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Based on interview and record review, the hospital failed to notify the patient's responsible party of the patient's change in condition for one of nine sampled patients (Patient 9) as per hospital P&P. This failure posed the risk of the family member not involving in decision making process and getting the patient's condition update.

Findings:

Review of the hospital's P&P titled Cardiopulmonary Resuscitation Team Response dated 2/21/24, showed the purpose is to establish the response of a Resuscitation Team to efficiently implement resuscitative measures for patients, visitors, and staff. If present, the family of the patient will be informed of the patient's condition by the primary physician. If family is not present, the social worker (or designee) will attempt to locate family members by phone. The physician will talk to the family as soon as the patient's condition allows.

On 11/18/24, review of Patient 9's medical record was initiated. Patient 9's medical record showed the patient came to the ED on 9/15/24, for abdominal pain with nausea and vomiting.

Review of ED nurse note dated 9/15/24 at 1745 hours, showed the ED physician was notified Patient 9's mental status was increasingly altered with abnormal posturing movements and dilated pupils. The ED physician came to patient's bedside to reevaluate the patient.

Review of ED nurse note dated 9/15/24 at 1836 hours, showed Patient 9 had cardiac arrest.

Review of the Code Record showed Patient 9 coded on 9/15/24 at 1836 hours and survived at 1853 hours.

Review of the Progress Note dated 9/16/24 at 0640 hours, showed Patient 9's family members at bedside.

On 11/19/24 at 1600 hours, an interview and concurrent review of Patient 9's medical record was conducted with the Director of Quality, Licensing and Accreditation. The Director of Quality, Licensing and Accreditation confirmed no documented evidence showing Patient 9's family member was notified after Patient 9 coded on 9/15/24.

Based on interview and record review, the hospital failed to ensure one of nine sampled patients (Patient 8) plan of care was updated to reflect the use of restraints during their hospitalization. This failure created the risk of substandard outcomes for the patient.

Findings:

Review of the hospital's P&P titled Restraints dated 2/21/24, showed a written modification to the patient's interdisciplinary plan of care is made when the restraint order is written.

On 11/19/24 at 1002 hours, medical record review for Patient 8 was initiated with ED Assistant Manager 2 and RNs 1 and 2.

Patient 8's medical record showed the patient came to the ED on 11/4/24.

Review of the physician's order dated 11/4/24 at 1908 hours, showed to initiate the restraints for Patient 8 to manage the violent behaviors.

Review of Patient 8's Restraint Documentation - ED dated 11/5/24, showed the behavioral restraints were initiated on 11/4/24 at 1849 hours, and discontinued on 11/5/24 at 0105 hours.

However, further review of Patient 8's medical record did not show Patient 8's plan of care was updated to reflect the use of restraints.

On 11/9/24, ED Assistant Manager 2 and RNs 1 and 2 verified the findings.

Based on interview and record review, the hospital failed to ensure the use of restraints for the management of violent or self-destructive (VSD) behaviors was renewed within four hours for one of nine sampled patients (Patient 8). This failure posed a risk of unnecessary restraint use and substandard outcomes for the patient.

Findings:

Review of the hospital's P&P titled Restraints dated 2/21/24, showed orders for a VSD restraint may only be renewed according to the following time limits for up to a total of 24 consecutive hours:

- Four hours for adults.

On 11/19/24 at 1002 hours, medical record review for Patient 8 was initiated with ED Assistant Manager 2 and RNs 1 and 2.

Patient 8's medical record showed the patient came to the ED on 11/4/24.

Review of Patient 8's Restraint Documentation - ED dated 11/5/24, showed the hard limb restraints were applied to the patient's all four extremities on 11/4/24 at 1849 hours, and discontinued on 11/5/24 at 0105 hours, for a total duration of 376 minutes (6 hours and 16 minutes).

Review of Patient 8's medical record showed that the initial physician's order for restraints to manage violent behavior was issued on 11/4/24 at 1908 hours.

However, the physician's order for renewal of the restraints was issued on 11/4/24 at 2349 hours (or more than four hours later).

On 11/9/24, ED Assistant Manager 2 and RNs 1 and 2 verified the findings. RN 2 verified the VSD restraint orders for adults could only be renewed for up to four hours at a time.

