HospitalInspections.org

Based on interview and record review, the facility failed to meet the Condition of Participation for Patient's Rights as evidenced by:

1. The facility failed to provide the appropriate translator services (helps bridge language barriers and ensure accurate interpretations and translation of medical information), in accordance with the facility's policy and procedure regarding the use of translation services, for one of 30 sampled patients (Patient 10), when a consent (a process in which a patient or their legal representative receives information about a medical procedure or treatment) was obtained. Patient 10's consent for blood transfusion (procedure that involves transferring blood or blood products) indicated no interpreter was used, instead Registered Nurse 11 (RN 11) was used in place of an interpreter. Patient 10's preferred language was Spanish.

This deficient practice violated Patient 10's right to receive effective communication in their preferred language (Spanish) to understand the information contained in the consent form and make informed decisions about the proposed procedure. This deficient practice also had the potential to result in inappropriate treatments thus putting a patient's health at risk. (Refer to A-0129)

2. The facility failed to ensure for one (1) of 30 sampled patients (Patient 20), safe care was provided when Patient 20 was observed not wearing an identification (ID, include patient's full name, hospital number, medical record number, date of birth, age, sex, and attending physician) band in accordance with the facility's policy and procedure regarding patient identification.

This deficient practice resulted in Patient 20 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)

3. The facility failed to ensure nine of nine patients received care in a safe environment, when one (Crash Cart 1) of two crash carts (or code cart, a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency) in the Critical Care Unit (CCU, provides care for people who have life-threatening injuries or illnesses) was missing the backboard (provides a firm surface for a patient who requires chest compressions during cardiopulmonary resuscitation [CPR, emergency treatment when someone's breathing or heartbeat stops]).

This deficient practice had the potential for emergency supplies to not be readily available in case of a medical emergency and may cause a delay in care. (Refer to A-0144)

4. The facility failed to ensure for two (2) of 30 sampled patients (Patients 26 and 29), Patient 26 and Patient 29 were free from restraint (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) when, Patients 26 and 29's four siderails of the bed were raised without a physician order, in accordance with the facility's policy and procedure regarding restraints use.

This deficient practice resulted in inappropriate, unnecessary, and prolonged use of restraints, and had violated Patients 26 and 29's right to be free from restraints. In addition, this deficient practice had the potential for Patients 26 and 29 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 the lack of proper monitoring in relation to the use of restraints. (Refer to A-0154)

5. The facility failed to ensure for one (1) of 30 sampled patients (Patient 20), Patient 20's soft wrist restraint (a manual method, physical or mechanical devices, material or equipment that immobilizes or reduces the ability of patient to move his or her arms, legs, body or head freely) was appropriately applied to the patient's (Patient 20) left and right wrist, in accordance with the physician's order.

This deficient practice resulted in an appropriate use of restraint and had the potential to compromise Patient 20's safety with complications such as strangulation (obstruction of blood vessels and/or airflow in the neck resulting in asphyxia (lack of oxygen), skin tear, etc. (Refer to A-0167)


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

Based on interview and record review the facility failed to provide the appropriate translator services (helps bridge language barriers and ensure accurate interpretations and translation of medical information), in accordance with the facility's policy and procedure regarding the use of translation services, for one of 30 sampled patients (Patient 10), when a consent (a process in which a patient or their legal representative receives information about a medical procedure or treatment) was obtained. Patient 10's consent for blood transfusion (procedure that involves transferring blood or blood products) indicated no interpreter was used, instead Registered Nurse 11 (RN 11) was used in place of an interpreter. Patient 10's preferred language was Spanish.

This deficient practice violated Patient 10's right to receive effective communication in their preferred language (Spanish) to understand the information contained in the consent form and make informed decisions about the proposed procedure. This deficient practice also had the potential to result in inappropriate treatments thus putting a patient's health at risk.

Findings:

During a review of Patient 10's Face sheet (document that gives a patient's information at a quick glance and includes the patient's name, date of birth, address, etc.) dated 9/17/2024, the FS indicated Patient 10 was admitted to the Facility (Facility 2) on 9/17/2024. The Face Sheet indicated that Patient 10's language was Spanish.

During a review of Patient 10's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 9/17/2024, the H&P indicated, Patient 10 was admitted for an active gastrointestinal bleeding (GI, bleeding that occur anywhere in the digestive [a long tube of organs that food and liquids pass through as they are digested and absorbed, and then leave the body as feces] from the mouth to the anus [where stool passes out of the body]).

During a concurrent interview and record review on 9/18/2024 at 3:37 p.m. with the Regulatory Compliance 1 (RC 1), Patient 10's informed consent (a process in which a patient or their legal representative receives information about a medical procedure or treatment) for blood transfusion (procedure that involves transferring blood or blood products), dated 9/17/2024, was reviewed. RC 1 stated that no interpreter was needed because RN 11 that obtained the consent spoke Spanish.

During an interview with the Chief Nursing and Clinical Executive 2 (CNCE 2) on 9/18/204 at 5:05 p.m., CNCE 2 stated that RN 11 was not formally trained in Spanish and the staff should have obtained a formally trained Spanish interpreter.

During a review of the facility's policy and procedure (P &P) titled, "Language Interpreter Services and Special Needs for the Hearing and Sight Impaired," revised 12/2021, the P &P indicated, "under most circumstances interpreters providing medical interpretation must be formally trained in medical terminology."

Based on observation, interview, and record review, the facility failed to ensure for one (1) of 30 sampled patients (Patient 20), safe care was provided when Patient 20 was observed not wearing an identification (ID, include patient's full name, hospital number, medical record number, date of birth, age, sex, and attending physician) band, in accordance with the facility's policy and procedure (P&P) regarding patient identification.

This deficient practice resulted in Patient 20 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:

During a concurrent observation and interview on 9/17/2024 at 1:56 p.m. with Registered Nurse 3 (RN 3), Patient 20 was observed in bed awake and was not wearing an ID band (ID, include patient's full name, hospital number, medical record number, date of birth, age, sex, and attending physician). RN 3 was observed to have called Patient 20 two different names and Patient 20 did not respond. Subsequently, RN 3 addressed Patient 20 with the name indicated in the intravenous (IV, in the vein) medication bag that was hanging in the patient's IV pole, Patient 20 was able to answer yes. RN 3 stated, Patient ID band was important to identify a patient for medication administration to prevent error in medication, procedure and care given to the wrong patient.

During a review of Patient 20's "History & (and) Physical (H&P, a formal and complete assessment of the patient and the problem)," dated on 9/13/2024, the H&P indicated Patient 20 was admitted to Facility 1 with a chief complaint of intracranial hemorrhage (bleeding from the skull). The H&P further indicated Patient 20 was brought in by ambulance to the Emergency Department (ED, provides treatment to patients in need of immediate care) following a fall (an unintentional event that results in the person coming to rest on the ground or another lower level) incident.

