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A. Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #25) clinical records reviewed for restraints, the Hospital failed to ensure that the required maximum time limits for each order of restraints for the management of violent behavior was followed.

Findings include:

1. On 12/1/2021, the Hospital's policy titled, "Use of Restraints Policy and Procedure" (reviewed by the Hospital on 7/2020) was reviewed and included, "... may only be renewed in accordance with the following limits for up to a total of 24 hours: a) 4 hours for adults 18 years of age or older..."

2. On 12/1/2021, the clinical record of Pt. #25 was reviewed. Pt. #25 was a 24 year-old patient who was brought to the Hospital's ED (emergency department) on 6/18/2021 with a diagnosis of schizoaffective disorder. The clinical record indicated that Pt. #25 was placed in soft wrist/ankle restraints on 6/18/2021 at 1:30 PM, and on 4 point velcro restraints on 6/19/2021 at 5:45 PM due to violent/self destructive behaviors. The maximum time limit reflected on each order to place Pt. #25 in restraints was for 24 hours instead of the required 4 hours.

3. On 12/1/2021 at approximately 11:30 AM, and on 12/2/2021, at approximately 11:30 AM, findings were discussed with E #8 (ED Manager) and E #9 (RN Informatics/Nurse Educator). E #8 confirmed that Pt. #25 was placed in restraints due to violent behaviors on 6/18/2021 and on 6/19/2021. E #9 confirmed that the order to place Pt. #25 in restraints due to violent behavior was for 24 hours. E #9 stated that use of restraints is not according to patient's age.

B. Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #25) clinical records reviewed for restraints, the Hospital failed to ensure that the requirement regarding the continued use of restraints was followed.

Findings include:

1. On 12/1/2021, the Hospital's policy titled, "Use of Restraints Policy and Procedure" (reviewed by the Hospital on 7/2020) was reviewed and included, "... Violent or Self Destructive Behavior ... Guidelines... 8. Restraint Orders for Management of Violent Behavior..At the end of the time frame, if the continued use of restraint to manage violent or self destructive behavior is deemed necessary based on an individualized patient assessment, another order is required."

2. On 12/1/2021, the clinical record of Pt. #25 was reviewed. The clinical record indicated that Pt. #25 was placed in soft wrist/ankle restraints on 6/18/2021, from 1:30 PM through 6:00 PM, for violent/self destructive behavior (4 hours and 30 minutes). The clinical record lacked documentation that another order was obtained for the continued use of restraints.

3. On 12/2/2021, at approximately 11:30 AM, findings were discussed with E #9 (RN Informatics/Nurse Educator). E #9 stated that the order obtained to place Pt. #25 in restraints was for 24 hours.

Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #25) clinical records reviewed for restraints, the Hospital failed to ensure that restraints were discontinued at the earliest possible time.

Findings include:

1. On 12/1/2021, the Hospital's policy titled, "Use of Restraints Policy and Procedure" (reviewed by the Hospital on 7/2020) was reviewed and included, "... Violent or Self Destructive Behavior...Guidelines... 11... Restraints must be discontinued at the earliest possible time, regardless of the length of time identified in the order..."

2. On 12/1/2021, the clinical record of Pt. #25 was reviewed. Pt. #25 was brought to the Hospital's ED (Emergency Department) on 6/18/2021 with a diagnosis of schizoaffective disorder. The clinical record indicated that Pt. #25 was placed in soft wrist/ankle restraints due to violent or self destructive behaviors on 6/18/2021 from 1:30 PM through 6:00 PM. The clinical record indicated that Pt. #25 was sleeping at 2:30 PM and at 5:20 PM.

3. On 12/2/2021, at approximately 11:30 AM, findings were discussed with E #9 (Nurse Informatics/Nurse Educator). E #9 stated that the restraints should have been taken out at the earliest possible time.

Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #25) clinical records reviewed for restraints, the Hospital failed to ensure that the patient was monitored every-15 minutes, as required.

Findings included:

1. On 12/1/2021, the Hospital's policy titled, "Use of Restraint Policy and Procedure" (reviewed by the Hospital on 7/2020) was reviewed and required, "... The nurse initiating restraint will follow the appropriate course of action described below: Procedure... 2. Restraint for Violent or Self-Destructive Behavior... e. Patients in restraint for violent or self destructive behavior will also have nutrition/hydration hygiene/elimination, safety, circulation, movement, mental status, cognitive functioning, sensation and readiness for discontinuation of restraints assessed every fifteen minutes... with appropriate documentation on the Restraint documentation in the patient's medical record."

