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Based on observations, interviews and record reviews the hospital failed to protect and promote Patient 1's rights when:

The hospital failed to ensure patients received care in a safe setting for one of three patients, Patient (Pt) 1, when Pt 1 was brought in by ambulance on 8/26/24 to the hospital's Emergency Department (ED) with a chief complaint of a ground level fall at home with a large bruise to the forehead and after being evaluated, treated and stabilized, was discharged to the nearest bus stop and not provided a safe transport home. Pt 1 was elderly, non-English speaking and had a history of dementia and determined to be ready for discharge on 8/26/24 at 10:43 p.m. Pt 1's clinical record documented she was discharged to the bus stop. Staff where aware buses did not run at that time of night. Pt 1 spent the night in the hospital lobby. The following morning 8/27/24 Pt 1 was escorted to the nearest bus stop and family was not contacted. Hospital social services was not consulted and utilized to evaluate safe transport home after discharge. (Refer to A-0144)

The cumulative effects of these systemic problems resulted in the hospitals inability to ensure care in a safe and effective manner for Pt 1 in accordance with the statutory-mandated Condition of Participation for Patient Rights.

Based on interview and record review, the hospital failed to ensure patients received care in a safe setting for one of three patients, Patient (Pt) 1, when Pt 1 was brought in by ambulance on 8/26/24 to the hospital's Emergency Department (ED) with a chief complaint of a ground level fall at home with a large bruise to the forehead and after being evaluated, treated and stabilized, was discharged to the nearest bus stop and not provided a safe transport home. Pt 1 was elderly, non-English speaking and had a history of dementia and determined to be ready for discharge on 8/26/24 at 10:43 p.m. Pt 1 was not provided safe transport home and clinical record documented provided bus stop. Staff where aware buses did not run at that time of night. Pt 1 apparently spent the night in the hospital lobby. The following morning 8/27/24 Pt 1 was escorted to the nearest bus stop and family was not contacted to provide a safe transport home. Hospital social services was not consulted and utilized to evaluate safe transport home after discharge.

These failures resulted in the hospital not ensuring a safe environment of care upon discharge, not treating Pt 1 with dignity and respect, and resulted in Pt 1 staying in an unknown area of the hospital overnight and wandering the streets of a local rural town approximately 10 miles from the hospital. Pt 1 was not found until the morning of 8/27/24 and experienced the night and early morning without food, water, shelter, and comfort. These failures resulted in extreme worry and mental anguish for family members of Pt 1.

Findings:

During an interview on 8/28/24, at 9:39 a.m., with Pt 1's Daughter (Dtr), the Dtr stated Pt 1 went by ambulance to the hospital on 8/26/24 for a fall with laceration to her forehead and was expecting the hospital to call when Pt 1 was ready to be discharged and she never received a call. Dtr stated she reached out to the hospital in the morning when she had no missed calls and was informed that Pt 1 was discharged by bus at 10:43 p.m. on 8/26/24. Dtr stated she asked for clarification and was told staff would not know more until the shift that discharged her came back in tonight because they could not locate any notes to indicate how Pt 1 left except by bus at 10:43 p.m. Dtr also stated that hospital staff told her the cameras for the ED were down and she could file a missing person request with the police department. Dtr stated on Pt 1's previous visit on 7/30/24 Pt 1 had a diagnosis of underlying dementia. Dtr stated the hospital was able to set up transport home for her last ED visit on 7/30/24. Pt 1 does not drive. Dtr stated she was never notified of her discharge on 8/26/24. Dtr stated on 8/27/24 around 3:13 p.m. Pt 1 was found by the police wandering around a rural town about 10 miles from the hospital.

During a review of Pt 1's face sheet (provides demographic information to include name, date of birth, contact information, insurance information, etc.), dated 8/26/24, indicated Pt 1 was admitted on 8/26/24 at 5:34 p.m., no discharge time or date noted, 74 year old female, primary language is Spanish and an interpreter is needed; chief complaint: Ground Level Fall (GLF) Hematoma (bruise) on forehead; contact person Daughter (Dtr).

During a review of Pt 1's ED Note titled "Final Report" dated 8/26/24, at 8:27 p.m., indicated, Pt 1 arrived by ambulance at 6:03 p.m. for a ground level fall (GLF) and presented with a large hematoma to forehead, alert and oriented times 4, denied any loss of consciousness. Pt 1 has past medical history (PMH) of Hypertension (elevated blood pressure), arthritis (inflammation in joints causing pain and stiffness), depression (mental disorder that can affect a person's feelings, thoughts, behaviors, and sense of well-being). On physical exam Pt 1 is in "No acute distress, alert and oriented x 3 ... forehead hematoma, partially obstructing the right eye". At 9:44 p.m. per treating provider reexamination/reevaluation "discussed all results, diagnosis, treatment plan, prescriptions, and discharge home. The patient verbalized understanding and agrees to be discharged at this time. They [referring to Pt 1] understand to return to the ED for worsening of symptoms or concerns for their safety." Final diagnosis this visit: Traumatic hematoma of forehead and GLF both discharged at 9:47 p.m. to home or self-care, condition stable.

