk for harm.

Based on observation, interview, and record review, the facility failed to ensure for two of 30 sampled patients (Patients 6 and 30), nursing care was provided in accordance with accepted standards of nursing practice and the facility's policy and procedure (P&P) when:

1. Patient 6's pain was not addressed and evaluated, in accordance with the facility's policy and procedure regarding pain assessment and management.

This deficient practice had the potential for Patient 6 to be uncomfortable due to unrelieved pain and adversely affecting Patient 6's psychological and physiological well-being.

2.a. Patient 30 was not reassessed, in accordance with the facility's policy and procedure regarding Medication Administration, after administering Seroquel (medication used to balance hormone levels in the brain), ordered as needed (PRN), for agitation (a feeling of irritability or severe restlessness).

This deficient practice had the potential to cause a delay in determining Patient 30's change of condition and/or a delay in the provision of care needed which could worsen the patients' condition.

2.b. Patient 30's daily weight was not obtained as ordered by the physician.

This deficient practice had the potential to cause a delay in determining Patient 30's change of condition and/or a delay in the provision of care needed which could worsen the patients' condition.

Findings:

1. During a review of Patient 6's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 9/18/2024, the H&P indicated, Patient 6 was admitted to the facility on 9/18/2024 for presyncope (feeling like one was going to pass out but without actual loss of consciousness) and weakness associated with difficulty of swallowing.

During a review of Patient 6's medical record (MR) titled, "Pain Assessment," dated 9/17/2024, the MR indicated the following:

On 9/17/2024, at 7:47 p.m., Patient 6's pain level was recorded 7 out of 10 (7/10, a numerical rating scale used to assess patient's pain intensity, where: 0 is no pain, 1-3 mild pain, 4-6 is moderate pain, and 7-10 denotes severe pain).

On 9/17/2024, at 10:22 p.m., Patient 6's pain level was again recorded 7/10 [severe pain].
During a review of Patient 6's Medication Administration Record (MAR), dated 9/17/2024, the MAR indicated, no pain-relieving medication orders were placed by the provider in Patient 6's MAR.

During a concurrent interview and record review on 9/18/2024 at 11:35 a.m. with the director of Emergency Department (Dir 4), Patient 6's medical record (MR) titled, "Pain Assessment," dated 9/18/2024, was reviewed. Dir 4 stated, on 9/18/2024, at 7:47 p.m. and at 10:22 p.m., Patient 6's pain level was recorded 7/10, but the registered nurse (RN), who assessed Patient 6, did not document the location of pain, the patient's (Patient 6) acceptable pain intensity (to determine the level of pain that is tolerable for the patient) and did not document if Patient 6's pain level 7/10 was addressed.

During an interview on 9/18/2024 at 11:35 a.m. with Director 4 (Dir 4), Dir 4 stated that the registered nurse who assessed Patient 6's pain level on 9/17/2024 and recorded the pain level as 7/10 should have informed the physician of the findings and addressed Patient 6's pain to ensure the patient's (Patient 6) comfort and well-being.

During a review of the facility's policy and procedure (P&P) titled, "Pain Assessment, Re-assessment and Management," dated 10/2022, the P&P indicated that patients experiencing pain will be educated and provided with educational materials on the various medications used for pain relief. The P&P also indicated that a comprehensive pain assessment will be performed, identifying the patient's pain location, pain level, and the patient's acceptable pain intensity/level. The RN (registered nurse) will assess and implement pain management interventions.

During a review of the facility's policy, titled, "Patient Rights and Responsibilities," (no date), the policy indicated, "Each patient is entitled to compassionate and professionally competent care delivered with respect for each individual. 10. Each patient has the right to appropriate assessment and management of pain, access to information about pain and pain relief measures, and the right to participate in decisions regarding their pain management."

2. During a review of Patient 30's "History and Physical" (H&P, a formal and complete assessment of the patient and the problem), dated 7/25/2024, the "H&P" indicated, Patient 30 had subarachnoid hemorrhages (bleeding between the layers of the brain), and had a history of dementia (problems with the brain related to memory, reasoning, and thinking ), depression (characterized by a persistent low mood or loss of interest in activities), and End Stage Renal Disease (poor kidney function) on dialysis (procedure that cleans the blood by removing extra fluids and waste).

2.a. During a review of Patient 30's "Order Information," dated 7/24/2024, the record indicated Patient 30 was on Seroquel (medication used to balance hormone levels in the brain) 12.5 milligram (mg, unit of measure) one tablet by mouth twice a day PRN (as needed) for agitation (feeling of irritability or severe restlessness).

During a concurrent interview and record review on 9/19/2024 at 3:00 p.m. with the Director of Medical-Surgical 6 (DIR 6) and the Nurse Manager 4 (NM 4), NM 4 verified Patient 30's "Medication Administration Record (MAR)," dated 9/17/2024 through 9/19/2024, indicated the following:

-On 9/17/2024 at 10:43 a.m. and at 6:26 p.m., Patient 30 was given Seroquel 12.5 mg.

- On 9/19/2024 at 4:17 a.m., Patient 30 was given Seroquel 12.5 mg.

During the same interview and record review on 9/19/2024 at 3:00 p.m., NM 4 stated, Patient 30's record had no documentation of the patient's reassessment (reevaluation) after the Seroquel was given to know if it was effective. DIR 6 stated there should be a note written by the nurses to monitor how effective the PRN medication was.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," dated 11/2024, the P&P indicated, "Safe Medication Administration: Monitoring of patient outcomes and efficacy in relation to medication administration, relevant lab values, expected side effects, adverse reactions and food/drug interactions."