Based on interview and record review, the hospital failed to ensure the staff reassessed and monitored one of nine sampled patients (Patient 8) while Patient 8 was restrained. This failure had the potential to result in unsafe care for the patient.

Findings:

Review of the hospital's P&P titled Restraints dated 2/21/24, showed under the section, Reassessment of the VSD Behavior Patient, that observation and monitoring will be done on an ongoing basis. Reassessment documentation will be completed as often as necessary depending on the patient's condition, and a minimum every one hour. Documentation of hourly assessment includes:
- Any signs of injury,
- Level of consciousness,
- Circulation,
- Sensory and motor function.

On 11/19/24 at 1002 hours, medical record review for Patient 8 was initiated with ED Assistant Manager 2 and RNs 1 and 2.

Patient 8's medical record showed the patient came to the ED on 11/4/24.

Review of Patient 8's Restraint Documentation - ED dated 11/5/24, showed the hard limb restraints were applied to the patient's all four extremities on 11/4/24 at 1849 hours, and discontinued on 11/5/24 at 0105 hours, for a total duration of 376 minutes (6 hours and 16 minutes).

Review of Patient 8's medical record showed documented hourly reassessments on 11/4/24 at 1850, 1949, 2049, 2149, and 2249 hours, and on 11/5/24 at 0049 hours. However, there was no documented hourly reassessment of Patient 8 between 11/4/24 at 2249 hours and 11/5/24 at 0049 hours.

On 11/9/24, ED Assistant Manager 2 and RNs 1 and 2 verified the findings.

Based on interview and record review, the hospital failed to ensure the ICU nursing staff adhered to the hospital's P&Ps for one of nine sampled patients (Patient 3) when the ICU nursing staff did not assess Patient 3's RASS score every one hour. This failure posed the potential to result in poor health outcomes to the patient.

Findings:

Review of Attachment A: Nursing Assessment/Reassessment Grid for Med/Surg ICU of the hospital's P&P titled Critical Care Practice Standards for ICU dated 9/20/22, showed to assess the Richmond Agitation Sedation Score, Scale RASS prior to initiation of the sedation, with each titration, and every one hour once the goal reached.

On 11/18/24 at 1308 hours, an interview and concurrent review of Patient 3's medical record was conducted with RN 1 and the ACNO.

Patient 3's medical record showed Patient 3 was admitted to the hospital on 11/12/24, and transferred to ICU on 11/14/24 at 1723 hours.

Review of the Order Sheet dated 11/15/24 at 1548 hours, showed to initiate propofol (a medication used to sedate a patient) at 5 mcg/kg/min and titrate incrementally by 5mcg/kg/min with the frequency of 5 minutes to maintain the RASS score from zero to minus 2, with a maximum dose of 100 mcg/kg/min.

Review of the Medication Administration Record showed Patient 3 received propofol at 45 mcg/kg/min on 11/17/24 at 1810 and 2249 hours; and 11/18/24 at 0450 hours.

Review of the RASS score showed Patient 3's RASS score was minus two on 11/17/24 at 2000 hours. There was no documented evidence to show the ICU nursing staff assessed Patient 3's RASS score every one hour on 11/17/24, from 2000 hours to 2300 hours (or at 2100, 2200, and 2300 hours) and on 11/18/24, from 0100 hours to 0400 hours (or at 0100, 0200, 0300, and 0400 hours) as per the hospital's P&P.

RN 1 confirmed the findings.

Based on observation, interview, and record review, the hospital failed to ensure the nursing staff followed the physician's orders to titrate the medications for three of nine sampled patients (Patients 1, 2, and 3) as evidenced by:

1. For Patient 1, the nursing staff did not titrate esmolol (a medication used to slow down a fast heartbeat and treat high blood pressure) to maintain the patient's heart rate less than 70 beats per minute as per the physician's order.

2. For Patient 2, the nursing staff did not titrate propofol as per the physician's order.

3. For Patient 3, the nursing staff did not titrate propofol as per the physician's order

These failures posed the risk of not attaining therapeutic goals, ineffective treatment, or adverse health outcomes for the patients.

Findings:

Review of the hospital's P&P titled Medication Administration dated 5/30/24, showed medications must be administered consistent with the physician's orders and consistent with the hospital's policies, medical staff bylaws, rules and regulations, and other applicable laws.