During a review of Pt 1's ED Physician Notes titled, "Final Report," dated 7/30/24, at 12:34 p.m., indicated Pt 1 came into the ED by ambulance on 7/30/24 at 11:50 a.m. for chief complaint of 5150 hold (a legal term for the involuntary psychiatric hospitalization of an adult who is experiencing a mental health crisis) for mental health evaluation "Per daughter PT [Pt 1] having Hallucinations". On physical exam Pt 1 presents as "agitated". Reexamination/Reevaluation done at 1:44 p.m. indicated, "Patient is medically clear for psychiatric evaluation". Medical Decision Making ED Course: " ... Patient denies any suicidal homicidal ideation has no neurodeficit has a history of dementia ...". Final diagnosis this visit: Acute psychosis (symptoms include hallucinations, delusions, disorganized thoughts, or behaviors, last about a month; causes brain damage, diseases, or substance abuse); elevated blood pressure; hypokalemia (low potassium level); dehydration (loss of fluids in body can cause increased thirst, tiredness, decreased urine output, dizziness, headaches, and confusion); medical clearance for psychiatric evaluation. Condition Stable.

Review of document titled, "Neurology/Stroke Note," dated 7/30/24 at 5:15 p.m., indicated, " ... Recommendations ... Discharge ... Impression Hallucinations ? (questionable) underlying dementia ... recommendations ... Outpatient neurology consultation ..."

During a concurrent interview and record review on 8/28/24, at 10:04 a.m. with ED Registered Nurse (RN) 13 Informaticist, Pt 1's electronic Health records (EHR) for ED visits on 8/26/24 and 7/30/24 were reviewed. Pt 1's EHR indicated on 8/26/24 Pt 1 arrived at 5:34 p.m. by ambulance for a ground level fall with large hematoma to forehead and was discharged to a bus on 8/26/24 at 10:43 p.m. RN 13 confirmed the bus does not run that late in this area but Pt 1's EHR does not indicate any other form of transportation used nor any family contacted about the discharge plan. RN 13 stated the EHR for Pt 1's ED visit on 8/26/24 does not indicate that Pt 1 has a diagnosis of dementia. RN 13 stated when patients who are confused or have dementia are discharged family is contacted and patient is placed in a secure area where they can be monitored until family arrives or transport is arranged for them to go back to their home. RN 13 stated the EHR for Pt 1's ED visit on 8/26/24 did not show that family was called for discharge of Pt 1. RN 13 stated Pt 1's EHR for ED visit on 7/30/24 indicated Pt 1 was brought in by ambulance as a 5150 gravely disabled patient and a psych evaluation was done that indicated Impression "Hallucinations ? (questionable) underlying dementia". RN 13 confirmed Pt 1 was discharged home on 7/31/24 by transport set up by social worker (SW).

During an interview on 8/28/24, at 12:18 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he started his shift in ED on 8/27/24 and around 7:30 a.m. he saw Pt 1 come to the registration window asking for assistance in Spanish and registration asked me to help because I speak and understand Spanish. LVN 1 stated Pt 1 wanted a taxi but did not have her wallet with her because she needed to go home. LVN 1 stated he tried to explain to Pt 1 where the bus stop was, but she asked for someone to show her instead. LVN 1 stated Pt 1 had her belongings with her, and he walked her to the bus stop but once outside the hospital Pt 1 stated, "I feel like I am drunk". LVN 1 stated Pt 1 told me she has a daughter, but she is pregnant and does not have family that can come and get her. LVN 1 stated he asked Pt 1 if she knew where she was going on the bus and she stated she lived near the airplanes and a clinic was across the street, LVN 1 stated he provided the name of the clinic and she agreed and told me she needed to go to a rural town about 10 miles from the hospital. LVN 1 stated he left Pt 1 at the bus stop after he pushed the button that informs the bus driver there is a passenger waiting for the bus. LVN 1 stated Pt 1 had told him that she had attempted to call her family earlier and did not know the results of that phone call. LVN 1 stated he knew Pt 1 was discharged the night before on 8/26/24 and did see her discharge paperwork. LVN 1 stated Pt 1 was answering questions appropriately.

During a concurrent interview and video review on 8/28/24, at 2:26 p.m. with Security Supervisor (SS), SS was able to bring up the video of the ED department on 8/27/24 at 7:45 a.m. and it showed Pt 1 and LVN 1 leaving the ED walking across the bridge Pt 1 was seen using the rail on the left side of the bridge for support while walking and once she let it go she appeared to be unsteady while walking. The SS stated the night shift Security Lead reviewed the video overnight and did not see Pt 1 leave the ED the night of 8/26/24. The SS confirmed some of the cameras have been down in the ED department and they are currently being worked on, so they had limited view in the ED itself.

During an interview on 8/29/24, at 7:45 a.m., with LVN 2, LVN 2 stated she works in the ED, and she was working on 8/26/24 from 7 p.m. to 7:30 a.m. LVN 2 stated she does recall discharging Pt 1 on 8/26/24. LVN 2 stated Pt 1 spoke Spanish and an interpreter was used. LVN 2 stated Pt 1 had told them that she did not know how to get ahold of her family. LVN 2 advised Pt 1 to speak with registration they would have her contact numbers and they can call for a ride for her. LVN 2 stated Pt 1 had informed them that her family works nights, and she did not have anyone to call until the morning, so she stayed in the lobby all night. LVN 2 stated she remembers seeing Pt 1 throughout the night when she brought other patients back into the ED. Pt 1 was still waiting in the ED lobby by the time she got off work at 7:30 a.m. on 8/27/24. LVN 2 stated when a patient has dementia and is being discharged, we have them wait in a more secure area in the back of the ED where we have access to them. LVN 2 stated she was not aware that Pt 1 had dementia. LVN 2 stated she did not investigate Pt 1's previous visits and only looked at her current visits. LVN 2 stated for those with dementia we make sure they are discharged with a family member, and she makes sure to document it in her notes. LVN 2 states we have needed to schedule transport for patients that need it before.