During a review of the facility's policy and procedure (P&P) titled, "Core Nursing Standards of Practice," dated 12/2021, the P&P indicated, "Documentation Expectations: Documentation is considered a communication tool. As such, nursing documentation should reflect the nursing assessment process ... plan of care and any treatment, interventions and associated outcomes including the patient's response."

2.b. During a review of Patient 30's "Daily Weight Order," dated 7/25/2024, the record indicated, "Frequency: qDay (every day).

During a concurrent interview and record review on 9/19/2024 at 3:00 p.m. with the Director of Medical-Surgical 6 (DIR 6), DIR 6 verified Patient 30 was on dialysis (procedure that cleans the blood by removing extra fluids and waste). DIR 6 verified Patient 30's "Measurements Flowsheet," dated 9/16/2024 - 9/19/2024, indicated the following:

9/16/2024: no weight documented

9/17/2024: a weight of 58 kg (kilograms, a unit of measure)

9/18/2024: no weight documented

9/19/2024: a weight of 57.3 kg

DIR 6 stated on 9/16/2024, the blank daily weight section had a note indicating staff was unable to weigh the patient because there was no bed scale. DIR 6 stated Patient 30 should have been weighed using a standing scale.

During a review of the facility's policy and procedure (P&P), titled "Core Nursing Standards of Practice," dated 12/2021, the P&P indicated, "Actual patient weight should be obtained and documented on admission, PRN (as needed) and each day per LP order or patient condition warrants."

Based on interview and record review, the facility failed to ensure for one of 30 sampled patients (Patient 27), Patient 27's care plan (part of the nursing process, and is a set of goals, assessments, and interventions for each problem) related to pneumonia (lung infection) was developed in accordance with the accepted standards of nursing practice and the facility's policy and procedure regarding care plans.

This deficient practice resulted in Patient 27 not having an individualized goal-oriented plan of care to provide a means for interdisciplinary communication for patient's care. In addition, this deficient practice had the potential for Patient 27's needs and risks to not be addressed.

Findings:

During a review of Patient 27's "Discharge Summary (a narrative document for communicating clinical information about what happened to the patient in the hospital)," dated 9/18/2024, the discharge summary indicated Patient 27 was admitted on 9/15/2024 for heart failure (heart is not effectively pumping blood throughout the body) and pneumonia (lung infection).

During a concurrent interview and record review on 9/18/2024 at 2:30 p.m. with the Director of Telemetry 5 (DIR 5), DIR 5 stated Patient 27's "Care Plans" did not have a care plan addressing Patient 27's pneumonia (lung infection). DIR 5 stated if a patient had pneumonia, it was expected to have a care plan developed addressing the patient's goals and needs for management.

During a review of the facility's policy and procedure (P&P) titled, "Interdisciplinary Care Planning," dated 2/2026, the P&P indicated, "The registered nurse (RN) initiates the care plan within 24 hours of admission for the interdisciplinary care team. Initiation of the care plan includes selection of appropriate: Problem/Condition, Goals, Interventions, Outcomes."

Based on observation, interview and record review, the facility failed to adhere to the facility's policies and procedures when:

1.The facility failed to label the enteral feeding container (a container that holds the liquid food mixture used for enteral feeding [a way to provide nutrition directly into the gut through a feeding tube]) with the date, time hung, and personnel's initials, for one of 30 sampled patients (Patient 12), in accordance with the facility's practice regarding enteral feeding.

This deficient practice had the potential to place Patient 12 at risk for being administered an expired or contaminated (growing microorganisms, that may cause infections) enteral feeding formula thus, compromising Patient 12's safety and well-being.

2. The facility failed to label the administration set for Intravenous (IV, into the vein) infusion (a method of putting fluids, including drugs, into the bloodstream) with the date, time hung, and personnel's initials for one of 30 sampled patients (Patient 12), in accordance with the facility's protocol regarding labeling administration set for IV infusions.

This deficient practice had the potential to place Patient 12 at risk for phlebitis (inflammation of the walls of a vein) or contamination (growing microorganisms, that may cause infections) associated with catheter (a device used to draw blood and give treatments) related bloodstream complications.

3. The facility failed to obtain a renewal order for bilateral (affecting the right and the left sides of the body) wrist restraints (a device, usually a wristlet, anklet, or other type of strap intended for medical purposes and that limits a patient's movements to the extent necessary for treatment, examination, or protection of the patient) for one of 30 sampled patients (Patient 30), in accordance with the facility's policy and procedure regarding restraints use.

This deficient practice had the potential to violate Patient 11's rights to be free from unnecessary restraints when Patient 11 was placed in restraints for 24 hours, without proper authorization by a qualified healthcare professional.

4. The facility failed to ensure that for one of 30 sampled patients (Patient 5), a call light (a system device used by the patient to call for help) was within the patient's (Patient 5) reach.

This deficient practice had the potential for Patient 5's needs to not be met since Patient 5 was unable to call for help with the call light being out of reach, which may result in a delay from receiving necessary care, potentially exacerbating the patient's (Patient 5) condition and causing unnecessary discomfort to Patient 5.


Findings:

1. During a review of Patient 12's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 9/3/2024, the H&P indicated, Patient 12 was admitted to the facility on 9/3/2024 with a diagnosis of back pain and bilateral lower extremity (occurring on both the left and the right legs) weakness. The H&P further indicated, Patient 12 had past medical history (PMH, records information about the patient's medical, personal, and family history) of liver cirrhosis (permanent scarring that damages the liver and interferes with its functioning) and atrial fibrillation (AFib, a type of irregular heartbeat, called arrhythmia).

