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Based on medical record reviews, staff interviews, and facility policies and procedures, it was determined that the facility failed to follow facility policies and procedures for nursing care. Specifically, the facility failed to provide daily hygiene care for one patient (P) (P#1) of four patient medical records reviewed (P#1, P#2, P#3, P#4).


Findings include:


A review of medical records revealed that P#1 was admitted to the facility on 7/30/25 at 4:22 p.m. for left elbow pain post elbow surgery. P#1's medical record revealed on 7/30/25 at 4:29 p.m. the implementation of a protocol started for daily hygiene to be conducted at 1:00 a.m. and 1:00 p.m.


P#1's medical record failed to reveal that P#1 received daily nightshift hygiene care on 7/31/25 through 8/4/25. The record also failed to reveal why P#1 did not receive hygiene care during nightshift on 7/31/25 through 8/4/25.


A review of the facility's policy titled "Nursing - Standards - Assessment Nursing Care and Documentation," effective 11/15/23 revealed an initial nursing history/assessment was completed within eight hours of admission by an RN. Reassessment of the patient occurred no less than each shift and as warranted by current condition. Assessment data was utilized by the RN to develop a plan of care. The nursing staff, patient, and other members of the health care team implemented a plan of care for the patient and evaluated and revised its content as needed. Documentation of care would be concise, pertinent, and reflect the patient's status, nursing intervention, and patient response.


A review of the facility's policy titled "Nursing - Standards: Of Care" effective 4/29/25 revealed hygiene and physical comfort measures were implemented to support activities of daily living that included periodic baths, hand washing, mouth care, hair grooming, fingernails and toes cleaned, skin care, assessment and changing of dressings, bandages, binders, or elastic stockings, and bed linen changes. Assistance in turning in the bed was given to the patient who could not turn themselves a minimum of every two hours and as needed.


An interview was conducted with Registered Nurse (RN) EE on 8/11/25 at 3:16 p.m. in a conference room. RN EE stated he was the Nurse Manager for the Five North West Ortho-Surgical Unit. He said night-shift daily hygiene care of patients was expected to be completed and documented into the patient's medical chart. RN EE agreed with this writer that P#1's medical charting did not reflect the completion of night-shift daily hygiene care from 7/31/25 through 8/4/25. He said P#1's medical chart was noted as documented to read, "not done; due to complete" hygiene care from 7/31/25 through 8/4/25.


An interview was conducted with RN HH on 8/12/25 at 11:07 a.m. in the conference room. RN HH stated she was the clinical coordinator and conducted rounding and reviewed staff charting. She said patients in odd number rooms received hygiene care during the nightshift. She agreed that P#1's EMR did not reflect that nightshift daily hygiene was completed for P#1 from 7/31/25 through 8/4/25. She said nightshift hygiene care was noted in P#1's medical chart as "not done; due to complete" from 7/31/25 through 8/4/25. She said after "shift assessment" was selected and completed within a patient's medical record within the facility's electronic medical record (EMR) system, when more than two criteria was selected the EMR prompted interventions that should be implemented, such as "apply dressing", etc.


A follow-up interview was conducted with RN EE on 8/12/25 at 12:21 p.m. at the Five North West Unit's nurse's station. RN EE stated that patients in odd number rooms received daily hygiene care during nightshift and the patients in even number rooms received their care during the dayshift.


An interview was conducted with Patient Care Technician (PCT) BB on 8/12/25 at 2:15 p.m. in the conference room. PCT BB stated he worked on Five North West on the dayshift and took care of P#1. He said, because P#1 didn't speak too much, he checked up on P#1 more frequently. He said patients in odd number rooms received hygiene care during the nightshift and odd number rooms received their care during the dayshift. PCT BB stated the PCT's documentation of hygiene care was done on the patient's room board and the charge nurse was notified when hygiene care was done.

Based on observation, staff interviews, and facility policies and procedures, it was determined that the facility failed to follow facility policies and procedures for properly storing medications prior to administration. Specifically, on 8/12/25 at 11:57 a.m., a single one-gram vial of Cefepime (antibiotic) and one IV (a medical process that administers fluids, medications and nutrients directly into a person's vein) mini bag were observed on top of a computer on wheels (COW) unsecured in the hallway.


Findings include:


On 8/12/2025 at 11:57 a.m., a computer on wheels (COW) was observed in the unit hallway for approximately two and a half minutes with a single one-gram vial of Cefepime and one IV mini bag on top of it. No staff members were presently visible in the hallway or standing next to the COW when the unsecured medication was observed.


A review of the facility's policy titled "Nursing - Medication: Floor Stock, (Non-Emergency) - Acquisition and Storage in Patient Care Areas," effective 6/27/24, revealed unauthorized persons could not obtain access to medications. No medications would be left at the patient's bedside, and no medications were left sitting out on counters, carts in hallways or unattended in any areas. Medication carts in hallways must be locked when not attended, and when not in use, must be at the Nursing Station under continuous observation. Medication administration assignments in Patient Care Areas would be strictly maintained to ensure adequate security for medications.


A review of the facility's policy titled "Pharmacy - Procedure: Medication Administration Guidelines," effective 6/24/25 revealed no medications would be left unsecured or at the beside.


An interview was conducted with Registered Nurse (RN) EE on 8/12/25 at 11:57 a.m. on the hallway outside a patient's room. RN EE stated the medication and IV mini bag that this writer discovered unsecured on top of a COW was medication for a patient and the nurse that left the medication was getting more medication for a patient. RN EE stated it was not practice for staff to leave medication sitting out on top of the COW. He said medications were not to be left in the hallway unsecured but were supposed to be locked away inside the COW.


An interview was conducted with RN KK on 8/12/25 at 11:59 a.m. on the hallway outside a patient's room. RN KK stated she left the medication discovered by this writer on top of the COW. She said medications were not supposed to be left out unsecured. RN KK stated medications were supposed to be locked inside the COW cart.