2. On 12/1/2021, the clinical record of Pt. #25 was reviewed. Pt. #25 was brought to the Hospital's ED (Emergency Department) on 6/18/2021, with a diagnosis of schizoaffective disorder. The clinical record indicated:

- Pt. #25 was placed in restraints on 6/18/2021, from 1:30 PM through 6:00 PM, due to violent behaviors. The clinical record lacked the required every-15 minutes monitoring from 1:45 PM through 3:15 PM, and from 3:45 PM through 5:15 PM (1 hour and 30 minutes respectively).

- Pt. #25 was placed in restraints on 6/19/2021 from 5:45 PM through 7:27 PM, due to violent behaviors. The clinical record lacked the required every-15 minutes monitoring from 6:00 PM through 7:15 PM (1 hour and 15 minutes).

3. On 12/2/2021 at approximately 11:30 AM, findings were discussed with E #9 (Nurse Informatics/Nurse Educator). E #9 stated that Pt. #25 was monitored every two hours while in restraints due to violent behavior. E #9 stated that she is not sure about the restraints policy in the ED.

Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #25) clinical records reviewed for restraints, the Hospital failed to document the required elements of the face-to-face evaluation 1 hour after the initiation of restraints.

Findings include:

1. On 12/1/2021, the Hospital's policy titled, "Use of Restraint Policy and Procedure" (reviewed by the Hospital on 7/2020) was reviewed and required, "... Violent or Self-Destructive Behavior... Level of Responsibility: RN (Registered Nurse), MD (Physician), Other Licensed Practitioners. Guidelines... 15. One-Hour Assessment Components: When restraint is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within (1) hour after the initiation of the intervention to evaluate: 1) The patient's immediate situation; b) The patient's reaction to the intervention; c) The patient's medical and behavioral condition; and, d) The need to continue or terminate the restraint...19. Requirement for documentation in the patient's medical record when Restraint is Used: a) The (1) hour face-to-face medical and behavioral evaluation if restraint is used to manage violent or self-destructive behavior..."

2. On 12/1/2021, the clinical record of Pt. #25 was reviewed. Pt. #25 was brought to the Hospital's ED on 6/18/2021, with a diagnosis of schizoaffective disorder. The clinical record indicated that Pt. #25 was placed in soft wrist/ankle restraints due to violent or self destructive behaviors on 6/18/2021, from 1:30 PM through 6:00 PM, and on 6/19/2021, from 5:45 PM through 7:27 PM. The clinical record lacked documentation of the required elements of the face-to-face evaluation 1 hour after the initiation of restraints.

3. On 12/2/2021, at approximately 11:30 AM, findings were discussed with E #9 (RN Informatics/Nurse Educator). E #9 stated that Pt. #25's clinical record lacked documentation of the required face-to-face evaluation 1 hour after initiation of the restraints.

Based on document review and interview, it was determined that for 3 of 3 quarterly reviews (January through March, April through June, and July through September) of data collected regarding Patients' Experience in 2021, the Hospital failed to take actions, measure its success, and track performance to ensure that improvements are sustained. This potentially affected an average daily census of 38 patients.

Findings include:

1. On 12/1/2021, the Hospital's Quality Assessment and Performance Improvement (QAPI) Plan for 2021 was reviewed. The plan included, "Purpose: The purpose of the... (QAPI) Plan is (to) provide a formal mechanism by which the (Name of the Hospital) utilizes objective measures to monitor and evaluate the quality of services provided to patients... III. Data Collection and Analysis... Implementation of Actions... Implementation begins and re-measurement occurs in actions if the desired outcome is not achieved... V. Scope of Activities... (Name of the Hospital) takes actions aimed at performance improvement and, after implementing those actions, it measures its success, and track performance to ensure that improvements are sustained... The 2021 QAPI areas of focus include... C. Improve Patient Experience..."

2. On 12/1/2021, the Hospital's meeting minutes and dashboard from January through October 2021, were reviewed. The QAPI Program dashboard indicated that the Hospital's performance for Elements of Patients Experience e.g., Communication with Nurses, Responsiveness of Hospital Staff, Communication with Doctors, Hospital Environment, Communication About Medicines, Discharge Information, and Care Transitions were below the Hospital's benchmark from January through September 2021. The meeting minutes dated October 19, 2021, included, "... 2. Goals still not met during the 3rd quarter... Patient Experience... No new initiatives to improve patient experience currently..."