During a concurrent observation and interview on 9/18/2024 at 11:04 a.m. with Charge Nurse (CN 5) 5, in Patient 12's room, an enteral feeding (nutrition delivered to the body through the gut) container with attached tubing was observed. The container lacked a label indicating who had initially hung the feeding and when it was spiked (the process of piercing a closed system formula container with a feeding set before feeding). CN 5 said, enteral feeding containers must be labeled with the date and time of spiking and administration to the patient (Patient 12) to ensure the proper management of the feeding process and patient safety and as per the facility's protocol.

During a concurrent interview and record review on 9/19/2024 at 3:13 p.m. with the Director of Critical Care (a hospital unit that provides intensive care for patients who are seriously ill or injured and require specialized treatment and monitoring) Unit (Dir 3), Patient 12's medical records (MR) titled, "Nutrition Documentation," dated 9/17/2024, and "Gastrointestinal (relating to the stomach and the intestines) Assessment," dated 9/18/2024, were reviewed. The MR indicated, on 9/17/2024, Patient 12 was ordered continuous administration of enteral nutrition by way of nasogastric tube (NG tube, a flexible plastic tube that's inserted through the nose and into the stomach). The MR further indicated, nursing services documented that Patient 12 was receiving enteral feeding on 9/17/2024 and on 9/18/2024, but the record did not indicate the date and time when the enteral feeding container was changed. Dir 3 stated, enteral feeding container can be hung for 24 hours only and nurses, initiating enteral feeding with new tubing set should label the container with the date, time, and their initials, as per the facility's practice.

During a review of the facility's policy and procedure (P&P) titled, "Assessment and Monitoring of Enteral Feeding and Oral Supplementation," dated 12/2022, the P&P indicated, Nursing will hang tube feeding formula for 24 hours and replace daily as long as patient remains on enteral feedings. Nursing services document intake of enteral feedings and oral supplements in the electronic medical records." The policy and procedure for enteral feeding formula labeling, aligning with the facility's practices, was requested. However, the facility did not provide. The facility's policy, "Assessment and Monitoring of Enteral Feeding and Oral Supplementation," dated 12/2022, did not provide clear guidelines to support its practices for labeling enteral feeding upon initiation. While the policy specifies that enteral feeding formula is to be changed every 24 hours, it lacks detailed documentation regarding the specific procedures staff must follow when changing the enteral feeding administration set and the container.

2. During a review of Patient 12's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 9/3/2024, the H&P indicated, Patient 12 was admitted to the facility on 9/3/2024 with a diagnosis of back pain and bilateral lower extremity (occurring on both the left and the right legs) weakness. The H&P further indicated, Patient 12 had past medical history (PMH, records information about the patient's medical, personal, and family history) of liver cirrhosis (permanent scarring that damages the liver and interferes with its functioning) and atrial fibrillation (AFib, a type of irregular heartbeat, called arrhythmia).

During a concurrent observation and interview on 9/18/2024 at 11:04 a.m. with charge nurse (CN 5) 5, in Patient 12's room, an intravenous (IV, into the vein) pole (IV pole, a medical device that holds bags of fluids or medicine administered to the patient), was observed. The IV tubing connected to the bag labeled Zosyn (antibiotic, medicine that fight bacterial infections in people) had a blue label, that was blank. CN 5 stated, according to the facility's policy a procedure, all IV tubing must be labeled with the date and time the tubing was changed to ensure proper patients' safety.

During a review of Patient 12's Medical Record titled, "Physician's Progress Note," dated 9/18/2024, the MR indicated, Patient 12's medication order indicated, Zosyn (antibiotic) was scheduled to be given every twelve (12) hours.

During an interview on 9/19/2024 at 3:18 p.m. with the Director of Critical Care (Dir 3), Dir 3 stated, intravenous (IV, administered into a vein) tubing, such as that, used to administer Zosyn (antibiotic), required nurses to change the tubing every 24 hours to reduce the risk of infection, in accordance with the facility's protocol. Dir 3 further stated, nurses should date and time the IV tubing, so they know when the IV tubing needs to be changed again.

The facility did not provide relevant nursing policy and procedure manual regarding IV Tubing Management, that would include guidelines for the facility's current practices for management and replacement of primary and secondary infusion tubing sets.

3. During a review of Patient 11's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 9/15/2024, the H&P indicated, Patient 11 was admitted to trauma services (medical services that treat patients with severe injuries that threaten life or limbs) after being struck by a car. The H&P further indicated, Patient 11 was intubated (a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their trachea [airway/windpipe] to provide means for mechanical ventilation), and underwent reduction (a procedure to line up the ends of a broken [fractured] bone without the need for surgery) of the left lower extremity (the part of the body that includes the hip, thigh, knee, leg, ankle, and foot) with splinting (an external device used to immobilize an injury or joint) and was admitted to intensive care unit (ICU, provides the critical care and life support for acutely ill and injured patients).

During an observation on 9/18/2024 at 11:30 a.m. in Patient 11's room, Patient 11 was observed in bed, with bilateral wrist restraints (bilateral [affecting the right and the left sides of the body] wrist restraints [a device, usually a wristlet, anklet, or other type of strap intended for medical purposes and that limits a patient's movements to the extent necessary for treatment, examination, or protection of the patient]) applied.