During an interview on 8/29/24, at 3:20 p.m. with EKG technician (TECH 1), TECH 1 stated he spoke with Pt 1's Dtr on 8/27/24. TECH 1 stated he noticed the Dtr seemed anxious and was loud and informed him that her mother, Pt 1, was discharged last night, and the hospital does not know where she is, and she mentioned Pt 1 had dementia. TECH 1 stated he remembered who Pt 1 was because she had a goose egg (large bruise) on her face. TECH 1 stated he went into the back of the ED and looked at the inter-facility log and noticed he could not find Pt 1's name on it and asked around about Pt 1. TECH 1 stated he looked up Pt 1 and saw she was discharged last night and noticed her visit did not mention Pt 1 had dementia. TECH 1 stated the Dtr was on the phone and then asked me what she should do, and I told her "I would call the police department and make a missing person report". TECH 1 said the Dtr was upset and was on the phone with Adult Protective Services (APS). TECH 1 stated he was going to see if he could find more information for her but when he came back the Dtr was gone.

During an interview on 8/29/24, at 4:18 p.m., with the Patient Relations Specialist (PRS), PRS stated Pt 1's Dtr came in at 11:50 a.m. on 8/27/24 and security called me to come speak with her. PRS stated the Dtr informed her that Pt 1 was missing and that she had already filed a missing person report and filled me in on how this had happened, provided a picture of her mom, and left her contact information. PRS stated she began looking into what happened to Pt 1 after her discharge and did multiple interviews and had staff look all inside of the facility and outside the surrounding of the facility and they were not able to locate her. PRS stated she let her own manager know what was going on and the footage from the cameras was reviewed. PRS stated she called the Dtr the following day and Pt 1 had been found in a rural town about 10 miles from the hospital.

During an interview on 8/30/24, at 12:55 p.m., with the Chief Nursing Officer (CNO), CNO stated the ED does not have a social worker (SW) on at night time. CNO stated if a patient needs a referral the face sheet is copied and placed on the SW desk with a message of what is needed for the patient and is addressed by the SW who comes in the next morning. The CNO stated she interviewed the staff that cared for Pt 1 on 8/26/24 and based on her interviews staff felt Pt 1 was alert and oriented. The CNO stated staff did not think it unusual for Pt 1 not to remember her contact numbers, none of her staff felt Pt 1 was in any danger or risk discharging her at night to herself. The CNO stated based on how Pt 1 presented the night of 8/26/24 her staff did what was appropriate for this patient. The CNO stated only issue is the documentation in Pt 1's chart for her discharge on 8/26/24 time 10:44 p.m. transportation type as bus and she understood the bus does not run that late at night.

During an interview on 8/3/24, at 10 a.m. with the Accreditation Regulatory Compliance Manager (ARM), ARM stated the facility did not have a separate discharge policy for the ED, so the "Discharge of the Adult Inpatient (PC 92)" is what is used.

During a review of the facility's policy titled, "Discharge of the Adult Inpatient (PC 92)" reviewed last on 6/22, indicated, "DEPARTMENTS: Hospital-wide POLICY: ... Discharge planning is to begin when the patient is admitted to the facility and is to be an ongoing planning process throughout their hospital stay. The patient, family and health care provider(s) from appropriate care disciplines are responsible or planning and coordination of the discharge ... GUIDELINES: A. The patient's Registered Nurse (RN) and Care Coordination will coordinate discharge-planning needs for the patient... 2. Staff will assist the patient, family and/or caregiver(s) in arranging, obtaining, or offering information appropriate to their discharge needs. 3. The patient will be assisted in contacting their family and/or caregiver(s) informing them of the impending discharge so timely preparation and transportation arrangements can be made. B. On Admission in Preparation for Discharge: 1. The admitting RN will document in Cerner: a. The patient contact information. B. Verify the patient primary care physician (PCP), transportation and preferred pharmacy ... d. Identify potential barriers to discharge (i.e. lack of insurance, transportation issues, homelessness, etc.) and notify Care Coordination. E. Verify transportation available for discharge ... D. Discharge Documentation in Cerner: 1. In Nursing Communication: for nursing units 4 through 7, ICU and ED in their appropriate sections ... E. Verify the Discharge Plan with and Document ... 3. Transportation Plan ... 9. The patient is escorted via wheelchair, or other appropriate mode of transport, and released to a responsible individual.

During a review of the facility's policy titled, "Patient's Right and Responsibilities (RI-01)", effective dated 1/24/19, indicated, " ... These rights and responsibilities are identified in the 'Patient Rights and Responsibilities' booklet ... Patients are informed of their rights and responsibilities upon admission to an inpatient setting, or upon initial presentation to an outpatient setting ..." Review of "Patient Rights and Responsibilities" dated 9/2017, indicated, "[name of hospital] complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation or gender identity ... Each patient is entitled to compassionate and professionally competent care delivered with respect for each individual ... to be made comfortable ... 2. Have a family member (or other representative of your choosing) and you own physician notified promptly of your admission to the hospital ... 14. Receive care in a safe setting, free from mental, physical, sexual, or verbal abuse and neglect, exploitation, or harassment ... 17. ... You have the right to be involved in the development and implementation of your discharge plan. Upon your request, a friend or family member may be provided this information also ... 19. Designate a support person as well as a visitor or your choosing, if you have decision making capacity ..."