3. On 12/1/2021, at approximately 2:30 PM, findings were discussed with E #6 (Director of Quality). E #6 stated that the Hospital has not formally written a plan regarding the Hospital's new initiatives to address the problem. E #6 said that the current plan of action was from last year (2020).

Based on document review and interview, it was determined that for 2 of 2 patients' (Pt. #15 and Pt. #16) clinical records reviewed in the Clinical Dependency Unit (CDU), the Hospital failed to reassess and document response to PRN (as needed) medications, to ensure a Registered Nurse evaluated the care for each patient.

Findings included:

1. On 11/30/2021 , the clinical record of Pt. #15 was reviewed. Pt. #15 was admitted to the Hospital's CDU on 11/28/2021, with a diagnosis of opioid use withdrawal. The clinical record included a physician's order for Xanax (anti-anxiety medication) 2 mg (milligrams) as needed, two times a day for anxiety/restlessness. The clinical record indicated that Pt. #15 was given Xanax on 11/29/2021 at 9:30 AM. There was no documentation of a nursing reassessment regarding Pt. #15's response to Xanax.

2. On 11/30/2021, the clinical record of Pt. #16 was reviewed. Pt. #16 was admitted to the Hospital's CDU on 11/25/2021, with a diagnosis of opioid dependence. The clinical record included a physician's order for Ativan (anti-anxiety medication) 1 mg four times a day, as needed for anxiety and restlessness. The clinical record indicated that Pt. #16 was given Ativan on 11/29/2021 at 6:33 PM. There was no documentation of a nursing reassessment regarding Pt. #16's response to Ativan.

3. On 11/20/2021,the Hospital's policy titled, "Medication Administration" (dated 4/28/2021) was reviewed and included, "Purpose: To provide a comprehensive approach to the hospital medication administration process, complying with requirements under the Nursing... Condition of Participation... IV... E. Documentation... 2. If giving PRN medication, document assessment and the patient's response in the patient record..."

4. On 12/1/2021, the Hospital's job description for Registered Nurses (undated), was reviewed and included, "Directs and supervises patient care activities... Performance expectations... 2. Adheres to Hospital/Departmental Policies..."

5. On 12/1/2021, at approximately 11:00 AM, findings were discussed with E #7 (Director of CDU). E #7 could not provide documentation to indicate that a nurse reassessed the patients' response to PRN medications given.

A. Based on document review, observation and interview, it was determined that the Hospital failed to manage daily dietary services by not ensuring that foods were labeled with an opened or use-by date. This has the potential to affect the fifty patients receiving oral diets on 11/30/2021.

Findings include:

1. On 11/30/2021, the Hospital's policy titled, "Rotation of Food FIFO (first in first out) Policy" (reviewed 2020) was reviewed and required, "...All items that have been opened are labeled with the contents, date and expiration date on the product..."

2. A tour of Dietary Services was conducted on 11/30/2021 at 11:15 AM. The following was observed:
- The walk in refrigerator #1 contained one tray of turkey burgers was not labeled with expiration date of 11/26 one tray of chicken with the expiration date of 11/26/21, cheese with expiration dated 11/5/21, open sweet soy sauce that was not labeled with the date opened or use-by date, 4 bags of rolls that was not labeled with date opened or use-by date, 2 bags of bagels that were not labeled with the date opened or use-by date, 2 packages of muffins that were not labeled with the date opened or use-by date and a container of celery with expiration date 11/24/21.
-The walk in refrigerator #2 contained 10 gelatins and 2 pieces of pie that were not labeled with the date opened or use-by date.
-The storage freezer contained one open bin of diced chicken with expiration date of 11/26.

3. On 11/30/2021 at 11:45 AM, an interview was conducted with the Dietary Production Manager (E #4). E #4 stated that all food items should be labeled with the date opened or use-by date.


B. Based on document review, observation and interview, it was determined that the Hospital failed to manage daily dietary services by not ensuring the foods which had expired were discarded. This had the potential to affect the fifty (50) patients receiving oral diets on 11/30/2021

Findings include:

1. On 11/30/2021, the Hospital's policy titled, "Rotation of Food" (reviewed 2020) was reviewed and required, "...Items that have been outdated are thrown away in the trash..."