During a concurrent interview and record review on 9/19/2024 at 2:28 p.m. with the director of Critical Care (Dir 3), Patient 11's medical record (MR) titled, "Physician's Orders," dated 9/15/2024 through 9/18/2024, was reviewed. The MR indicated that on 9/15/2024, a new order for bilateral wrist restraints was placed for Patient 11 to prevent Patient 11 from attempting to remove lines, tubes, or necessary for life and safety medical equipment. The MR further indicated that no renewal order for the bilateral wrist restraints was placed on 9/16/2024. The MR showed that on 9/17/2024 and 9/18/2024, renewal orders for bilateral wrist restraints were placed for Patient 11 on both days. Dir 3 verified that on 9/16/2024, Patient 11's MR contained no record of a physician's renewal order for bilateral wrist restraints. Dir 3 further stated, a renewal order for restraints must be placed every 24 hours as per facility's policy, but nursing did not ensure the renewal order was placed in Patient 11's medical chart.

During a concurrent interview and record review on 9/19/2024 at 2:20 p.m. with Dir 3, Patient 11's medical record (MR) titled, "Restraints," dated 9/16/2024, was reviewed. The MR indicated that on 9/16/2024, nurses documented Patient 11 was in bilateral wrist restraints. Dir 3 stated that all patients who are placed in restraints must have a physician's order or a renewal physician's order (A renewal order for restraints is a new order written by a provider to extend the duration of the original order) to authorize the application of restraints if deemed necessary.

During a review of the facility's policy and procedure (P&P) titled, "Restraint Use," dated 6/2022, the P&P indicated, "Restraint orders and renewal orders for non-violent or non-self-destructive restraints must be obtained from a medical doctor or licensed practitioner and the practitioner must be notified by the RN immediately when the restraints are applied. Restraint orders and renewal orders must not exceed 24 hours."

4. During an observation on 9/18/2024 at 12:03 p.m. with the director of Emergency Department (Dir 4), in the Emergency Department (ED, a specialized medical facility within a hospital that provides immediate care to patients with acute illnesses or injuries requiring urgent medical attention.) Patient 5 was observed in bed. The patient's (Patient 5) monitor (a monitor refers to a medical device or system used to continuously observe and display a patient's vital signs [includes temperature, respiratory rate, heart rate, and blood pressure]) was alarming, and the call light was attached to an IV (Intravenous, into the vein) pole (a stand used to hold intravenous fluids and equipment). Patient 5 stated, "I have been waiting for my nurse for half an hour because the monitor keeps beeping."

During a concurrent observation and interview on 9/18/2024 at 12:03 p.m. with Patient 5 and Director 4 (Dir 4), Dir 4 found the call light (a system device used by the patient to call for help) wrapped around an IV pole behind Patient 5's bed, and Patient 5 was then handed the call light. Patient 5 stated, "I did not know I had a call light that I could use to call for my nurse." Patient 5 then attempted to use the call light, but it was not working. Dir 4 stated "the call light does not work. Let me call your nurse." Dir 4 then emphasized that the call light must always be placed within the patient's reach and "should be functioning properly."

During a review of Patient 5's "HPI (History of Present Illness)-ED (Emergency Department General)," record, dated 9/18/2024, the HPI indicated, Patient 5 was seen in the ED for weakness and near syncope episode (feeling like one was going to pass out but without actual loss of consciousness).

During a review of the facility's policy titled, "Patient Rights and Responsibilities," (no date), the policy indicated, "Each patient is entitled to compassionate and professionally competent care delivered with respect for each individual.
The facility did not provide a specific policy regarding call lights, stating that the facility had no relevant policy in place.

Based on interview and record review, the facility failed to ensure that the Condition of Participation for Surgical Services was met as evidenced by:

1. The facility failed to ensure patient safety practices and care requirements unique to the operating room (OR, a facility within a hospital where surgical operations are carried out in an aseptic [free of germs] environment) were consistently followed for one of 30 sampled patients (Patient 1) when the facility did not use paper tape (a type of medical tape with a paper backing and an adhesive layer that's used for securing dressings and medical devices), as recommended for patients with a documented latex allergy (a reaction to certain proteins found in natural rubber latex ), and did not document the use of paper tape, with a specified patient's (Patient 1) allergy to tape. Additionally, the facility lacked an established policy and/or process to address safety practices for patients with latex or tape allergies.

This deficient practice resulted in Patient 1 sustaining a skin reaction that led to blistering, pain, and scarring. (Refer to A-0951)

2. The facility failed to adhere to the outpatient surgery rules and regulations for one of 30 sampled patients (Patient 1) when the discharge summary for Patient 1 did not include a record of provisions for follow-up care-that is, it lacked documentation outlining the plans and instructions for the patient's continued care after discharge, such as scheduled appointments, medication prescriptions, wound care guidelines, or referrals to other healthcare providers.

This deficient practice had the potential for Patient 1 to experience delays in receiving necessary care, prolonging recovery time and negatively impacting Patient 1's overall well-being after discharge. (Refer to A-0951)


3. The facility failed to provide an updated and accurate history and physical (H&P, a formal and complete assessment of the patient nd the problem) examination for one out of 30 sampled patients (Patient 1). Patient 1's H&P contained no documentation of their allergies to penicillin (antibiotic) and tape.