During a review of the facility policy and procedure (P&P) titled, "Patient Identification for Clinical Care and Treatment" revised in 07/2021, the P&P indicated, "The identification band will include the patient's full name, hospital number, and medical record number, date of birth, age, sex, and attending physician ...Before any procedure is carried out, the identification band shall be on the patient and will be checked by the responsible care provider for the following two (2) identifies to ensure that the right patient is involved: Patient name, Patient date of birth ...Whenever possible, staff should also verbally assess the patient to assure proper identification, asking patient's name and date of birth and matching the verbal confirmation to the written information on the identification band"

Based on observation, interview, and record review, the facility failed to ensure nine of nine patients received care in a safe environment, when one (Crash Cart 1) of two crash carts (or code cart, a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency) in the Critical Care Unit (CCU, provides care for people who have life-threatening injuries or illnesses) was missing the backboard (provides a firm surface for a patient who requires chest compressions during cardiopulmonary resuscitation [CPR, emergency treatment when someone's breathing or heartbeat stops]).

This deficient practice had the potential for emergency supplies to not be readily available in case of a medical emergency and may cause a delay in care.

Findings:

During a concurrent observation and interview on 9/17/2024 at 3:06 p.m. with the Director of Emergency Services (DES), two crash carts (or code cart, a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency) were observed in the Critical Care Unit (CCU, provides care for people who have life-threatening injuries or illnesses). One of the carts (Crash Cart 1) was missing the backboard (provides a firm surface for a patient who requires chest compressions during cardiopulmonary resuscitation [CPR, emergency treatment when someone's breathing or heartbeat stops]). The DES verified that the backboard was missing and stated that the backboard was used during cardiopulmonary resuscitation (CPR). The DES stated the crash cart should be checked daily to ensure all supplies are available for use in the event of a medical emergency. Supplies should be replaced after each use.

During a review of the "Code Cart Checklist," dated 9/2024 in the Critical Care Unit, the Check list indicated the following: The Crash Cart is to be checked each calendar day and marked with a check mark in all columns when completed ...Your signature and lock number below indicate that the cart is properly locked, the defibrillator (devices that apply an electrical charge to the heart to restore a normal heart beat)/supplies have been checked and corrected as needed ...Items listed to be checked marked include ...backboard present.

During a review of the facility's policy and procedure (P&P) titled, "Emergency Cart-Code Cart Maintenance - [initials of the facility] # EC=140," dated 1/2023, the P&P indicated the following: "Equipment, supplies, and medication usually required to treat a life-threatening situation, such as cardiac and/or respiratory arrest (when the heart stops beating and the person stops breathing) are maintained in an emergency cart for ready access on patient care areas. An itemized list of contents is attached to each cart ...All equipment will be operable and ready for use ..."

Based on observation, interview, and record review, the facility failed to ensure for two (2) of 30 sampled patients (Patients 26 and 29), Patient 26 and Patient 29 were free from restraint (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) when, Patients 26 and 29's four siderails of the bed were raised without a physician order, in accordance with the facility's policy and procedure regarding restraints use.

This deficient practice resulted in inappropriate, unnecessary, and prolonged use of restraints, and had violated Patients 26 and 29's right to be free from restraints. In addition, this deficient practice had the potential for Patients 26 and 29 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.

Findings:

1. During a concurrent observation and interview on 9/17/2024 at 2:46 p.m. with Registered Nurse (RN 4) 4, Patient 26 was observed in bed, awake and able to respond only with a yes or no to questions. Patient 26's 4 side rails of the bed were raised. RN 4 stated she (RN 4) was the RN assigned to Patient 26 and the patient does not have a physician order for restraint (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely). RN 4 stated Patient 26's four (4) side rails should not be raised; it is a risk for the patient (Patient 26) to fall if all four (4) side rails are up.

During a review of Patient 26's "History & Physical (H & P, a formal and complete assessment of the patient and the problem)," dated 9/12/2024, the H&P indicated Patient 26 was admitted to Facility 1 for Diabetic Ketoacidosis (a complication of diabetes [a disease that results in too much sugar in the blood] in which acids build up in the blood to levels that can be life-threatening.)

During a concurrent interview and record review on 9/18/2024 at 12:26 p.m. with RN 7, RN 7 stated Patient 26's record did not indicate an order for restraints.

During a review of the facility's policy and procedure (P & P) titled, "Restraints Seclusion PC-380," reviewed on 07/2024, the P & P indicated, "Restraint/seclusion (involuntary confinement of a patient alone in a room or area and prevented from leaving) has the potential to produce serious consequences such as physical or psychological harm, safety issues, loss of dignity, violation of an individual's rights and even death ...Physical Restraint: is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely, or a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition ...Use of 4 side rails for a patient that is not in seizure (a sudden, uncontrolled burst of electrical activity in the brain) precautions is considered a restraint and requires an order."

2. During a concurrent observation and interview on 9/18/2024 at 10:14 a.m. with Registered Nurse (RN 8) 8, Patient 29 was observed awake, oriented x (times) 4 (someone who is fully aware of their person, place, time, and situation), with 4 side rails of the bed raised. RN 8 stated it should only be 3 side rails up for patient safety. RN 8 stated the 4 side rails is considered a restraint (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely).

During a review of Patient's 29's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)" dated 9/17/2024, the H&P indicated Patient 29 was admitted to Facility 1 for left side weakness.

During a concurrent interview and record review on 9/19/2024 at 11:03 a.m. with Quality Review Nurse (QRN 2) 2, QRN 2 stated Patient 29's medical record had no physician's order for restraints of 4 side rails up. QRN 2 stated the patient could fall if the 4 side rails are up.

During a review of the facility's policy and procedure (P & P) titled, "Restraints Seclusion (involuntary confinement of a patient alone in a room or area and prevented from leaving) PC-380," reviewed on 07/2024, the P & P indicated, "Restraint/seclusion has the potential to produce serious consequences such as physical or psychological harm, safety issues, loss of dignity, violation of an individual's rights and even death ...Physical Restraint: is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely, or a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition ...Use of 4 side rails for a patient that is not in seizure (a sudden, uncontrolled burst of electrical activity in the brain) precautions is considered a restraint and requires an order."

Based on observation, interview, and record review, the facility failed to ensure for one (1) of 30 sampled patients (Patient 20), Patient 20's soft wrist restraint (a manual method, physical or mechanical devices, material or equipment that immobilizes or reduces the ability of patient to move his or her arms, legs, body or head freely) was appropriately applied to the patient's (Patient 20) left and right wrist, in accordance with the physician's order.

This deficient practice resulted in an appropriate use of restraint and had the potential to compromise Patient 20's safety with complications such as strangulation (obstruction of blood vessels and/or airflow in the neck resulting in asphyxia (lack of oxygen), skin tear, etc.

Findings:

During a concurrent observation and interview, on 9/17/24 at 1: 56 p.m., with Registered Nurse 3 (RN 3), Patient 20 was observed in bed awake and calm. Patient 20 had a soft vest restraint and a right soft wrist restraint. Patient 20's right soft wrist restraint was placed near the patient's right elbow. Patient 20's left wrist was not on restraint.