Based on interview and record review, the facility failed to have a well-organized and effective nursing service when:

1. Licensed Nurses failed to meet the needs for Patient (Pt) 3 and 4 when the nursing care plans (goals of treatment for safe nursing care) did not include nursing interventions (actions that were performed to help patients reach their goals of care) corresponding to the primary diagnoses and treatments of each patient (Refer to A396).

2. Licensed Nurses did not follow physician orders for high risk/high-alert titratable (continuous intravenous medication that can be changed to a higher or lower dose based off of physician order parameters) medications (Medications that have a heightened risk of causing significant patient harm when they are used in error) according to the facility's P&P ""Medication "High Alert, Administration of ..." (Refer A398).

3. Patient 13 was administered the incorrect amount of high-risk/high-alert medications 14 different times (Medications that have a heightened risk of causing significant patient harm when they are used in error) and Patient 14 was administered medication ordered for moderate pain (pain that interferes with daily living activities and can be ignored for a period of time) eight separate times, when the pain score (a tool that helps people describe how much pain they are feeling, and is used by medical professionals to assess and manage pain) was documented as severe (disabling or intense pain that prevents someone from doing their daily living activities completely) (Refer 405).

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

Based on interview and record review, the hospital failed to develop and keep current care plans for two of five patients in accordance with the policy " Plan of Care Development (PC-59)". The primary care needs related to Patient 3 and Patient 4 were not assessed and developed and not documented in the patients' care plans.

This failure had the potential to result in Patient 3 and Patient 4 care needs to go unmet.

Findings:

During a concurrent observation tour and interview on 8/27/24 at 2:00 p.m. with Nurse Manager (RNM4), on the 6th Floor Medical Surgical Unit , Patient 3 was observed lying in bed, in a designated isolation room. The Nursing Manager (RNM6) stated Patient 3 had been admitted on 8/24/24 at 3:56 a.m. with diagnoses of COVID and pneumonia.

During a concurrent interview and record view on 8/28/24 at 2:00 p.m., with RNM4, Pt 3's electronic health record (digital collection of medical information) "History and Physical (H&P-the formal document that physicians produce through interview with the patient, physical exam, and the summary of testing either obtained or pending)", dated 8/24/24 at 4:03 a.m. was reviewed. Pt 3's H&P indicated Pt 3 "was admitted on 8/24/24 with a previous complex medical history including anemia, asthma who continues to smoke cigarettes, coronary artery disease status post MI (myocardial infarction), pulmonary hypertension (type of high blood pressure that affects the right side of the heart), type 2 diabetes (a chronic disease characterized by elevated blood sugars), hypothyroidism (deficiency of thyroid hormone that can disrupt heart rate, body temperature and all aspects of metabolism), GERD (gastro esophageal reflux syndrome), end stage renal disease (kidney function failure) receiving hemodialysis (a treatment that filters blood to remove waste and fluids when the kidneys are not working), generalized weakness and shortness of breath." The "H&P" assessment plan identified current treatment needs as: "Severe sepsis related to COVID-pneumonia, COVID pneumonia, End-Stage Renal Disease on hemodialysis, Diabetes to be treated with [insulin] sliding scale. Hyperthyroidism (a condition when the thyroid gland produces too much thyroid hormone) and coronary artery disease (heart disease that affects the main blood vessels that supply blood to the heart)." On 8/28/24 at 2:00 p.m., four days after Pt 3 was admitted, Pt 3's Care Plan only listed two areas of need: Pain and Shortness of breath. RNM4 stated the "Care Plan was incomplete and should have at a minimum added care plans for dialysis, diabetes, fluid balance, hypertension and falls precautions." RNM4 stated staff "did not follow the hospital's Plan of Care Development policy and procedure."

During a concurrent interview and record review on 8/28/24 at 2:30 p.m. with RNM4, Pt 4's electronic health record (digital collection of medical information) was reviewed. Pt 4's admission "History and Physical (H&P-the formal document that physicians produce through interview with the patient, physical exam, and the summary of testing either obtained or pending)", dated 8/21/24 at 10:00 p.m., was reviewed. Pt 4's H&P indicated Pt 4 was admitted on 8/21/24 with "worsening nausea and vomiting over the past 2 days." The H&P indicated that Pt 4 was 81 years of age and lives alone. Pt 4 has a "past medical history of hypertension, seizure disorder and Type 2 Diabetes." The H&P Assessment plan in the 8/21/24 H&P identified the following medical issues: Fever of unknown origin (possibly due to aspiration), Hyponatremia (low sodium levels), Hypokalemia (low potassium levels), Intractable nausea and vomiting, Abdominal pain, Hypertension (high blood pressure), and Seizure disorder (a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements, feelings and level of consciousness)." Physician Note dated 8/27/24 8:00 p.m. indicated Pt 4 "has been experiencing break-through seizures (seizures occurring regardless of medication treatment) since admission" and a new diagnosis of chronic kidney disease. A review of Pt 4's Care Plan listed the following areas of need as: Nutrition -not eating, fluid volume excess (when the body has too much fluid), Risk for Infection, electrolyte imbalance (when certain minerals in your body become too high or too low), and fall risk. RNM4 stated that the care plans should also have included seizure activity, diabetes, pain and at risk for aspiration (when material enters a person's airway and lungs by accident). RNM4 stated "staff did not follow the hospital's Plan of Care Development policy and procedure".

During a review of the facility's policy and procedure (P&P) titled, "Plan of Care Development (PC-59)" dated 5/2022, indicated, " ...POLICY, Guidelines ...Developing a Plan of Care ...After completion of the admission assessment, the registered nurse (RN) initiates the Plan of Care by selecting a Care Plan that addresses the admitting, supplemental diagnoses and or identified problems of the patient ...Individualizing the Plan of Care ...Once the necessary standardized Plan of Care has been chose, the RN may modify the interventions based on the patients unique needs ...Revising the Plan of Care ...Revision to the Care Plan is made when changes occur in the patient's status or clinical condition ...When needed ...Adding new diagnoses or problems.