This deficient practice had the potential to result in adverse reactions (rashes, etc.) to Patient 1 due to the lack of documented allergies. (A-0952)

4. The facility failed to address a heart rate below the acceptable range (acceptable range per facility is 51-119 beats per minute) for one of 30 sampled patients (Patient 4) during Patient 4's post-operative recovery after a surgical procedure. In addition, the facility's surgical staff failed to make the physician aware of unfavorable variances (Patient 4's heart rate dropping below 51 beats per minute) experienced by Patient 4 during the discharge phase when recovering after the procedure in accordance with the facility's policies and procedures regarding post-procedural anesthesia (a procedure that prevents patients from feeling pain during medical procedures and surgery) monitoring.

This deficient practice had the potential to result in adverse patient outcomes, such as delayed recognition and treatment of bradycardia (abnormally low heart rate), which could lead to decreased cardiac output, hypotension (low blood pressure), dizziness, fainting, or more serious cardiac complications. (Refer to A-0957)

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

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

1. Ensure patient safety practices and care requirements unique to the operating room (OR, a facility within a hospital where surgical operations are carried out in an aseptic [free of germs] environment) were consistently followed for one of 30 sampled patients (Patient 1) when the facility did not use paper tape (a type of medical tape with a paper backing and an adhesive layer that's used for securing dressings and medical devices), as recommended for patients with a documented latex allergy (a reaction to certain proteins found in natural rubber latex ), and did not document the use of paper tape, with a specified patient's (Patient 1) allergy to tape. Additionally, the facility lacked an established policy and/or process to address safety practices for patients with latex or tape allergies.

This deficient practice resulted in Patient 1 sustaining a skin reaction that led to blistering, pain, and scarring.

2. Adhere to the outpatient surgery rules and regulations for one of 30 sampled patients (Patient 1) when the discharge summary for Patient 1 did not include a record of provisions for follow-up care-that is, it lacked documentation outlining the plans and instructions for the patient's continued care after discharge, such as scheduled appointments, medication prescriptions, wound care guidelines, or referrals to other healthcare providers.

This deficient practice had the potential for Patient 1 to experience delays in receiving necessary care, prolonging recovery time and negatively impacting Patient 1's overall well-being after discharge.

Findings:

1. During an interview on 9/17/2024 at 9:55 a.m. with Patient 1, Patient 1 stated, "I had two procedures done at the facility, and both times I had a severe allergic reaction to the tape the facility used when the dressing was applied to my breast. I told my surgeon before the procedure and I told the facility's staff that I was allergic to tape, but they still used the tape on my skin after each surgery, and I ended up with blisters and scarring."

During a review of Patient 1's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 5/28/2024, the H&P indicated, Patient 1 was seen for medical clearance for right breast lumpectomy (surgery to remove abnormal tissue from the breast) and right axillary (armpit area) lymph node (part of the body's immune system that helps fight infection) biopsy (a procedure that removes tissue or cells from the body to examine for damage or diseases). The H&P also indicated; Patient 1 was documented to be allergic to penicillin (an antibiotic). The H&P further indicated, the surgeon (MD 5) signed the original H&P on 5/31/2024, indicating the H&P was reviewed, the patient (Patient 1) was examined, and no change has occurred since 5/28/2024.

During a review of Patient 1's "Anesthesia (a procedure that prevents patients from feeling pain during medical procedures and surgery) Documentation" medical record (MR), dated 5/31/2024, the MR indicated that Patient 1 had three recorded active allergies:

1. Penicillin: A broad-spectrum antibiotic used to treat bacterial infections, causing a severe reaction-anaphylactic shock (a severe, life-threatening allergic reaction that can develop rapidly and affect the entire body. It can be in response to substances such as latex).

2. Latex: A natural rubber product that can cause allergic reactions due to certain proteins, causing a severe reaction-rash.

3. Tea Tree (topical): An essential oil used topically, causing a moderate rash reaction.

During a review of Patient 1's medical record (MR) titled, "Surgical Documents," dated, 5/31/2024, the MR indicated, Patient 1's wound dressing consisted of the following items: gauze (a loosely woven, almost translucent fabric that's used to bandage wounds) fluffs (soft cotton gauze), Steri-Strips (thin, adhesive bandages that are used to close small cuts and wounds), and tape (type of pressure-sensitive adhesive tape used in medicine and first aid to hold bandages and dressings in place on wounds).

During a review of Patient 1's medical record (MR) titled, "Physician's Progress Note-Outpatient Office Visit," dated 6/17/2024, the MR indicated that Patient 1 had complained to MD 6 that the facility's staff was informed of an allergy to tape prior to a surgical procedure that took place on 5/31/2024. However, the adhesive tape was still used on Patient 1's skin by the facility's staff, and Patient 1 was alarmed by the significant scar formation.

During a review of Patient 1's "Post Operative Note," dated 7/3/2024, the note indicated, on 7/3/2024, Patient 1 underwent re-excision for margins (a second surgery that removes a small amount of tissue around the area of a previous surgical site) of right breast.

During a review of Patient 1's H&P, dated 7/3/2024, the H&P indicated, Patient 1 had no known drug allergies (NKDA). No allergy to tape was listed in Patient 1's H&P, dated 7/3/2024.

During a review of Patient 1's medical record (MR) titled, "Anesthesia Documentation," dated 7/3/2024, the MR indicated that Patient 1 was severely allergic to penicillin and tape.

During an interview on 9/18/2024 at 10:30 a.m. with Registered Nurse (RN 7), who worked in the perioperative area (the period around a surgical operation, including the preoperative, operative, and postoperative stages), RN 7 stated, "We typically use surgical tape (a type of pressure-sensitive adhesive tape used in medicine and first aid to hold bandages and dressings in place on wounds) for dressings, unless patient is allergic to tape, then we use paper tape (hypoallergenic paper tape that is gentle to the skin yet adheres well and leaves minimal adhesive residue upon removal). We have three different types of tape that we can use, and the surgeon typically specifies which tape to use. The surgeon is responsible for writing wound care orders and directing wound care instructions."