Review of the hospital's P&P titled Medication Titration dated 2/23/23, showed the following:

- Medications are titrated to specific endpoint/effect as per physician order.

- All medication drip rates ordered to be titrated will be adjusted according to suggested guidelines unless otherwise specified by the prescriber as appropriate.

- The nurse is responsible for documenting parameters and titration adjustments in the medical record as per policy.

1. On 11/18/24 at 1051 hours, medical record review for Patient 1 was initiated with the Director of Quality, Licensing and Accreditation.

Patient 1's medical record showed the patient was admitted to the hospital on 10/20/24.

Review of the physician's order dated 10/20/24 at 1335 hours, showed to initiate esmolol 250 ml at 50 mcg/kg/min. The order specified titrating the medication incrementally by 50 mcg/kg/min every 5 minutes to maintain a heartrate less than 70 beats per minute, with a maximum dose of 200 mcg/kg/min.

Review of Patient 1's medications flowsheet showed the esmolol IV drip was initiated on 10/20/24 at 1353 hours.

Review of Patient 1's Vital Signs showed on 10/20/24, Patient 1's heart rate was as follows:
- At 1402 hours, Patient 1's heart rate was 80 beats per minute,
- At 1416 hours, Patient 1's heart rate was 87 beats per minute, and
- At 1422 hours, Patient 1's heart rate was 89 beats per minute.

However, review of Patient 1's medical record did not show evidence the esmolol IV drip was titrated to maintain the patient's heart rate below 70 beats per minute.

On 11/18/24, the Director of Quality, Licensing and Accreditation verified the findings and acknowledged the nursing staff did not follow the physician's orders to titrate the medication to maintain the patient's heart rate below 70 beats per minute.


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2. On 11/18/24 at 1015 hours, a tour of ICU was conducted with the ACNO and Director of Quality, Licensing and Accreditation. Patient 2 was observed lying on the bed in Room A. Propofol was observed infusing to the patient.

On 11/18/24 at 1046 hours, an interview and concurrent review of Patient 2's medical record was conducted with RN 1 and the ACNO.

Patient 2's medical record showed Patient 2 was admitted to the hospital on 11/17/24 at 0318 hours and came to the ICU on 11/17/24 at 0557 hours from the ED.

Review of the Order Sheet dated 11/17/24 at 0058 hours, showed to initiate propofol at 5 mcg/kg/min and titrate incrementally by 5mcg/kg/min with the frequency of 5 minutes to maintain the RASS score from zero to minus 2, with a maximum dose of 100 mcg/kg/min; replace propofol and tubing every 12 hours.

Review of the RASS Vital Sign and IV Drips showed the nursing staff did not titrate the propofol for Patient 2 as per the physician's order. For examples,

* On 11/17/24:

- At 0035 hours, Patient 2's RASS score was zero and the rate of the propofol was infused at 10 mcg/kg/min.

- At 0040 hours, Patient 2's RASS score was zero and the rate of the propofol was increased to 15 mcg/kg/min.

- At 0045 hours, Patient 2's RASS score was minus one and the rate of the propofol was increased to 20 mcg/kg/min.

The rate of the propofol was increased instead of remained at the same rate when Patient 2's RASS score was within the goal, from zero to minus two.

* On 11/17/24:

- At 0245 hours, Patient 2's RASS score was zero and the rate of the propofol was 35 mcg/kg/min.

- At 0250 hours, Patient 2's RASS score was minus one and the rate of the propofol was increased to 40 mcg/kg/min. The rate of the propofol was increased instead of remained at the same rate when Patient 2's RASS score was within the goal, from zero to minus two.

- At 0320 hours, Patient 2's RASS score was minus three and the rate of the propofol was increased to 45 mcg/kg/min. The rate of the propofol was increased instead of decreased when Patient 3's RASS score was minus three.

* On 11/17/24:

- At 0406 hours, Patient 2's RASS score was minus one and the rate of the propofol was 45 mcg/kg/min.

- At 0530 hours, Patient 2's RASS score was minus one and the rate of the propofol was increased to 50 mcg/kg/min. The rate of the propofol was increased instead of remained at the same rate when Patient 2's RASS score was within the goal, from zero to minus two.