During the same observation and interview on 9/17/2024 at 1: 56 p.m., RN 3 stated, Patient 20's right soft wrist restraint was applied incorrectly. RN 3 stated, Patient 20 should also have the left soft wrist restraint applied. RN 3 stated Patient 20 was on soft wrist restraint to prevent pulling out intravenous (IV, in the vein) line.

During a review of Patient 20's "History & (and) Physical (H&P)," dated 9/13/24, the H&P indicated Patient 20 was admitted to Facility 1 with a chief complaint of intracranial hemorrhage (bleeding from the skull). The H&P further indicated Patient 20 was brought in by ambulance to the Emergency Department (ED, provides treatment to patients in need of immediate care) following a fall (an unintentional event that results in the person coming to rest on the ground or another lower level) incident.

During a concurrent interview and record review on 9/18/2024 at 11:20 a.m. with Charge Nurse (CN 1), CN 1 verified Patient 20's "View Order Detail -Restraint Non-Violent Protocol," had a renewal order for Patient 20's Restraint Non-Violent wrist restraint to the left and right arm on 9/17/2024 at 1:47 p.m.

During a review of the facility's policy and procedure (P&P) titled, "Restraints Seclusion (involuntary confinement of a patient alone in a room or area and prevented from leaving)," revised in 7/2024, the P&P indicated, "Types of Restraints ...2. Cloth limb (soft wrist restraints, soft ankle restraints) ...b. Care should be taken to avoid placing the restraint, which would compromise integrity of an area ...Assure cuffs are secure and snug (two finger width space) to prevent circulation impairment ...Ongoing Monitoring every two (2) hours the RN will conduct the patient assessment which will include the following ...Appropriate type of restraint."

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

1. The facility failed to ensure fall precautions (actions taken to prevent a fall) were in place, in accordance with the facility's policy and procedure regarding fall reduction and precautions, at one of two facilities (Facility 1), for one of 30 sampled patients (Patient 3), who was a high fall risk (at high risk for falls) patient, when Patient 3's bed alarm (detect a patient's movement out of bed) was off at the time of the patient's (Patient 3) fall (an unintentional event that results in the person coming to rest on the ground or another lower level).

This deficient practice resulted in Patient 3 falling and sustaining a traumatic brain injury (TBI, when a sudden, external, physical assault damages the brain causing a disruption in the normal function of the brain). (Refer to A-0395)

2. The facility failed to ensure a baseline neurological (relating to the nervous system, which includes the brain, spinal cord, and nerves) pupil (the black opening in the middle of the colored part of your eye) assessment (systematic and continuous process of collecting, analyzing, and interpreting data to evaluate a patient's health) and ongoing neurological assessments were completed, per the Intensive Care Unit (ICU, a unit in a hospital providing intensive care for critically ill or injured patients) standard of care and Policy & Procedure, every two hours, for one of 30 sampled patients (Patient 3), when Patient 3 was transferred to the ICU.

This deficient practice had the potential for neurological changes not to be identified, resulting in delayed diagnosis or treatment of neurological changes, which may worsen the patient's (Patient 3) condition and prolong hospitalization. (Refer to A-0398)

3. The facility failed to ensure the policies and procedures were implemented when:

3.a. Registered Nurse 9 (RN 9), who was assigned to the care of Patient 19, was observed coming out of the patient's (Patient 19) room wearing gloves after providing patient care.

This deficient practice had the potential for the introduction of pathogens (a microorganisms such as bacteria or virus that can cause a disease process) from RN 9 not performing hand hygiene and the potential for risk of transmission of microorganism to other patients and staff in the facility. (Refer to A-0398)

3.b. Patient 19's midline catheter (a thin, flexible tube inserted into a vein in the upper arm to deliver medication or fluids directly into the bloodstream) dressing did not have a label with the insertion date and the dressing was not changed every 7 days, in accordance with the facility's policy and procedure regarding intravenous (IV, into the vein) catheter management.

This deficient practice had the potential to result in Patient 19 developing bloodstream infection and other fatal complication that could negatively affect Patient 19's recovery. (Refer to A-0398)

3.c. Patient 20, who was on seizure (a sudden, uncontrolled burst of electrical activity in the brain) precaution, was observed with all the side rails x (times) 4 not padded, in accordance with the facility's policy and procedure regarding seizure precautions (safety measures to reduce the risk of harm to people who are at risk of having a seizure).

This deficient practice had the potential for Patient 20 to suffer from pain and injury during seizure activity. (Refer to A-0398)

3.d. Patient 20 and Patient 27, who were at risk for fall (an unintentional event that results in the person coming to rest on the ground or another lower level), were observed not wearing a fall risk armband (a yellow armband indicating the patient was at risk for fall) and Patient 27's bed was not in a low position, in accordance with the facility's policy and procedure regarding fall precautions (actions or interventions taken to reduce the risk of accidental falls).

This deficient practice had the potential to result in an unsafe care that may lead to Patients 20 and patient 27 suffering from a fall injury. (Refer to A-0398)

4. The facility failed to ensure nursing staff followed the facility's "Transmission Based Precaution (a set of infection control measures used when a patient may be infected to prevent transmission) Policy," for one of 30 sampled patients (Patient 12), when Patient 12 was admitted to the facility with a diagnosis for COVID-19 (COVID-19 is caused by the SARS-CoV-2 virus. COVID-19 can cause mild to severe respiratory illness, including death) and staff did not properly discard Personal Protective Equipment (PPE, equipment used to prevent contagious infection from spreading, PPE examples include regular mask, N95 respirator mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles [a mixture of solid particles and liquid droplets found in the air]), gowns, gloves,) after providing care to Patient 12.

This deficient practice had the potential to spread infection to other staff members and patients in the unit, when a used N95 respirator mask is not discarded after each use. (Refer to A-0398)

5. The facility failed to ensure nursing staffed followed the facility's "Peripherally Inserted Central Venous Catheter Policy" for one of 30 sampled patients (Patient 13) when Patient 13 had a PICC line (Peripheral Inserted Central Catheter, is an intravenously placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava, and used for intravenous treatment that is required over a long period) placement done and staff did not verify PICC placement by calling the Radiologist to verify if the PICC line is okay to use.

This deficient practice had the potential for unsafe use of a PICC line that was not verified for proper placement which may result in complications such as intravenous infiltration (medication is absorbed in the tissues and not the blood), serious burns, scarring, nerve damage, etc. (Refer to A-0398)

6. The facility failed to ensure for one of 30 sampled patients (Patients 28), Patient 28's Norco (narcotic pain medication) was administered as ordered by the physician.

This deficient practice resulted in delay of treatment and had the potential to cause adverse health outcomes which could negatively affect Patient 28's health and safety due to unsafe medication administration and may lead to prolonged hospitalization. (Refer to A-0405)

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

Based on interview and record review, the facility failed to ensure fall precautions (actions taken to prevent a fall) were in place, in accordance with the facility's policy and procedure regarding fall reduction and precautions, at one of two facilities (Facility 1), for one of 30 sampled patients (Patient 3), who was a high fall risk (at high risk for falls) patient, when Patient 3's bed alarm (detect a patient's movement out of bed) was off at the time of the patient's (Patient 3) fall (an unintentional event that results in the person coming to rest on the ground or another lower level).