Based on interview and record review, the facility failed to complete and document independent double checks at shift change for two of two sampled patients (Patient 13, Patient 14), on high risk/high-alert titratable (continuous intravenous medication that can be changed to a higher or lower dose based off of physician order parameters) medications (Medications that have a heightened risk of causing significant patient harm when they are used in error).

This failure resulted in the potential for harm for both patients due to the lack of adherence to safeguards prior to drug administration and not following the hospital policy and procedure "Medication "High Alert, Administration of ...".

Findings:

During a review of Patient (Pt) 13's "History and Physical (H&P)", dated 8/26/24, the H&P indicated, Pt 13 was diagnosed with acute respiratory distress (a serious lung condition that can be life-threatening where patient has difficulty breathing), COPD (Chronic Obstructive Pulmonary Disease- a common lung disease causing restricted airflow and breathing problems) exacerbation (sudden worsening of symptoms), history of smoking and hyperglycemia (elevated blood sugar). The H&P indicated Pt 13 was intubated (a process where a healthcare provider inserts a tube through a person's mouth or nose that delivers air or oxygen into a person's lungs) and transferred to the Intensive Care Unit (ICU- a specialized hospital unit that provides critical care and life support to patients who are very ill or injured).

During a review of Pt 14's "H&P", dated 8/25/24, the H&P indicated, Pt 14 was diagnosed with DKA (Diabetic Ketoacidosis- a serious life-threatening condition when a patient's blood sugar becomes dangerously high) and severe sepsis (serious condition from harmful bacteria in the blood that can lead to malfunctions of organs). Pt 14 was transferred to the ICU and put on an insulin titratable drip (continuous medication administration intravenously).

During a concurrent interview and record review on 8/29/24 at 11:45 a.m., with the Intensive Care Unit (ICU) Nurse Shift Manger (NSM), Patient (Pt) 14's "Medication Details (MD)", dated 8/26/24 (1) and 8/27/24 (2) was reviewed. The MD 1 indicated, " ... Route: IV (intravenous) ... Insulin (a medication to control a patient's blood sugar) regular ... Given on August 26, 2024, 7 p.m. ... Action List: ... Perform by Registered Nurse (RN) 6 on 8/26/24, 7:21 p.m. ... VERIFY by RN 6 on 8/26/24, 7:21 p.m. ...". The MD 2 indicated, " ... Route: IV (intravenous) ... Insulin regular ... Given on August 27, 2024, 7 p.m. ... Action List: ... Perform by RN 6 on 8/27/24, 7:56 p.m. ... VERIFY by RN 6 on 8/27/24, 7:56 p.m. ...". The ICU NSM verified there was no two licensed nurse hand-off communication (two licensed nurses verify and document medication is delivered at a set rate that is ordered) between nurses at shift change for Pt 14's the insulin drip. ICU NSM verified there was only one licensed nurse documented on Pt 14's hand-off, RN 6.

During a concurrent interview and record review on 8/29/24 at 12:15 p.m., with the ICU NSM, Pt 13's Electronic Medical Record (EMR), dated 8/26/24 to 8/29/24 was reviewed. The EMR indicated Pt 13 did not have an independent double check (two licensed nurses document and independently check the rate the medication infusion was running while verifying that with the physician order). Pt 13's EMR indicated there was not a two licensed nurse hand-off documented for norepinephrine (medication to rapidly elevate blood pressure) and fentanyl (powerful medication used for pain relief) titratable drip medications for shift changes on shifts 7 a.m. to 7 p.m. and 7 p.m. to 7 a.m. . The ICU NSM stated that the lack of an independent double check was a safety issue for Pt 13. The ICU NSM stated the nursing staff did not follow hospital policy for administration of high alert medications.

During an interview on 8/29/24 at 7:40 a.m., with RN 3, RN 3 stated she was the nurse for Pt 13 8/26/24 through 8/28/24. RN 3 stated she never knew nursing staff was required to document a hand-off communication for a patient's titratable drips. RN 3 stated the staff did not know the policy "Medication "High Alert" Administration" ever "existed". RN 3 stated that by not completing this two-nurse verification for the "High Alert" medications, that it put Pt 13's safety at risk.

During an interview on 8/29/24 at 10:40 a.m., with RN 4, RN 4 stated she was responsible for Pt 13's care 8/27/24 and 8/28/24. RN 4 stated staff should have verified and documented the drip titration rates for norepinephrine and fentanyl at shift change and they did not. RN 4 stated it was important to complete this check to make sure the patient had the right dose of high alert titratable drips and make sure the drip rate was appropriate at that time.

During an interview on 8/29/24 at 4:40 p.m., with the ICU Clinical Manager (ICM), the ICU CM stated nurses should be "signing off (two different license nurse independent check)" the titratable drips with the oncoming shift. The ICU CM stated the nurses should have done this for Pt 13's and Pt 14's safety, "bottom line" and they could have harmed the patient. The ICU CM stated nursing staff did not follow hospital policy and procedure.

During an interview on 9/3/24 at 12:30 p.m. with the Chief Nursing Officer (CNO), the CNO stated that two licensed nurses should have communicated and documented what Pt 14's insulin and Pt 13's, norepinephrine and fentanyl rates were at shift change. The CNO stated that this was a patient safety issue and the patients could have potentially had negative outcomes. The CNO stated the nurses did not follow the policy and procedure, "Medication "High Alert" Administration".