2. A tour of Dietary Services was conducted on 11/30/2021 at 11:15 AM. The following was observed:
- The dry storage area contained 2 boxes of corn bread with expiration date 8/26/2021 and 4 bags of cornmeal with expiration date 9/25/2021.

3. On 11/30/2021 at 11:45 AM, an interview was conducted with the Dietary Production Manager (E #4). E #4 stated that food should be discarded according to the use date/expiration date.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted on November 30, 2021 and December 1, 2021 the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted on November 30, 2021 and December 1, 2021 the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

A. Based on observation, document review, and interview, it was determined that for 1 of 1 IV (intravenous) poles stationed in the Radiology Department, the Hospital failed to ensure staff adherence to infection and control policies to prevent cross contamination as required.

Findings include:

1. On 11/30/2021, at approximately between 1:15 PM - 2:00 PM, an observational tour of the Radiology Services was conducted. During the tour, one (1) IV pole stationed in the ultrasound room was observed, with one unlabeled, opened one liter bag of IV saline solution hanging with tubing connected.

2. The Hospital's policy titled, "Pharmaceutical Waste Management Policy and Procedure (revised 5/20)" was reviewed and required, "...All pharmaceutical and hazardous waste will be disposed of in a way that minimizes the impact on the environment...Purpose: To ensure all pharmaceutical waste, including hazardous waste is properly and safely managed...7. Non-hazardous pharmaceutical waste including: all large volume intravenous bags containing only saline...can be disposed of in a sink.

3. On 12/01/2021, at approximately 1:09 PM, an interview was conducted with E #11/Radiology Supervisor. E #11 stated, "The IV bag was used for a previous patient during an ultrasound. The nurse accompanying the patient left it there."

4. On 12/02/2021, at approximately 2:15 PM, an interview was conducted with E #6 Director of Quality/Interim Infection Control Manager stated, "The IV bag should not have been left sitting there, it should have been removed."

B. Based on documentation review and interview, it was determined that for 3 of 4 in-patient clinical record reviewed for isolation precautions, the Hospital failed to ensure staff adherence to prevention of spread of nosocomial infection as required.

Findings include:

1. On 12/02/2021, the Hospital's policy titled, "Isolation Precaution Policy" (reviewed by the Hospital 04/2020) was reviewed and required, " ...1. Isolation precautions will be used to prevent transmission of disease to patients, healthcare workers, and others...A. Procedure for isolation of patients....2. Isolation precaution is documented in the system under isolation checklist and infection control report.

2. The clinical record of Pt. # 9 was reviewed on 12/02/2021. Pt. #9 was admitted on 11/19/2021, with a diagnosis of Covid-19 (respiratory infection) and Urinary Tract Infection. The clinical record indicated that Pt. #9 was placed in isolation precautions on 11/19/2021, for diagnosis of Covid-19. The clinical record lacked documentation of isolation checklist and infection control report.

3. The clinical record of Pt. #31 was reviewed on 12/02/2021. Pt. #31 was admitted on 11/04/2021, with a diagnosis of Respiratory Distress. The clinical record indicated that Pt. #31 was placed in isolation precautions on 11/04/2021 for diagnosis of rule-out Covid. The clinical record lacked documentation of isolation checklist and infection control report.

4. The clinical record of Pt. #32 was reviewed on 12/02/2021. Pt. #32 presented to the emergency department on 11/26/2021 for complaints of shortness of breath and was admitted with a diagnosis of Renal Failure on 11/27/2021. The clinical record indicated that Pt. #32 was placed in isolation precautions on 11/26/2021, for diagnosis of rule-out Covid. The clinical record lacked documentation of isolation checklist and infection control report.

5. On 12/02/2021 at approximately 2:10 PM, the findings were discussed with the Director of Quality/Interim Infection Control Manager/E #6. E #6 stated, "The infection control checklist and infection control reports are missing, they are suppose to be completed upon initiation of isolation."

C. Based on documentation review and interview, it was determined that for 2 of 2 in-patient clinical records reviewed for central line monitoring, the Hospital failed to ensure staff adherence to prevention of spread of nosocomial infection as required.