This deficient practice resulted in Patient 3 falling and sustaining a traumatic brain injury (TBI, when a sudden, external, physical assault damages the brain causing a disruption in the normal function of the brain).

Findings:

During an interview on 9/17/2014 at 2:50 p.m. with Registered Nurse (RN 4) 4, RN 4 stated the following: Patients are identified as low (not a fall risk), moderate or high risk for falls using the Morse fall scale (MFS, a rapid and simple method of assessing a patient's likelihood of falling). If a patient is moderate or high risk for falls, interventions are implemented including the bed alarm (detect a patient's movement out of bed).

During an interview on 9/19/2024 at 8:35 a.m. with Registered Nurse 10 (RN 10), RN 10 stated that he (RN 10) was the primary nurse for Patient 3 on 6/6/2024, when Patient 3 had a fall (an unintentional event that results in the person coming to rest on the ground or another lower level) and suffered a traumatic brain injury (TBI, when a sudden, external, physical assault damages the brain causing a disruption in the normal function of the brain).
RN 10 also said the following: After Patient 3 fell in the hallway, he (Patient 3) had no pulse, was resuscitated (to revive someone from unconsciousness or apparent death) by cardiopulmonary resuscitation (CPR, an emergency treatment that is done when someone's breathing or heartbeat has stopped), then transferred to the Intensive Care Unit (ICU, a unit in a hospital providing intensive care for critically ill or injured patients). He (RN 10) does not recall if Patient 3's bed alarm was on when he (RN 10) responded to the fall. The bed alarm is a high-pitched sound and if the alarm was going off, it would be noticeable. It is important to use the bed alarm for patients identified as a high fall risk for safety and so nearby staff can intervene to prevent a patient fall. Patient 3's fall was witnessed by the Painter Plant Operations (PPO).

During an interview on 9/19/2024 at 9:45 a.m. with the Monitor Tech/Unit Clerk (MTUC), the MTUC stated the following: She (MTUC) was at the nurse's station when she (MTUC) heard a yell and thump. She (MTUC) observed Patient 3 on the floor with visible bleeding from the head. She (MTUC) did not hear a bed alarm coming from Patient 3's room. The bed alarm is a loud sound that could have been heard by her (MTUC) from the nurse's station if alarming. The PPO was near Patient 3's room.

During an interview on 9/19/2024 at 10:43 a.m. with the PPO, the PPO stated the following: On 6/6/2024, he (PPO) was in front of Patient 3's room and witnessed Patient 3 fall. Patient 3 was standing in his (Patient 3's) room doorway for about 2 minutes. Patient 3 was looking and calling for the nurse when he (PPO) heard Patient 3 say "oh, shit" and fall onto the floor in the hallway hitting his head. Patient 3 had blood coming out of one ear in a flow. He (PPO) did not hear a bed alarm. If a bed alarm was going off, he (PPO) would have heard it and he (PPO) knows what it sounds like.

During a review of Patient 3's face sheet (gives information at a quick glance), the face sheet indicated Patient 3 was admitted to the facility on 5/24/2024 at 5:59 p.m.

During a review of Patient 3's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 5/24/2024, the H&P indicated Patient 3 had a history of end-stage-renal disease (ESRD, a chronic medical condition where a person's kidneys stop functioning on a permanent basis), cirrhosis (permanent scarring of the liver that causes an interference with its functioning) of the liver with ascites (a condition where fluid builds up in the abdomen, or belly, and can cause swelling), gangrene (when tissue in the body dies due to a lack of blood supply) of the right heel, and amputation (surgical removal of a body part or limb) of the 1st and 2nd toes of the left foot. Patient 3 presented to the facility on 5/24/2024 with a chief complaint of fluid overload (too much fluid in your body), gross ascites, and gangrene of the heel.

During a review of Patient 3's "Morse Fall Scale," dated 5/24/2024 at 6:01 p.m., the fall scale indicated Patient 3 had a score of 80, high fall risk, on admission. The fall scale further indicated Patient 3 had the bed alarm in use.

During a review of Patient 3's "Morse Fall Scale," dated 6/6/2024 at 8:00 a.m., the fall scale indicated Patient 3 had a score of 85, high fall risk. The fall scale further indicated Patient 3 had the bed alarm in use.

During a review of Patient 3's "Nurse Note," dated 6/6/2024 at 4:15 p.m., the note indicated the following: "1:10 p.m., Patient found on hallway floor by [MTUC] ... Blood noted on floor coming from nose and ears. Pulseless, apneic (temporary cessation of breathing), seizing (a sudden, uncontrolled episode of abnormal electrical activity in the brain). Code blue (a hospital emergency code that indicates a patient is in critical condition and needs immediate medical attention) initiated ..."

During a review of Patient 3's "neurosurgery consultation," dated 6/6/2024 at 4:34 p.m., the neurosurgery consultation indicated the following: " ...Traumatic brain injury with delayed recovery ... 43-year-old male who reportedly fell today and appears to have sustained a moderate traumatic brain injury ..."

During a review of the facility Policy and Procedure (P&P) titled, "Fall Reduction and Precautions," dated 12/2021, the P&P indicated: "Statement of Policy: Safety measures will be implemented for all patients identified as being at risk for falls . ... Definitions: B. Morse Scale ... High risk is greater than 45 ... Procedure: 2. Fall prevention interventions are to be implemented for patients identified as moderate or high risk ... 5. In addition to above strategies, for patients identified as high risk, implement high risk prevention interventions: d. consider use of bed alarms if appropriate..."

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

1. Ensure a baseline neurological (relating to the nervous system, which includes the brain, spinal cord, and nerves) pupil (the black opening in the middle of the colored part of your eye) assessment (systematic and continuous process of collecting, analyzing, and interpreting data to evaluate a patient's health) and ongoing neurological assessments were completed, per the Intensive Care Unit (ICU, a unit in a hospital providing intensive care for critically ill or injured patients) standard of care and Policy & Procedure, every two hours, for one of 30 sampled patients (Patient 3), when Patient 3 was transferred to the ICU.

This deficient practice had the potential for neurological changes not to be identified, resulting in delayed diagnosis or treatment of neurological changes, which may worsen the patient's (Patient 3) condition and prolong hospitalization.

2. Ensure the policies and procedures were implemented when:

2.a. Registered Nurse 9 (RN 9), who was assigned to the care of Patient 19, was observed coming out of the patient's (Patient 19) room wearing gloves after providing patient care.

This deficient practice had the potential for the introduction of pathogens (a microorganisms such as bacteria or virus that can cause a disease process) from RN 9 not performing hand hygiene and the potential for risk of transmission of microorganism to other patients and staff in the facility.

2.b. Patient 19's midline catheter (a thin, flexible tube inserted into a vein in the upper arm to deliver medication or fluids directly into the bloodstream) dressing did not have a label with the insertion date and the dressing was not changed every 7 days, in accordance with the facility's policy and procedure regarding intravenous (IV, into the vein) catheter management.