During a concurrent interview and record review on 9/18/2024 at 2:38 p.m. with Registered Nurse (RN 17), who worked in the "Same Day Surgery (Patients can go home on the same day of surgery, without staying overnight in the hospital)" unit, Patient 1's medical record (MR) titled, "Surgical Documents," dated 7/3/2024, was reviewed. The MR indicated that Patient 1's wound dressing consisted of gauze, fluffs, Steri-Strips, and tape, however, the record did not specify what type of tape was used. RN 17 stated, "It is possible to document the type of tape used in the patient's medical records, but I don't think we specifically identify and document the type of tape used for dressings."

During an interview 9/19/2024 at 1:30 p.m. with Registered Nurse (RN 18) 18, RN 18 stated, "I remember Patient 1 from their last surgery on 7/3/2024, I reviewed Patient 1's allergies and asked if it was okay for me to use paper tape. Patient 1 verbally agreed. Typically, we only document the materials used for wound care, but we don't specify the type of tape, such as paper tape or surgical tape. We just document tape."

During an interview on 9/20/2024 at 11:20 a.m. with Surgeon (MD 5), MD 5 stated that when Patient 1 had their first surgery on 5/31/2024, the facility staff were not aware of Patient 1's tape allergy. MD 5 further stated, "I only found out Patient 1 was allergic to tape after the first surgery." MD 5 also reviewed Patient 1's History and Physical (H&P), dated 7/3/2024, which contained no documentation of a tape allergy or known drug allergies. MD 5 verified that no tape or drug allergies were documented in Patient 1's H&P prior to the surgery on 7/3/2024 (In contrast, the Anesthesia Documentation, dated 5/31/2024, indicated three active allergies including latex. Likewise, the Anesthesia Documentation on 7/3/2024 also included allergy to tape).

During the same interview on 9/20/2024 at 11:20 a.m. MD 5 stated that they (facility staff) were not aware of Patient 1's recorded latex allergy on 5/31/2024, when the first surgery took place.

During an interview on 9/20/2024 at 11:38 a.m. with Surgeon (MD 6), MD 6 stated, "I saw Patient 1 twice after each surgery (on 5/31/2024 and on 7/3/2024). The first time (after surgery on 5/31/2024), Patient 1 presented with a rash that was unrelated to the surgery. The second time (after surgery on 7/3/2024), I saw her (Patient 1) in the office, and Patient 1 had blisters that were related to the tape. I called the surgical staff, and they reassured me that they had used paper tape on Patient 1."

During the same interview on 9/20/2024 at 11:38 a.m. with Surgeon (MD 6), MD 6 stated, "I wouldn't know if adhesive tape can be used for patients with latex allergies."

During an interview on 9/20/2024 at 4:00 p.m. with the Director of Quality and Patient Safety (DQPS), the DQPS stated that the facility does not have a specific policy regarding latex or tape allergies. The DQPS further stated, "If a patient is allergic to latex, paper tape should be used."
The facility does not have a protocol in place nor was the facility able to provide a policy and procedure for staff to follow regarding patient safety related to latex and tape allergies.

2. During an interview on 9/17/2024 at 9:55 a.m. with Patient 1, Patient 1 stated, "I had two procedures done at the facility (5/31/2024 and 7/3/2024), and both times, I did not receive specific discharge instructions for the management of my wound care. I had to go to the emergency department because my incision (opening of the skin after surgery) would not stop bleeding, and I had a severe allergic reaction to the tape the facility used when the dressing was applied to my breast. I was told to follow up with my surgeon (MD 5), but the office told me the surgeon was away, and I was eventually referred to another physician (MD 6) who was very empathetic and took care of my wound."

During a review of Patient 1's "Post (after) Operative Note," dated 5/31/2024, the note indicated, on 5/31/2024, Patient 1 underwent right breast lumpectomy (a surgical procedure to remove a tumor and some surrounding tissue from the breast while leaving the rest of the breast intact) and right axillary (relating to armpit) sentinel lymph node biopsy (sentinel node biopsy is a procedure to see if cancer has spread). The "Post Operative Note" contained no information regarding provisions for follow-up care, documentation outlining the plans and instructions for the patient's continued care after discharge, wound care guidelines, or medication prescriptions.

During a review of Patient 1's medical record, dated 5/31/2024, no pre-operative note or discharge summary (a narrative document for communicating clinical information about what happened to the patient in the hospital) was found in the medical chart.

During a review of Patient 1's nursing "Discharge Instructions," dated 5/31/2024, the instructions indicated that Patient 1 was instructed not to remove the dressing and to call for a follow-up appointment with the surgeon (MD 5) within two weeks. The discharge instructions did not contain information regarding any new prescriptions given to Patient 1.

During a review of Patient 1's "Post Operative Note," dated 7/3/2024, the note indicated, on 7/3/2024, Patient 1 underwent re-excision for margins (a second surgery that removes a small amount of tissue around the area of a previous surgical site) of right breast.

During a review of Patient 1's medical record, dated 7/3/2024, no pre-operative note or discharge summary was found in the medical chart. The "Post Operative Note" contained no information regarding provisions for follow-up care, documentation outlining the plans and instructions for the patient's continued care after discharge, wound care guidelines, or medication prescriptions.