During a review of the facility's policy and procedure (P&P) titled, "Medication "High Alert, Administration of ...'", dated 1/22 was reviewed. The P&P indicated, " ...High-Alert medications are those medications involved in a high percentage of errors and/or sentinel (event that results in death or permanent harm) events as well as medications that carry a higher risk for abuse or other adverse outcomes. To promote safe management of High-Alert medications ... require specific safeguards prior to administration to reduce the risk of harm to patients ...Medications to be considered "High Alert" are ... 2. Insulin (drips only)- IV only. 3. Narcotic drips ... 6. Vasopressor (medication that raises a patient's blood pressure) Drips (e.g. (for example) Norepinephrine ... All "High Alert" medications will have an independent double check performed and documented prior to initial administration, during dosage adjustment, and "hand off" communication/shift change (for continuous drip medications). This will be carried out by two (2) licensed nurses ... c. Each nurse independently verifies that the correct dose ... e. Each nurse independently documents in the e-MAR (electronic Medication Administration Record) ...".

Based on interview and record review, the facility failed to ensure nursing staff followed physician medication orders for two of two sampled patients (Patient 13 and Patient 14) when:

1. Patient 13 was administered the incorrect amount of high-risk/high-alert medications 14 different times (Medications that have a heightened risk of causing significant patient harm when they are used in error).

2. Patient 14 was administered the medication ordered for moderate pain (pain that interferes with daily living activities but can be ignored) eight separate times, when the pain score (a tool that helps people describe how much pain they are feeling, and is used by medical professionals to assess and manage pain) was documented as severe (disabling or intense pain that prevents someone from doing their daily living activities completely).

These failures placed Patient 13 and Patient 14 at risk for not receiving the desired patient therapeutic medication goals (meaningful outcome for patients).

Findings:

1. During a review of Patient (Pt) 13's "History and Physical (H&P)", dated 8/26/24, the H&P indicated, Pt 13 was diagnosed with acute respiratory distress (a serious lung condition that can be life-threatening where patient has difficulty breathing), COPD (Chronic Obstructive Pulmonary Disease- a common lung disease causing restricted airflow and breathing problems) exacerbation (sudden worsening of symptoms), history of smoking and hyperglycemia (elevated blood sugar). The H&P indicated Pt 13 was intubated (a process where a healthcare provider inserts a tube through a person's mouth or nose that delivers air or oxygen into a person's lungs) and transferred to the Intensive Care Unit (ICU- a specialized hospital unit that provides critical care and life support to patients who are very ill or injured).

During an observation on 8/27/24 at 11:45 a.m., in the ICU, Pt 13 was on a ventilator with his eyes closed in a medically induced coma (use of medications to put the patient in a reversible state of unconsciousness that doctors use to protect the brain from damage and allow the body to heal). Pt 13's titratable medications, fentanyl (a potent medication for pain relief), propofol (potent medication to rapidly sedate and put someone to sleep) and norepinephrine (potent medication to treat life-threatening low blood pressure) were actively being administered by an IV medication pump.

During a review of Pt 13's "Order Information (OI)", dated 8/26/24, the OI indicated, " ...Order information ... Fentanyl additive 2,500 mcg (microgram- unit of measurement)/50 mL (milliliters- unit of measurement) ... Volume dose: 250 mL ... Route of administration: IV (intravenous) ... Titration Range: 0 - 300 mcg/hr (hour) ... Titrate Instructions: Titrate by 25 mcg/hr as often as every 15 minutes, to achieve CPOT (Critical Care Pain Observation Tool- pain assessment tool for intubated patients based off of non-verbal cues) ... less than 3; if PRN (as-needed) fentanyl is available, only titrate infusion after two PRN doses have been administered and COPT remains 3 or greater ...".

During a review of Pt 13's "Order Sheet (OS)", dated 8/27/24, the OS indicated, " ... Norepinephrine 14mcg/minute ... IV... 52.5 mL/hr ... Titration Range: 0 - 50 mcg/min, Titrate by 2 mcg/min as often as every minute to max 50 mcg/min. MAP (Mean Arterial Pressure- a measurement of how well blood is pumped throughout the body and is important for ensuring organs receive enough oxygen and nutrients) greater than 65, if MAP less than 50, than increase to 20 mcg/min and then resume titration ... Start: 8/26/24 @ 11:22 p.m., ... Start Dose based on systolic (point at which a person's blood pressure is highest when the heart beats, pumping the blood) blood pressure (SBP): SBP greater than 90: 4 mcg/min, SBP 80-89: 6 mcg/min, SBP: 70 - 79: 10 mcg/min, SBP less than 70: 15 mcg/min ...".