This deficient practice had the potential to result in Patient 19 developing bloodstream infection and other fatal complication that could negatively affect Patient 19's recovery.

2.c. Patient 20, who was on seizure (a sudden, uncontrolled burst of electrical activity in the brain) precaution, was observed with all the side rails x (times) 4 not padded, in accordance with the facility's policy and procedure regarding seizure precautions (safety measures to reduce the risk of harm to people who are at risk of having a seizure).

This deficient practice had the potential for Patient 20 to suffer from pain and injury during seizure activity.

2.d. Patient 20 and Patient 27, who were at risk for fall (an unintentional event that results in the person coming to rest on the ground or another lower level), were observed not wearing a fall risk armband (a yellow armband indicating the patient was at risk for fall) and Patient 27's bed was not in a low position, in accordance with the facility's policy and procedure regarding fall precautions (actions or interventions taken to reduce the risk of accidental falls).

This deficient practice had the potential to result in an unsafe care that may lead to Patients 20 and patient 27 suffering from a fall injury.

3. Ensure nursing staff followed the facility's "Transmission Based Precaution (a set of infection control measures used when a patient may be infected to prevent transmission) Policy," for one of 30 sampled patients (Patient 12), when Patient 12 was admitted to the facility with a diagnosis for COVID-19 (COVID-19 is caused by the SARS-CoV-2 virus. COVID-19 can cause mild to severe respiratory illness, including death) and staff did not properly discard Personal Protective Equipment (PPE, equipment used to prevent contagious infection from spreading, PPE examples include regular mask, N95 respirator mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles [a mixture of solid particles and liquid droplets found in the air]), gowns, gloves,) after providing care to Patient 12.

This deficient practice had the potential to spread infection to other staff members and patients in the unit, when a used N95 respirator mask is not discarded after each use.

4. Ensure nursing staffed followed the facility's "Peripherally Inserted Central Venous Catheter Policy" for one of 30 sampled patients (Patient 13) when Patient 13 had a PICC line (Peripheral Inserted Central Catheter, is an intravenously placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava, and used for intravenous treatment that is required over a long period) placement done and staff did not verify PICC placement.

This deficient practice had the potential for unsafe use of a PICC line that was not verified for proper placement which may result in complications such as intravenous infiltration (medication is absorbed in the tissues and not the blood), serious burns, scarring, nerve damage, etc.

Findings:

1. During a concurrent interview and record review on 9/18/2024 at 2:28 p.m. with the Charge Nurse 2 (CN 2) and the Director of Emergency Services and Critical Care (DES), the CN 2 verified the following information in Patient 3's medical record: The neurological (relating to the brain, spine and nerves) assessment (systematic and continuous process of collecting, analyzing, and interpreting data to evaluate a patient's health) documentation dated 6/6/2024 at 2:00 p.m. through 6/8/2024 at 11:59 p.m., indicated Patient 3's neurological assessments were not documented every 2 hours. The CN 2 stated the following: Patient 3's neurological assessments should have been documented at least every two hours per the Intensive Care Unit (ICU, a unit in a hospital providing intensive care for critically ill or injured patients) standard of care. However, this was not completed every two hours. It is important to perform neurological assessments per standards of care and document, to ensure neurological changes are identified and reported to the physician right away. If neurological assessments are not completed per the ICU standard of care, the patient can have a neurological decline.

During a concurrent interview and record review on 9/18/2024 at 3:00 p.m. with the Charge Nurse 1 (CN 1), the CN 1 stated the following should be documented within the medical record for neurological assessments: parameter (a limit that affects how something can be done), level of consciousness (describes a person's awareness, alertness, and how well they respond to attempts to get their attention), arousable to, neurological symptoms, speech pattern, eye opening, verbal response, motor response (muscle movement), Glasgow Coma Scale (GCS, a scale used to objectively describe the extent of impaired consciousness in all types of acute [sudden and severe in onset, and symptoms appear, change, or worsen quickly] medical and trauma (a sudden and severe physical injury that requires immediate medical attention] patients) total, pupils (the black opening in the middle of the colored part of your eye) size and reaction, strength (left upper extremity, left lower extremity, right upper extremity, right lower extremity), cough/gag reflex (reflex is to contract the throat to prevent a person from choking), and neurological comment. RN 1 verified Patient 3's neurological assessments were incomplete and not completed every 2 hours.

During a concurrent interview and record review on 9/19/2024 at 3:45 p.m. with the DES, the DES verified the following information in Patient 3's medical record: There was no baseline neurological assessment for pupil size and reaction upon transfer to the ICU on 6/6/2024 at 2:00 p.m. The neurological assessments dated 6/6/2024 at 2:00 p.m. through 6/8/2024 at 11:59 p.m. were documented every 4 hours. The DES stated the following: Patient 3 should have had a baseline pupil assessment when transferred to the ICU to establish a baseline for ongoing assessments to detect neurological changes. The baseline pupil assessment can be compared to ongoing assessments to determine if there is a worsening of condition and to trigger a notification to the physician. The physician should be notified of any pupil changes as soon as identified, as this can be an indication of neurological changes. The neurological assessments should have been documented every two hours.

During a review of Patient 3's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 5/24/2024, the H&P indicated Patient 3 had a history of end-stage-renal disease (ESRD, a chronic medical condition where a person's kidneys stop functioning on a permanent basis), cirrhosis (permanent scarring of the liver that causes an interference with its functioning) of the liver with ascites (a condition where fluid builds up in the abdomen, or belly, and can cause swelling), gangrene (when tissue in the body dies due to a lack of blood supply) of the right heel, and amputation (surgical removal of a body part or limb) of the 1st and 2nd toes of the left foot. Patient 3 presented to the facility on 5/24/2024 with a chief complaint of fluid overload (too much fluid in your body), gross ascites, and gangrene of the heel.

During a review of Patient 3's "Physical Assessment," dated 6/6/2024 at 2:00 p.m. through 6/9/2024 at 12:00 a.m., the physical assessment indicated Patient 3's neurological assessments were completed on the following dates and times: 6/6/2024 at 4:00 p.m., 8:00 p.m., and 11:59 p.m.; 6/7/2024 at 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m., 8:00 p.m., and 11:59 p.m.; 6/8/2024 at 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m., 8:00 p.m., and 11:59 p.m.

During a review of Patient 3's "Nurse Note," dated 6/6/2024 at 2:31 p.m., the nurse note indicated "Patient arrived in ICU ... 2:00 p.m., this Registered Nurse (RN) assumed care of patient at this time ..."

During review of a document provided by the facility, no date, titled "ICU/Critical Care Unit (CCU) Unit Standard of Practice," the standard of practice indicated that every two hours neurological checks were to be conducted and documented.