Findings include:

1. On 12/01/2021, the Hospital's policy titled, "Insertion and Care of Central Venous Catheters (reviewed by the Hospital 04/2020)" was reviewed and included, "...To reduce the patient's risk of acquiring an intravascular catheter-related infection... 1. When inserting a central venous artery catheter, maximal sterile barrier precautions are recommended... Post Procedure... 12. The nurse assisting the physician will complete the central line insertion monitoring tool.

2. The clinical record of Pt. #9 was reviewed on 12/01/2021. Pt #9 was admitted on 11/19/2021, with a diagnosis of Covid-19 and Urinary Tract Infection. The clinical record indicated that Pt. #9 had a central line placed on 11/28/2021. However, the clinical record lacked documentation of the central line insertion monitoring tool.

3. The clinical record of Pt. #10 was reviewed on 12/01/2021. Pt. #10 was admitted on 11/18/2021, with a diagnosis of Diabetic Ketoacidosis (production of excess blood ketones) and Sickle Cell Crisis. The clinical record indicated that Pt. #10 had a central line placed on 11/18/2021. However, the clinical record lacked documentation of the central line insertion monitoring tool.

4. On 12/01/2021, at approximately 2:00 PM, an interview was conducted with the Chief Nursing Executive/E #2. E #2 stated the central line monitoring tool is used Hospital-wide and should be completed whenever a central line catheter is placed.

5. On 12/02/2021, at approximately 2:15 PM, the findings were discussed with the Director of Quality/Interim Infection Control Manager/ E #6. E #6 stated, "The central line insertion monitoring tool wasn't completed for these patient's, it should have been completed.

Based on document review and interview, it was determined that for 2 of 2 (Pt. #28 and Pt. #29) clinical records reviewed for organ and procurement, the Hospital failed to ensure that timely notification was made to the organ procurement organization (OPO) for individuals who have died in the hospital.

Findings include:

1. The "Organ and Tissue Procurement Agreement" was reviewed and required, "This Organ and Tissue Procurement Agreement ... and (Name of Hospital) effective as of 1st day of July, 2014 ... 1.11 ... Timely Notification for Organ Donation means notification by telephone to Gift of Hope (GOH) prior to declaration of brain death, or when patient meets the Clinical Trigger criteria for Imminent Death ... Even if Hospital does not consider an individual to be a Potential Donor, Hospital must notify Gift of Hope as soon as possible after the Death of that individual. Timely notification will allow GOH to evaluate patients for donation ..."

2. The Hospital's policy titled, "Organ and Tissue Donation" (revised 11/16) was reviewed and required, "... At the Time of Death or Near (Imminent) Death... A. Contact the Donor Hotline... for every death..."

3. The clinical record of Pt. #28 was reviewed on 12/2/2021. Pt. #28 was admitted on 11/07/2021 with diagnosis of shortness of breath/COVID-19. The clinical record included the following:

-Physician Progress note dated 1/20/2021 at 10:04 AM, "A code blue was called on 1/20/2021 at 9:38 AM, ACLS (Advanced Cardiovascular Life Support) protocol was initiated... The attempt to resuscitate the pt (Pt. #28) was unsuccessful. Pt was pronounced dead at 9:58 AM on 1/20/21.
-Nursing Progress note dated 1/20/21 at 2:27 PM, included, "Called gift of hope... Reference #716..." The OPO was contacted 4 hours and 25 minutes after Pt. #28 was pronounced.

4. The clinical record of Pt. #29 was reviewed on 12/2/2021. Pt. #29 was admitted on 7/16/2021 with diagnosis of pneumonia. The clinical record included, the following:

-Physician Progress note dated 7/25/2021 at 11:15 AM, and included, "Code blue was called for cardiac arrest. ACLS protocol was initiated... The attempt to resuscitate the pt (Pt. #29) was unsuccessful... was pronounced death at 11:07 AM on 7/25/2021."
-Nursing Progress note dated 7/25/2021 at 2:10 PM, included, "... Called Gift of Hope... Reference #716..." The OPO was contacted 3 hours and 3 minutes after Pt. #29 was pronounced.

5. On 12/02/2021 at 1:33 PM, an interview was conducted with the Chief Nursing Executive (E#2). E#2 stated that staff must contact the OPO, as soon as possible when a death is imminent or whenever a patient expires in the Hospital. E#2 confirmed that for Pt. #28 and Pt. #29, staff did not contact the OPO in a timely manner. E#2 stated that the OPO provides staff education several times a year.