During a review of Patient 1's nursing "Discharge Instructions," dated 7/3/2024, the instructions indicated that Patient 1 was instructed not to remove the dressing and to call for a follow-up appointment with the surgeon (MD 5) within two weeks. The discharge instructions did not contain information regarding any new prescriptions given to Patient 1.

During an interview on 9/20/2024 at 11:20 a.m. with Surgeon (MD 5), MD 5 stated, "I typically don't document a discharge summary in patients' charts. I have preset discharge orders for nurses to follow, and my discharge orders are typically routine." MD 5 also stated, "I do prescriptions for medications through my office, where I typically see patients before surgery, but I don't document this information in the patient's chart at the facility."

During an interview on 9/20/2024 at 12:15 p.m. with the Chief of Surgery (COS), the COS stated, "Per the facility's rules and regulations, surgeons are required to document discharge summaries, discharge orders, and discharge instructions in patients' medical records."

During an interview on 9/20/2024 at 12:20 p.m., the Chief of Medical Staff (CMS) stated, "For same-day surgeries, the scheduled procedure is typically discussed with patients in the surgeon's outpatient medical office. All aftercare arrangements should be made prior to surgery and documented in the patient's medical record. We usually include these details in the pre-operative note, such as any prescriptions and wound care instructions, if applicable. Registered nurses should confirm the discharge instructions with the surgeon before discharging the patient."

During a review of the facility's Surgery Department (SD) Rules and Regulations (R&R), dated 4/2020, the SD R&R, indicated, "The surgeon is responsible for writing postoperative instructions for the patient on the Outpatient Surgery discharge summary prior to the patient being discharged. Outpatient nurses are responsible for completing explanation to the patient of post-operative instructions."

Based on an interview and record review, the facility failed to provide an updated and accurate history and physical (H&P, a formal and complete assessment of the patient and the problem) examination for one out of 30 sampled patients (Patient 1). Patient 1's H&P contained no documentation of their allergies to penicillin (antibiotic) and tape.

This deficient practice had the potential to result in adverse reactions (rashes, etc.) to Patient 1 due to the lack of documented allergies.

Findings:

During an interview on 9/17/2024 at 9:55 a.m. with Patient 1, Patient 1 stated, "I had two procedures done at the facility (5/31/2024 and 7/3/2024), and both times I had a severe allergic reaction to the tape the facility used when the dressing was applied to my breast. I told my surgeon before the procedure and I told the facility's staff that I was allergic to tape, but they still used the tape on my skin after each surgery, and I ended up with blisters and scarring."

During a review of Patient 1's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 5/28/2024, the H&P indicated, Patient 1 was seen for medical clearance for right breast lumpectomy (a surgical procedure to remove a tumor and some surrounding tissue from the breast while leaving the rest of the breast intact) and right axillary (armpit) lymph node (part of the body's immune system that helps fight infection) biopsy (a procedure that removes tissue or cells from the body to examine for damage or diseases. The H&P also indicated: Patient 1 was documented to be allergic to penicillin (antibiotic). The H&P further indicated, the surgeon (MD 5) signed the original H&P on 5/31/2024 (First Surgery), indicating the H&P was reviewed, the patient (Patient 1) was examined, and no change has occurred since 5/28/2024.

During a review of Patient 1's "Anesthesia Documentation" medical record (MR) dated 5/31/2024, the MR indicated that Patient 1 had three recorded active allergies:

1. Penicillin: A broad-spectrum antibiotic used to treat bacterial infections, causing a severe reaction-anaphylactic shock (a severe, life-threatening allergic reaction that can develop rapidly and affect the entire body. It can be in response to substances such as latex).
2. Latex: A natural rubber product that can cause allergic reactions due to certain proteins, causing a severe reaction-rash.

During an interview on 9/20/2024 at 11:20 a.m. with Surgeon (MD 5), MD 5 stated that when Patient 1 had their first surgery on 5/31/2024, they (Facility Staff) were not aware of Patient 1's tape allergy. MD 5 further stated, "I only found out Patient 1 was allergic to tape until after the first surgery (5/31/2024)." During the same interview on 9/20/2024 at 11:20 a.m. MD 5 stated that they were not aware of Patient 1's recorded latex allergy on 5/31/2024, when the first surgery took place (In contrast, the Anesthesia Documentation, dated 5/31/2024, indicated three active allergies including latex. Likewise, the Anesthesia Documentation on 7/3/2024 also included allergy to tape.

During a review of Patient 1's "Post (after) Operative Note," dated 7/3/2024, the note indicated, on 7/3/2024, Patient 1 underwent re-excision for margins (a second surgery that removes a small amount of tissue around the area of a previous surgical site) of right breast.

During a review of Patient 1's H&P, dated 7/3/2024, the H&P indicated, Patient 1 had no known drug allergies (NKDA). No allergy to tape was listed in Patient 1's H&P, dated 7/3/2024.

During a review of Patient 1's medical record (MR) titled, "Anesthesia Documentation," dated 7/3/2024, the MR indicated that Patient 1 was severely allergic to penicillin and tape.

During an interview on 9/20/2024 at 11:20 a.m. with MD 5, MD 5 reviewed Patient 1's History and Physical (H&P), dated 7/3/2024, which contained no documentation of a tape allergy or known drug allergies and verified that no tape or drug allergies were documented in Patient 1's H&P prior to the surgery on 7/3/2024.

During an interview on 9/20/2024 at 12:15 p.m. with Chief of Surgery (COS), the COS stated that a history and physical (H&P) examination must be completed before a surgical procedure and should be updated if there are any changes to the patient's condition. The COS then added, "Allergies should be reviewed and documented, as per the facility's surgical rules and regulations."