2.a. During a concurrent observation and interview on 9/18/2024 at 9:32 a.m. with the Corporate Director for Performance Improvement and Accreditation (CDPIA) and the Registered Nurse (RN 9) 9, in the Medical Surgical Unit (provides care to patients with various medical conditions who are not critically ill), RN 9 was observed walking out of Patient 19's room wearing gloves in his hands. RN 9 walked towards the portable computer, located outside of Patient 19's room, and started documenting in the portable computer with gloves on both hands. RN 9 stated he (RN 9) just finished administration of intravenous (IV, through the vein) medication to Patient 19.

During an interview on 9/18/2024 at 9:35 a.m., with RN 9, RN 9 stated he (RN 9) administered IV medication to Patient 19 and forgot to remove his gloves. RN 9 stated "I apologize for that, I need to remove gloves and perform hand hygiene to prevent infection to others."

During a review of the facility's policy and procedure (P&P) titled, "Hand Hygiene Policy," revised on 04/2022, the P&P indicated, "All health care staff is to perform hand hygiene when entering/exiting a patient room/cubicle/bay ...Hand hygiene is to be done a. before and after having direct contact with patients. b Before entering patient room/after leaving patient room. C. Before performing an aseptic task, i.e., IV starts/stops, dressing changes, medication preparation ...e. Remember to always perform hand hygiene after the removal of personal protective equipment, including gloves."

2.b. During a concurrent observation and interview on 9/18/2024 at 9:32 a.m., with Registered Nurse (RN 9) 9, Patient 19 was observed in bed with a midline catheter (a thin, flexible tube inserted into a vein in the upper arm to deliver medication or fluids directly into the bloodstream) on his right upper arm. The midline catheter dressing did not have a label. RN 9 stated Patient 19's midline dressing should have a label with the date the midline catheter was inserted and initial of the RN. RN 9 said the importance of dating a midline dressing was to know the time and day it was inserted or the last dressing change. RN 9 stated midline catheter dressing should be changed once a week.

During a review of Patient 19's "History & Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/8/2024, the H&P indicated Patient 19 was admitted to Facility 1 with a chief complaint of Covid-19 (respiratory illness caused by a virus), respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide [a waste product or gas that is breathed out after the body uses oxygen] in the body), seizure (uncontrolled jerking, loss of consciousness, blank stares, or other symptoms caused by abnormal electrical activity in the brain) and sepsis (a serious condition in which the body responds improperly to an infection and may progress to septic shock which is a life-threatening condition).

During a review of Patient 19's "Interventional Radiology" note, dated 9/9/2024, the note indicated Patient 19 had an order for Interventional Radiology (IR, medical specialty that uses minimally invasive procedure and imaging to diagnose and treat variety of condition) guided catheter (a flexible tube that can be inserted into the vein to deliver fluids, medications, or blood products directly into the bloodstream), insert midline stat (without delay) due to difficult IV (in the vein) access.

During a concurrent interview and record review on 9/19/2024 at 11:46 a.m. with Charge Nurse 1 (CN 1), CN 1 stated Patient 19's "PICC (Peripheral Inserted Central Catheter, is an intravenously placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava, and used for intravenous treatment that is required over a long period)/Mid Line Insertion," dated 9/9/2024 indicated, Patient 19's Midline catheter was placed on the patient's (Patient 19) right upper extremity.

During the same interview and record review on 9/19/2024 at 11:46 a.m. with CN 1, CN 1 stated, Patient 19's "IV/Invasive Line, Place/Manage - flowsheet," indicated Patient 19's midline dressing was changed on 9/18/2024 at 8 p.m. (total of 9 days since Patient 19's midline was inserted). CN 1 stated, Patient 19's midline catheter dressing should have been changed on 9/16/2024 (on the seventh day of insertion) to help prevent development of infection.

During an interview on 9/19/2024 at 11:50 a.m. with the Quality Review Nurse (QRN) 2, QRN 2 stated the Midline should be changed every 7 days.

During a review of the facility's Policy & Procedure (P&P) titled, "Peripherally Inserted Central Venous (PICC)," last reviewed in 4/2024, the P&P indicated, "A Midline catheter will be utilized for short or long-term peripheral access to the peripheral venous system for selected intravenous therapies and blood sampling ...Dressing Change and Site Care ...Procedure 2. Post insertion, change dressing every 7 days or in 24 hours if a gauze dressing was used."

2.c. During a concurrent observation and interview on 9/17/2024 at 1:56 p.m. with Registered Nurse 3 (RN 3), Patient 20 was observed in bed with side rails x (times) 4 raised, the two upper and one lower side rails were padded (with a blue blanket) and the one lower side rails had no pads. RN 3 stated, Patient 20's side rails x 4 should all have been padded for seizure (a sudden, uncontrolled burst of electrical activity in the brain) precaution.

During a review of Patient 20's "History & (and) Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/13/2024, the H&P indicated Patient 20 was admitted to Facility 1 for intercranial hemorrhage (bleeding within the skull). The H&P further indicated Patient 20 was brought in by ambulance to the Emergency Department (ED, provides treatment to patients in need of immediate care) following a fall (an unintentional event that results in the person coming to rest on the ground or another lower level) incident and Patient 20's plan included placing the patient on seizure precaution (safety measures taken before an individual experiences seizure).

During a concurrent interview and record review on 9/18/2024 at 11:20 a.m. with Charge Nurse (CN 1) and the Director of Emergency Services (DES), CN 1 stated, Patient 20's "Care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) document," dated 9/14/2024 indicated, seizure precautions were initiated. The interventions included padded bedrails with all four bedrails up and locked. The DES stated, Patient 20's siderails x 4 should all be padded to ensure patient safety in case of episode of patient convulsing (involuntary contraction of the muscles resulting in an uncontrolled shaking of the body).

During a review of the facility policy and procedure (P&P) titled, "Seizure Precautions," revised in 01/2024, the P&P indicated, "Obtain seizure pads from Sterile Processing Department (SPD)/Central Services (CS) and pad side rails on bed, assuring that the bed controls are accessible. Keep (4) side rails up at all times."

2.d.
1. During a concurrent observation and interview on 9/17/2024 at 1:45 p.m. with the Director of Neuro Science Unit (DNSU), Patient 20's room was observed to have a "falling star" signage by the door. The DNSU stated the falling star signage indicated the patient was at risk for fall (an unintentional event that results in the person coming to rest on the ground or another lower level). The DNSU stated fall risk intervention included a bed alarm, the falling star magnet and the patient should have a fall risk arm band and yellow socks. In addition, Patient 20 was observed not wearing a fall wrist arm band.

During an interview on 9/17/2024 at 1: 56 p.m. with Registered Nurse 3 (RN 3), RN 3 stated, Patient 20 should have a yellow Fall Risk armband to indicate the patient (Patient 20) was at risk for fall.

During a review of Patient 20's "History & (and) Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/13/2024, the H&P indicated, Patient 20 was admitted to Facility 1 with a chief complaint of intracranial hemorrhage (bleeding within the skull). The H&P further indicated Patient 20 was brought in by ambulance to the Emergency Department (ED, provides treatment to patients in need of immediate care) following a fall incident.

During a review of Patient 20's "Care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) document," the care plan indicated, Patient 20's fall prevention intervention included "fall risk wristband on."