- At 0545 hours, the section of RASS score was left blank and the rate of the propofol was increased to 55 mcg/kg/min. The rate of the propofol was increased when there was no documented evidence to show the nursing staff assessed Patient 2's RASS score.

- At 0600 hours, Patient 2's RASS score was minus two and the rate of the propofol was increased to 60 mcg/kg/min. The rate of the propofol was increased instead of remained at the same rate when Patient 2's RASS score was within the goal, from zero to minus two.

RN 1 verified the above findings.

3. On 11/18/24 at 1308 hours, an interview and concurrent review of Patient 3's medical record was conducted with RN 1 and the ACNO.

Patient 3's medical record showed Patient 3 was admitted to the hospital on 11/12/24.

Review of the Order Sheet dated 11/15/24 at 1548 hours, showed to initiate propofol at 5 mcg/kg/min and titrate incrementally by 5mcg/kg/min with the frequency of 5 minutes to maintain the RASS score from zero to minus 2, with a maximum dose of 100 mcg/kg/min; replace propofol and tubing every 12 hours.

Review of the RASS Vital Sign and IV Drips showed the nursing staff did not titrate the propofol for Patient 3 as per the physician's order. For example,

* On 11/15/24:

- At 1615 hours, Patient 3's RASS score was zero and the propofol was infused at 75 mcg/kg/min.

- At 1620 hours, Patient 3's RASS score was minus one and the rate of the propofol was increased to 80 mcg/kg/min.

- At 1625 hours, Patient 3's RASS score was minus one and the rate of the propofol was increased to 85 mcg/kg/min.

The rate of the propofol was increased instead of remained at the same rate when Patient 2's RASS score was within the goal, from zero to minus two.

* On 11/16/24 at 2315, 2330, and 2345 hours, the rate of the propofol was decreased to 70, 65, and 60 mcg/kg/min respectively. However, the sections of RASS score were left blank on at 2315, 2330, and 2345 hours.

RN 1 verified the findings.

Based on observation, interview, and record review, the hospital failed to ensure the physician's verbal orders were written for two of nine sampled patients (Patients 2 and 3) as per the hospital's P&P. This failure posed the potential to result in poor health outcomes to the patients.

Findings:

Review of the hospital's P&P titled Medication Administration dated 5/30/24, showed the medications must be administered to be consistent with the physician's orders and hospital's policies, medical staff by laws, rules and regulations, and other applicable laws.

Review of the hospital's P&P titled Physician Orders: Acceptance, Recording and Routing for Authentication dated 6/21/23, showed verbal/telephone orders are patient care, treatment, and service order issued verbally by a physician either directly face to face or via telephone to a licensed professional authorized to receive and record such orders. Verbal or telephone orders must be entered in the patient's EHR at the time the order is received, except in life threatening emergencies, if order entry is thought to delay effective emergency response. Verbal or telephone order entries shall be authenticated/attested within 48 hours by the ordering licensed provider.

1. On 11/18/24 at 1015 hours, a tour of ICU was conducted with the ACNO and Director of Quality, Licensing and Accreditation. Patient 2 was observed lying on the bed in Room A. Precedex (a medication used to start or maintain sedation) was observed infusing at 1.4 mcg/kg/hr to Patient 2.

On 11/18/24 at 1046 hours, an interview and concurrent review of Patient 2's medical record was conducted with RN 1 and the ACNO.

Patient 2's medical record showed Patient 2 was admitted to the hospital on 11/17/24 at 0318 hours and went to the ICU on 11/17/24 at 0557 hours, from the ED.

Review of the Order Sheet dated 11/18/24 at 0926 hours, showed to initiate dexmedetomidine (same as Precedex) at 0.2 mcg/kg/hr and titrate incrementally 0.2 mcg/kg/hr with the frequency of 30 minutes to maintain the RASS score from zero to minus two, with the maximum dose of 1.4 mcg/kg/hr.

Review of the Medication Administration Record showed the dexmedetomidine was started at 1.4 mcg/kg/hr for Patient 2 on 11/18/24 at 0932 hours. The Result Comment section showed "ok per MD to max dose..."