During a review of the facility's Medical Staff General Rules and Regulations, dated 12/2021, the document indicated," A complete examination to include all pertinent findings resulting from review and examination of all body systems must be recorded before a surgical procedure or any procedure with procedural sedation."

Based on interview and record review, the facility failed to address a heart rate below the acceptable range (acceptable range per facility is 51-119 beats per minute) for one of 30 sampled patients (Patient 4) during Patient 4's post-operative recovery after a surgical procedure. In addition, the facility failed to make the physician aware of unfavorable variances (Patient 4's heart rate dropping below 51 beats per minute) experienced by Patient 4 during the discharge phase when recovering after the procedure, in accordance with the facility's policies and procedures regarding post-procedural anesthesia (a procedure that prevents patients from feeling pain during medical procedures and surgery) monitoring.

This deficient practice had the potential to result in adverse patient outcomes, such as delayed recognition and treatment of bradycardia (abnormally low heart rate), which could lead to decreased cardiac output, hypotension (low blood pressure), dizziness, fainting, or more serious cardiac complications.

Findings:

During a review of Patient 4's medical record (MR) titled, "Physician Note," dated 5/31/2024, the MR indicated, Patient 4 underwent an elective (a surgical procedure that is scheduled in advance and is not an emergency) surgical procedure- repair of umbilical hernia (a surgical procedure that fixes a weakness in the abdominal wall near the belly button that allows a sac to push through).

During a review of Patient 4's "Vital Signs (VS, measurements of the body's basic functions, such as temperature, heart rate, breathing rate, and blood pressure)," dated 5/31/2024, the "VS" record indicated, on 5/31/2024 at 10:54 a.m., Patient 4's heart rate (HR) [before surgery] was recorded 84 beats per minute (bpm) [Before a medical procedure or surgery, a patient's baseline vital signs are recorded. These pre-procedure levels serve as a reference point for comparing post-procedure vital signs to assess the patient's recovery and detect any complications].

During a review of Patient 4's "VS" record, dated 5/31/2024, the record indicated, on 5/31/2024, at 5:15 p.m., in the PACU (Post Anesthesia Care Unit- a recovery unit where patients are temporarily admitted after any surgical procedures), Patient 4's HR was recorded 48 bpm, prior to Patient 4's discharge back to home.

During a concurrent interview and record review on 9/18/2024 at 3:30 p.m. with charge nurse (CN 2) 2, Patient 4's medical record (MR) titled, "Vital Signs," dated 5/31/2024, was reviewed. The MR indicated, on 5/31/2024 at 4:22 p.m., Patient 4 was transferred to the PACU unit, where the following heart rate (HR) was recorded:

At 4:29 p.m., HR was recorded 50 bpm (facility's reference range 51-119 bpm)
At 4:32 p.m., HR was recorded 51 bpm
At 4:30 p.m., HR was recorded 49 bpm
At 4:34 p.m., HR was recorded 51 bpm
At 4:53 p.m., HR was recorded 59 bpm
At 5:00 p.m., the HR was recorded 47 bpm
At 5:15 p.m., HR was recorded 48 bpm
CN 2 stated, Patient 4's medical record contained no documentation regarding notification of physician about Patient 4's heart rate being below 51 bpm.

During a concurrent interview and record review on 9/19/2024 at 10:30 a.m. with PACU Registered Nurse (RN 8) 8, RN 8 reviewed Patient 4's "Vital Signs (VS)" record dated 5/31/2024. RN 8 stated that it was not necessary to notify the physician about Patient 4's heart rate being below 51 bpm during recovery in the PACU and prior to discharge. RN 8 further stated that PACU nurses follow standardized protocol (Discharge of Phase I and Phase II Postoperative Patients), and that the discharge criteria for patients' safe discharge are determined based on the Aldrete score (a scoring system of a patient's physiological recovery after anesthesia by evaluating five parameters: respiration, circulation, consciousness, color, and level of activity). RN 8 stated that Patient 4's Aldrete score was above 8, indicating that Patient 4 qualified for safe discharge.

During an interview on 9/20/2024 at 11:20 a.m. with the Chief Medical Officer (CMO), the CMO stated that the software (the programs and other operating information used by a computer) in electronic patient records automatically establishes the acceptable parameters for patients' vital signs, such as heart rate. The CMO reviewed Patient 4's "Vital Signs" record dated 5/31/2024 and stated that, according to the established parameters for Patient 4, the acceptable range for Patient 4's heart rate (HR) was 51-119 beats per minute (bpm), and a HR below 51 bpm was not within acceptable limits for Patient 4.

During a review of the facility's policy and procedure (P&P), titled, "Standardized Procedure: Discharge of Phase II Postoperative, Post Procedural Anesthesia, Sedation Patients," dated 12/2021, the P&P indicated, "Registered nurses with appropriate completion of competencies may execute orders for discharge in accordance with an approved standardized procedure for discharge from the hospital of phase I and II post-operative patients. The physician must be contacted for any unfavorable variances experienced by the patient during discharge phase I and/or II when the following criteria is not met (but not limited to): Vital signs are not within +/- 20 % of pre procedure level (A variation of ±20% from the pre-procedure vital sign levels is generally considered an acceptable range during recovery, indicating that the patient's vital signs are within normal limits relative to their baseline. When vital signs are not within ±20% of these pre-procedure levels, it means that there are significant deviations that may require medical attention). Documentation in the electronic health record is required."