During a concurrent interview and record review on 9/18/2024 at 11:20 a.m. with Charge Nurse (CN 1), Patient 20's "Morse Fall Scale -Assessment," dated 9/15/2024 through 9/18/2024, indicated, Patient 20's Morse Fall Scale (a tool use for patient to identify risk factors for falls) was 75 (above 45 is high risk). CN 1 stated, Patient 20 was a high risk for fall. CN 1 said the importance of yellow Fall Risk armband was for everyone to identify patients who were at risk for fall to ensure patient safety.

During a review of the facility's policy and procedure (P&P) titled, "Fall Reduction and Precautions," revised in 12/2021, the P&P indicated, "For Patient identified as moderate risk, implement moderate fall risk prevention interventions when able ...Apply yellow Fall Risk armband ...In addition to above strategies, for patients identified as high risk, implement high risk prevention interventions ..."

2. During a concurrent observation and interview on 9/17/2024 at 3:25 p.m. with Registered Nurse (RN 5) 5, Patient 27's room was observed to have a falling star signage magnet (symbol magnet that the hospital adopts for the fall risk patient) located at the patient's (Patient 27) room door. In addition, Patient 27 was observed in bed, awake, and oriented to name. RN 5 stated Patient 27 has a Morse fall scale (is a rapid and simple method of assessing a patient's likelihood of falling) score of 50. RN 5 said a patient is considered high fall risk if the score was 45 or greater. RN 5 stated for the patient that was high risk for fall, the patient should have a fall armband. RN 5 verified Patient 27 did not have the fall armband.

During the same observation and interview on 9/17/2024 at 3:25 p.m. Patient 27's bed was observed to be in a high position, to the level of the waistline. RN 5 stated Patient 27's bed was on a high position. RN 5 stated Patient 27's bed should be in a low bed position to ensure safety and prevent fall.

During a concurrent interview and record review on 9/18/2024 at 2:17 p.m. with Quality Review Nurse (QRN 2), QRN 2 stated the patient's "History & Physical (H & P, a formal and complete assessment of the patient and the problem)" dated 9/15/2024, indicated, Patient 27 was admitted to the facility for Shortness of Breath (difficulty breathing) and hypoxia (absence of enough oxygen in the tissues to sustain bodily functions).

During the same interview on 9/18/2024 at 2:17 p.m. with QRN 2, the QRN 2 stated Patient 27's "Morse Fall Scale," dated 9/17/2024 indicated a score of 50 (high fall risk). Patient 27's Morse fall scale intervention included "fall risk armband on" and "bed in low position."

During a review of the facility's policy and procedure (P & P) titled, "Fall Reduction and Precautions," dated 12/2021, the P & P indicated, "...for patients identified as moderate risk, implement moderate fall risk prevention interventions, when able: ...apply yellow fall risk armband ...maintain bed in low position with wheels locked ...In addition to above strategies, for patients identified as high risk, implement high risk prevention interventions."


3. During a review of Patient 12's "Face Sheet (document that gives a patient's information at a quick glance and includes the patient's name, date of birth, address, etc.)," dated 9/15/2024, the Face Sheet indicated Patient 12 was admitted to the facility on 9/15/2024 at 5:57 p.m. for being COVID (respiratory illness caused by a virus) positive and "Hard time to breathe."

During a review of Patient 12's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/15/2024, the "H&P" indicated the following: Patient 12 with a history of weakness and fatigue (a feeling of tiredness or lack of energy that interferes with daily activities). Chief Complaint of having COVID.

During a review of Patient 12's "ED Nurse Note," dated 9/15/2024, the ED Nurse Note indicated the following: "Patient 12 is alert and oriented (a person's level of awareness of their surroundings, including time, place, and identity), and COVID precautions (interventions to prevent the spread of infection) in place with ongoing plan of care."

During a review of Patient 12's "Infection Control Note," dated 9/16/2024, the "Infection Control Note" indicated the following: "Patient 12 is on isolation precaution (a set of measures used to prevent the spread of germs and infectious agents in healthcare settings) with positive COVID results confirmed. N-95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles [a mixture of solid particles and liquid droplets found in the air]) required for all high-risk procedure. Limit the number of health care workers attending to patient. Contact & Droplet Isolation."

During a review of Patient 12's "Care Plan (provides a framework for evaluating and providing patient care needs related to the nursing process)," dated 9/16/2024, the Care Plan indicated the following: Patient 12 has a care plan for SARS-CoV-2 (virus that causes COVID), COVID-19 Infection care plan was started on 9/16/2024 and targeted dated outcome on 9/21/2024. The care plan also indicated to maintain isolation precaution for SARS-CoV-2 until cleared per isolation discontinuation guidelines.

During a concurrent observation and interview on 9/17/2024 at 3:10 p.m. with Registered Nurse (RN 18) 18, in the Anteroom (small room leading to a patient's main room, a room used for Personal Protective Equipment [PPE] donning and doffing) of Patient 12's room, a N95 mask (respirator mask used to protect from airborne infection) was observed with a name written on top of the N95 mask, was observed lying on top of the counter in the anteroom. RN 18 stated the following: Confirmed N95 mask on the counter belonged to RN 18 and had a written name on the N95 mask. Wrote name on the N95 mask to know the N95 mask belongs to RN 18. Confirmed RN 18 reuses N95 mask and does not discard N95 mask after each use or visit to Patient 12. Been doing this for a while. Confirmed Patient 12 was on airborne (a mixture of solid particles and liquid droplets found in the air) isolation for positive COVID results and needed to wear N95 mask when caring for Patient 12

During an interview 9/17/2024 at 3:17 p.m. with the Corporate Director of Nursing (CDN 1) 1, CDN 1 stated the following: CDN 1 confirmed that the anteroom for Patient 12 had N95 mask with written name by RN 18, lying on top of the counter. CDN 1 confirmed having heard RN 18 stated N95 mask belonged to RN 18 and was not discarded after each use. RN 18 was not following infection control policy for COVID patients. RN 18 should be discarding N95 mask after each use and getting a new mask when entering Patient 12's room. It is an infection control risk for not following infection control policy. Will educate staff about donning (putting on) and doffing (taking off) PPE (Personal Protective Equipment, equipment used to prevent contagious infection from spreading, PPE examples include regular mask, N95 respirator mask [a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles]). Confirmed the facility had plenty of N95 mask for staff to use.

During an interview 9/18/2024 at 10:05 a.m. with the Infection Preventionist (IP) 1, IP 1 stated the following: Patient confirmed to have COVID, the staff should not be reusing N95 mask, should be discarding N95 mask after exiting room of the COVID positive patient. Reusing N95 mask can potentially spread infection. "We have plenty of PPE for staff. We will be providing Inservice education for staff on PPE training donning and doffing."