When asked, RN 1 stated it was the verbal order to administer the dexmedetomidine to the patient with the maximum dose of 1.4 mcg/kg/hr. When asked, RN 1 was unable to find a verbal order was written to initiate the dexmedetomidine with the maximum dose as of 1.4 mcg/kg/hr for the patient.

2. On 11/18/24 at 1308 hours, an interview and concurrent review of Patient 3's medical record was conducted with RN 1 and the ACNO.

Patient 3's medical record showed Patient 3 was admitted to the hospital on 11/12/24.

Review of the Order Sheet dated 11/15/24 at 1548 hours, showed to initiate propofol at 5 mcg/kg/min and titrate incrementally by 5mcg/kg/min with the frequency of 5 minutes to maintain the RASS score from zero to minus 2, with a maximum dose of 100 mcg/kg/min.

Review of the Medication Administration Record showed on 11/15/24, the propofol was infused to the patient at 5 mcg/kg/min at 1549 hours. At 1550 hour, the propofol was increased to 50 mcg/kg/min and the Result Comment section showed "initiated during bronchoscopy procedure. MD aware."

When asked, RN 1 stated the physician was aware the propofol was administered at 50 mcg/kg/min to the patient on 11/15/24 at 1550 hours. When asked, RN 1 was unable to find a verbal order was written to administer 50 mcg/kg/min to the patient during the bronchoscopy procedure.

On 11/18/24 at 1430 hours, during a follow-up interview with RN 1, RN 1 confirmed the above verbal orders were not written for Patients 2 and 3 as per the hospital's P&P.

Based on interview and record review, the hospital failed to ensure the nursing staff followed the hospital's P&P for the Administration of Blood and Blood Products for one of nine sampled patients (Patient 7) to assess and document the vital signs before, during, and after the blood transfusion. This posed the risk for potential complications, including undetected changes in the patient's condition, delayed interventions, and overall compromised patient safety during the blood transfusion process.

Findings:

Review of the hospital's P&P titled Administration of Blood and Blood Products dated 5/30/24, showed the following:

* Prior to blood/blood product pick up from the blood bank, obtain baseline vital signs (blood pressure, heart rate, temperature, and respiratory rate) to assure expected normalcy before proceeding with blood/blood products transfusion.

* During the transfusion, the RN will assess and document vital signs (blood pressure, heart rate, temperature, and respiratory rate) and oxygen saturation as follows:

- At 15 minutes from the beginning of the transfusion,

- Then every one hour up until transfusion completion, and

- At the end of the transfusion.

On 11/19/24 at 0915 hours, medical record review for Patient 7 was initiated with the Senior Director of Critical Care Services, ICU Director, and RN 1.

Patient 7's medical record showed the patient was admitted to the hospital on 11/12/24.

a. Review of the physician's order dated 11/12/24 at 2304 hours, showed to transfuse two units of red blood cells to Patient 7.

Review of Patient 7's Blood Transfusion Summary showed the second unit of red blood cells was transfused on 11/13/24 from 0500 hours to 0800 hours. However, there was no documented evidence Patient 7's vital signs were assessed at the end of the blood transfusion on 11/12/24 at 0800 hours.

b. Review of the physician's order dated 11/13/24 at 1349 hours, showed to transfuse one unit of plasma to Patient 7.

Review of Patient 7's Blood Transfusion Summary showed the one unit of plasma was transfused on 11/13/24 from 1449 hours to 1544 hours. However, there was no documented temperature 15 minutes after the start of the transfusion and no documented evidence Patient 7's vital signs were assessed at the end of the blood transfusion on 11/13/24 at 1544 hours.

c. Review of the physician's order dated 11/14/24 at 1352 hours, showed to transfuse two units of red blood cells to Patient 7.

Review of Patient 7's Blood Transfusion Summary showed that the first unit of red blood cells was transfused on 11/14/24 from 1417 hours to 1440 hours, and the second unit was transfused on 11/14/24 from 1441 hours to 1533 hours. However, there were no documented baseline vital signs at the start of the first unit transfusion, no documented respiratory rate at 1440 hours (the end of the first unit transfusion), and no documented temperature at 1535 hours (the end of the second unit transfusion).

On 11/19/24, the Senior Director of Critical Care Services, ICU Director, and RN 1 verified the findings.