During a review of Pt 13's "Norepinephrine Titrations and Vital Signs (NT VS)" dated 8/26/24 to 8/28/24, the NT VS indicated, " ...
Date/Time: 8/27/24 @ 8:35 a.m. VS BP- 136/68 mmHg, (Titration) 28 mcg/min ... VS BP-136 (systolic) mmHg (unit of measurement)/68 (diastolic) mmHg, No MAP recorded ...
Date/Time: 8/27/24 at 8:37 a.m. (Titration) 30 mcg/min ... No VS at this time ... (Drip was titrated up- per order need a MAP below 65 for titration) ...
Date/Time: 8/27/24 at 9 a.m. VS BP- 73/50 mmHg, MAP- 58 (no titration- per order there should have been a titration) ...
Date/Time: 8/27/24 at 9:05 a.m. VS BP- 71/47 mmHg, No MAP recorded (no titration- per order there should have been a titration) ...
Date/Time: 8/27/24 at 9:08 a.m. VS BP- 90/62 mmHg, No MAP, (Titration) 32 mcg/min ... (Drip was titrated up- per order need a MAP below 65 for titration) ...
Date/Time: 8/27/24 at 9:15 a.m. VS BP- 142/87 mmHg, No MAP, (Titration) 34 mcg/min (Drip was titrated up- per order need a MAP below 65 for titration) ...
Date/Time: 8/27/24 at 10 a.m. VS BP- 135/75 mmHg, MAP 99, (Titration) 36 mcg/min (Drip was titrated up- per order need a MAP below 65 for titration) ...
Date/Time: 8/27/24 at 10:15 a.m. VS BP- 96/63 mmHg, No MAP, (Titration) 38 mcg/min (Drip was titrated up- per order need a MAP below 65 for titration) ...
Date/Time: 8/27/24 at 10:26 a.m. VS BP- 87/51 mmHg, MAP 64, (Titration) 38 mcg/min (Drip was titrated down- per order need a MAP below 65 titration should have been up) ...".

During a concurrent interview and record review on 9/3/23 at 11:50 a.m. with the Manager of Education (MOE) Pt 13's "Fentanyl Titrations and CPOT Scores (FT CS)" dated 8/26/24 to 8/28/24 was reviewed. The MOE validated edits had been made to the "FT CS" after initial review. The FT CS notes indicated, " ...

Date/Time: 8/27/24 at 7:59 a.m. CPOT score 8, no titration (per order should have been titrated up by 25 mcg/hr) ...
Date/Time: 8/27/24 at 8:45 a.m. CPOT score (not recorded), titration of 25 mcg/hr from 150 mcg/hr to 175 mcg/hr (per order should not have been a titration due to not having a CPOT score) ...
Date/Time: 8/27/24 at 11:06 a.m. CPOT score 4, no titration (per order should have been titrated up by 25 mcg/hr) ...
Date/Time: 8/27/24 at 12:03 p.m. CPOT score 4, titration went down 25 mcg/hr from 225 mcg/hr to 200 mcg/hr (per order should have been titrated up by 25 mcg/hr) ...
Date/Time: 8/27/24 at 3:02 p.m. CPOT score 2, titration went up by 25 mcg/hr from 150 mcg/hr to 175 mcg/hr (per order Pt 13 was at goal and a titration up was not warranted) ...".

During an interview on 8/28/24 at 2:30 p.m. with Registered Nurse (RN) 1, RN 1 stated she was Pt 13's nurse on 8/27/24 and 8/28/24. RN 1 stated she was an orientee (1-month on the unit) and had a preceptor (RN 4- an experienced practitioner who provides supervision during clinical practice) with her at all times. RN 1 stated she did not follow the physician orders for the titratable drips because "the preceptor told me too". RN 1 stated physician orders are there for the safety and continuity of Pt 13's care. RN 1 stated that ultimately the physicians orders were not followed.

During an interview on 8/29/24 at 10:40 a.m., with RN 4, RN 4 stated she was RN 1's preceptor and responsible for Pt 13's care. RN 4 stated she told RN 1 when to titrate the drips and watched her input the titrations into the electronic medical record (EMR). RN 4 stated after review of the EMR, it appears physician orders were not followed and the drips were not titrated appropriately. RN 4 stated nurses are expected to follow the physician orders and they did not. RN 4 stated these errors put Pt 13's safety at-risk.

During an interview on 8/29/24 at 12:15 p.m., with ICU Nurse Shift Manager (ICU NSM), the ICU NSM stated the expectation for ICU nurses was to follow the physician's orders and they were not. The ICU NSM stated Pt 13 would be negatively affected by orders not being followed. The ICU NSM stated norepinephrine and fentanyl were "High Alert" medications.

During an interview on 8/29/24 at 4:40 p.m., with the ICU Clinical Manager (ICM), the ICU CM stated nurses need to follow the physician's orders as that is the "guide for a plan of care". The ICU CM stated Pt 13's physician orders were not followed. The ICU CM stated norepinephrine and fentanyl are high-risk medications and the nurses put the patient's safety at-risk. The ICU CM stated nursing staff did not follow hospital policy and procedure.

During an interview on 9/3/24 at 12:30 p.m. with the Chief Nursing Officer (CNO), the CNO stated staff should follow physician orders. The CNO stated that this was a patient safety issue and the patients could have potentially had negative outcomes. The nurses did not follow the policy and procedure, "Adult Critical Care Nursing Standards of Practice".

During a review of the facility's policy and procedure (P&P) titled, "Adult Critical Care Nursing Standards of Practice", dated 11/2023 was reviewed. The P&P indicated, " ... the standards of practice for adult critical care units serve as guidelines for the provision of nursing care and professional performance expectations. These standards are based upon ... the American Nurses Association scope and standards of practice and the American Association of Critical Care Nurses. They are used in conjunction with ... authorized licensed practitioners (LP) responsible for patient care orders. These standards of practice ... represent minimal, safe standards ... STANDARDS OF CARE: ... 5. Implementation ... c. Care Delivery- the registered nurse performs and/or overseas delivery of care according to the patient need, licensed practitioner orders and the plan of care to achieve identified outcomes ... 9. Medication Administration. A) medication should be administered according to the six rights of medication safety, licensed practitioner orders, and hospital policies ...".