During a concurrent interview and record review on 9/18/2024 at 4:25 p.m. with the Corporate Director of Nursing (CDN 1) 1, the facility's policy and procedure (P&P) titled, "Transmission Based Precaution Policy," dated October 2023 was reviewed. The P&P indicated, Policy: Transmission based precautions (airborne, droplet and contact) will be used when caring for patients documented with or suspected of being infected with highly transmissible or epidemiologically significant organisms to prevent the transmission of these organisms. MASK OR RESPIRATOR: Front of mask/respirator is contaminated - DO NOT TOUCH! If your hands get contaminated during mask/respirator removal, immediately wash your hands or use an alcohol-based hand sanitizer. Grasp bottom ties or elastics of the mask/respirator, then the ones at the top, and remove without touching the front. Discard in a waste container." The CDN 1 stated the following: This is the policy staff should be following for donning and doffing PPE. N95 mask should be discarded not reused. Staff did not follow it, should discard N95 mask. Will provide education to staff regarding PPE donning and doffing.

4. During a review of Patient 13's "Face Sheet (document that gives a patient's information at a quick glance and includes the patient's name, date of birth, address, etc.)," dated 9/13/2024, the Face Sheet indicated, Patient 13 was admitted to the facility on 9/13/2024 at 3:09 p.m. During a review of Patient 13's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/13/2024, the "H&P" indicated the following: Patient 13 with a history of Arterial Bleed (the most severe and urgent type of bleeding), Acute Kidney Injury (when the kidneys suddenly lose their ability to filter waste from the blood), and Lung Cancer (a disease that occurs when cells in the lungs grow out of control and form a tumor [a mass of abnormal cells in the body]).

During a review of Patient 13's "Intraoperative Report," dated 9/11/2024 (performed at Facility 1 before Patient 13 was transferred to Facility 2 [sister facility]), the Intraoperative Report indicated the following: Patient 13 with PICC (Peripheral Inserted Central Catheter, is an intravenously placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava, and used for intravenous treatment that is required over a long period) line placement to the Left Upper Arm.

During a review of Patient 13's "Assessment Flowsheet," dated 9/13/2024 to 9/16/2024, the Assessment Flowsheet indicated the following: PICC line was used on 9/13/2024 to 9/16/2024 for Chemotherapy and fluid medication infusion. No documentation by nurses notifying the primary medical doctor or radiologist verifying PICC line was ok to use.

During a concurrent interview and record review on 9/18/2024 at 10:20 a.m. with the Quality Review Nurse (QRN 4) 4, Patient 13's "Xray (used to generate images of structures inside the body for diagnostics) Report," dated 9/11/2024, was reviewed. The Xray report indicated, on 9/11/2024, Xray was done with a position location of the PICC line placement noted and with no documentation indicating "Ok to use" PICC line. QRN 4 stated the following: Confirmed there was no documentation "Ok to use" PICC line documented in the Xray report.

During an interview 9/18/2024 at 10:46 a.m. with the PICC Registered Nurse (PRN 1) 1, PRN 1 stated the following: PRN 1 confirmed placing PICC line for patients in the hospital. Chest Xray was done after placement of PICC line to patients and the radiologist will report "ok to use" PICC line. The nurses on the unit will know if the PICC line is ok to use based on the reading in the Xray report with the positioning of the PICC line.

During a concurrent interview and record review on 9/18/2024 at 3:59 p.m. with the Director of Intensive Care Unit (DICU) 1, the facility's policy and procedure (P&P) titled, "Peripherally Inserted Central Venous Catheter Policy," dated 2024 was reviewed. The P&P indicated, "Confirm the placement of the catheter tip before initiating infusion therapy. Radiologist to read x-ray and state "ok to use." The DICU 1 stated the following: Radiology Xray report should indicate from the Radiologist "Ok to use PICC line." Confirmed P&P for PICC Line was not being followed and will educate the staff. Nursing staff will not know location of the PICC line based off the Xray reading of the Radiologist and not know when it was ok to use or not if it was not documented by the Radiologist.

During a concurrent interview and record review on 9/18/2024 at 4:18 p.m. with the Corporate Director of Nursing (CDN) 1, the facility's policy and procedure (P&P) titled, "Peripherally Inserted Central Venous Catheter Policy," dated 2024, was reviewed. The P&P indicated, "Confirm the placement of the catheter tip before initiating infusion therapy. Radiologist to read x-ray and state "ok to use." The CDN 1 stated the following: MD reading the X ray report have to put "Ok to use" PICC line in the Xray reading report. The nurses on the floor will not know based on the documentation of the PICC line if ok to use it. Radiologist not following PICC line P&P, will educate staff.

During an interview 9/19/2024 at 2:31 p.m. with Professional Developer Nursing Education (PDNE) 1, PDNE 1 stated the following: PICC line education for nurses happens during orientation. There is no training for nurses to read X ray reports and determine if it is "ok to use" PICC line. Nursing cannot determine correct PICC line position based off the X ray readings. It is up to the physician to determine "Ok to use" PICC line. Nurses need to get "Ok to use" confirmation from the doctors prior to using the PICC line.

During a review of the

Based on interview and record review, the facility (Facility 1) failed to ensure for one of 30 sampled patients (Patients 28), Patient 28's Norco (narcotic pain medication) was administered as ordered by the physician.

This deficient practice resulted in delay of treatment and had the potential to cause adverse health outcomes which could negatively affect Patient 28's health and safety due to unsafe medication administration and may lead to prolonged hospitalization.

Findings:

During a review of Patient 28's "Neurointerventional Consult Note," dated 9/17/2024, the Neurointerventional Consult Note indicated Patient 28 was admitted to Facility 1 after a surgical procedure of an anterior (in front of) cervical (relating to the neck) discectomy (surgical removal of abnormal disc material) and fusion (ACDF, a surgical procedure that treats spinal cord or nerve root compression in the neck.)

During a review of Patient 28's "Medication Administration Report (MAR)," dated 9/17/2024, the MAR indicated a physician's order for Patient 28 to receive the following:

- Norco 7.5/325 milligram (mg, a unit of measurement) 1 tablet by mouth every 4 hours as needed (PRN) for moderate pain (pain score 4-6 is moderated pain) with a start date of 9/17/2024; and,

- Norco 10/325 mg 1 tablet by mouth every 4 hours PRN for severe pain (pain score 7-10 is severe pain) with a start date of 9/17/2024.

During a concurrent interview and record review on 9/18/2024 at 2:52 p.m. with Registered Nurse (RN 7) 7, RN 7 verified that Patient 28's MAR indicated on 9/17/24 at 6:38 p.m., Patient 28 was given Norco 7.5/325 mg 1 tablet by mouth (ordered for moderate pain). The corresponding pain assessment indicated Patient 28's pain score was 8 (severe pain).

During the same interview on 9/18/2024 at 2:52 p.m., RN 7 stated it was important to give the right medication based on the patient's (Patient 28) pain score assessment to manage the patient's pain. RN 7 confirmed Patient 28 received Norco 7.5/325 mg 1 tablet by mouth that was ordered for moderate pain, Patient 28 should have been given pain medication as ordered for severe pain

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," dated 02/2022, the P&P indicated, "Before administering a medication, the licensed independent practitioner or qualified individual administering the medication shall follow the seven (7) right of medication administration. Medications must be administered as ordered."