Based on document review and staff interview it was determined that for 1 of 4 days (10/29/2021) in October 2021 and 10 of 30 days in November 2021 (11/5, 11/7-8, 11/11-11/12, 11/14-11/15, 11/20, 11/25 and 11/29), that the Hospital failed to ensure adequate respiratory staff were available to provide care to all patients. This potentially affected the average daily census of 38 patients.

Findings include:

1. On 12/02/2021, the Hospital's policy titled, "Respiratory Department (revised 04/2021)", was reviewed and required, "Purpose: To provide adequate staffing to perform respiratory treatments and procedures...The respiratory department provides coverage on 24-hour basis...There are three shifts: 7:00 AM-3:00 PM, 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM. There are two therapist per shift. In times of low census, the respiratory department will be staffed with two therapist.

2. On 12/02/2021, at approximately 1:00 PM, the Hospital's Respiratory Care Staffing Schedule from 10/28/2021 to 12/01/2021 (5 weeks) were reviewed. The Respiratory Care Staffing Schedule included:

-On 10/29/2021 during the night shift (11:00 PM-7:00 AM) there was one (1) Respiratory Therapist providing coverage for the Hospital.

-On 11/08/2021, 11/11/2021, 11/20/2021 and 11/29/2021 during the night shift (11:00 PM-7:00 AM) there was one (1) Respiratory Therapist providing coverage for the Hospital. (short one Respiratory Therapist)

-On 11/05/2021, 11/07/2021, 11/12/2021, 11/14/2021, 11/25/2021 and 11/29/2021 during the evening shift (3:00 PM-11:00 PM) there was one (1) Respiratory Therapist providing coverage for the Hospital. (short one Respiratory Therapist)

-On 11/15/2021, and 11/25/2021 during the morning shift (7:00 AM-3:00 PM) there was one (1) Respiratory Therapist providing coverage for the Hospital. (short one Respiratory Therapist)

3. On 12/02/2021 at approximately 2:00 PM, an interview was completed with the Director of Quality/ E #6. E #6 stated that she is covering for the Respiratory Manager who is out for personal reasons at this time. E #6 stated, "We have many vacancies in the respiratory department....we are not meeting the minimum of two respiratory therapist per shift on some days."

Based on document review and interview, it was determined that for 1 of 1 (Pt. #30) clinical record reviewed for patients on mechanical ventilation, the Hospital failed to document a safety assessment for ventilator parameters, to ensure services were delivered in accordance with the medical staff directives.

Findings include:

1. On 12/01/2021, the Hospital's policy titled, "Mechanical Ventilation (revised 04/2021) was reviewed and included, "To establish guidelines concerning the application of mechanical ventilation... A. Ventilator checks include an assessment and flow sheet. These checks are to be completed upon an initial ventilator. B. Ventilators are to be checked three (3) times per shift, for example: The first hour of every shift and 3 hours post...6. Ventilator assessments and checks are to be documented in (Name of electronic medical records system) electronic flow sheets."

2. On 12/21/2021, the clinical record of Pt. #30 was reviewed. Pt. #30 was admitted on 11/24/2021, with a diagnosis of Hyperkalemia (abnormal labs), Acute Renal Failure, and COVID-19. Pt. #30 was intubated in the ER on 11/24/2021, at 5:10 PM. Pt. #30's clinical record included a physician's order, dated 11/27/2021, for continuous mechanical ventilation with the following parameters: AC (assist control/mode of ventilation), rate of 20, 450 TV (Tidal Volume), PEEP (positive end expiratory pressure) of 6.0, and 50% FIO2 (oxygen concentration). However, the clinical record lacked documentation of ventilator checks three times per shift between 11/26/2021 at 2:35 PM until 11/27/2021 at 12:40 AM (approximately 9 hours) and on 11/29/2021 at 12:00 AM until 11/29/2021 at 8:40 AM (approximately 8 hours 40 minutes).

3. On 12/01/2021, at approximately 10:00 AM, an interview was conducted with E #12/ Respiratory Therapist stated, "Pt. #30 was on a ventilator, he should have been charted on during the shift."

4. On 12/02/2021 at approximately 2:05 PM, an interview was conducted with the Director of Quality/E #6. E #6 stated, "The charting was not completed, it should have been done."