Review of Registered Nursing.org Professional Reference titled, "Does a Nurse Always Have to follow a Doctor's Orders?" dated 1/30/23, (found at https://www.registerednursing.org/does-nurse-always-follow-doctors-orders/) indicated, " ...nurses cannot just randomly decide which order to follow and which not to follow. Unless there is a safety concern (I.E., medication not indicated for patient and/or task conflicts with facility policy/protocol) or an order that conflicts with personal or religious beliefs, failing to carry out orders can be grounds for discipline by the employer as well as the board of nursing, as it could be deemed "neglect."

2. During a review of Pt 14's "H&P", dated 8/25/24, the H&P indicated, Pt 14 was diagnosed with DKA (Diabetic Ketoacidosis- a serious life-threatening condition where a patient's blood sugar was dangerously high) abdominal pain and severe sepsis (serious condition from harmful bacteria in the blood that can lead to malfunctions of organs). Pt 14 was transferred to the ICU and put on an insulin titratable drip (continuous medication administration intravenously).

During a review of Pt 14's "Morphine Order (MO)", dated 8/25/24 to 9/24/24, the MO indicated, " ...Morphine (a medication used to treat severe pain) 2mg ... IV Push ... Q4hr (Every 4 hours) ... PRN (as needed) reason: Pain Moderate (4-6) ... Comment: ... IV Push Rate: 2 mg/min ... ".

During a review of Pt 14's "Pain Flowsheet (PF)", dated 8/25/24 to 8/30/24, the PF indicated, " ...
Date/Time: 8/26/24 at 11:08 a.m., (Medication given) Morphine 2 mg (milligram- unit of measurement), Pain intensity: 10, Pain scale used: Numeric rating (0 to 10- with 10 being most severe) ...
Date/Time: 8/26/24 at 3:22 p.m., (Medication given) Morphine 2 mg, Pain intensity: 10, Pain scale used: Numeric rating ...
Date/Time: 8/26/24 at 8:10 p.m., (Medication given) Morphine 2 mg, Pain intensity: 9, Pain scale used: Numeric rating ...
Date/Time: 8/27/24 at 1:06 a.m., (Medication given) Morphine 2 mg, Pain intensity: 9, Pain scale used: Numeric rating ...
Date/Time: 8/27/24 at 5:37 a.m., (Medication given) Morphine 2 mg, Pain intensity: 7, Pain scale used: Numeric rating ...
Date/Time: 8/27/24 at 9:32 p.m., Medication given) Morphine 2 mg, Pain intensity: 8, Pain scale used: Numeric rating ...
Date/Time: 8/28/24 at 1:29 a.m., Medication given) Morphine 2 mg, Pain intensity: 8, Pain scale used: Numeric rating ...
Date/Time: 8/28/24 at 5:43 a.m., Medication given) Morphine 2 mg, Pain intensity: 8, Pain scale used: Numeric rating ...".

Phone interview was attempted for Pt 14 to talk about her pain experience, but phone calls were never returned.

During an interview on 9/3/24 at 10:50 a.m., with the ICU Clinical Manager (ICM), the ICU CM stated nurses should have read the physician orders and gave the correct pain medications. The ICU CM stated Pt 14's pain was not adequately addressed and she could potentially have had a negative outcome because of that. The ICU CM stated staff put Pt 14's safety at risk. The ICU CM stated nursing staff did not follow hospital policy and procedure.

During an interview on 9/3/24 at 11:15 a.m., with RN 4, RN 4 stated she was responsible for Pt 14's care. RN 4 stated she should have given the medication for severe pain based off of the Pt 14's reported pain score. RN 4 stated "it was an oversight" that she gave the medication for moderate pain. RN 4 stated Pt 14 was "screaming like hell for pain medications". RN 4 stated the physician's order was not followed and she gave the wrong medication. RN 4 stated pain control would not be effective because she gave the lesser pain medication. RN 4 stated this was a patient safety issue due to not treating Pt 14's pain adequately and she did not follow the hospital policy and procedure for pain management.

During an interview on 9/3/24 at 12:30 p.m. with the Chief Nursing Officer (CNO), the CNO stated the nurse should have followed the physicians orders in regard to pain management. The CNO stated that this was a patient safety issue and Pt 14 could have potentially had a negative outcome. The nurses "absolutely" did not follow the policy and procedure, "Pain, Assessment and Management of".

During an interview on 9/3/24 at 1 p.m., with RN 6, RN 6 stated she was responsible for Pt 14. RN 6 stated she "didn't really look at the order" when she gave her the pain medication for moderate pain when Pt 14 told her, her pain was severe. RN 6 stated that if Pt 14's pain was not treated "appropriately" than she was not "going to get better and have a longer hospital stay". RN 6 stated giving the lesser pain medication was a patient safety concern and a "med-error if overlooked". RN 6 stated she did not follow the hospital policy and procedure in regard to pain management.

During a review of the facility's policy and procedure (P&P) titled, "Pain, Assessment and Management of", dated 2/2023 was reviewed. The P&P indicated, " ... patients have the right to attentive pain management and that the single most reliable indicator of the existence and intensity of pain is the patient's self-report ... staff is to provide careful assessment of pain levels, timely and appropriate interventions, accurate evaluation of those interventions, communication of the effectiveness of interventions ... pain management goals are to be mutually set by the care providers and patient ... E. Appropriate pain control interventions are initiated as indicated ... 1. Medications administered for the control or relief of pain ... F. Patient ... regarding effective pain management will include ... 1. The right to attentive pain management 2. The use of pharmacologic ... methods ... 5. The concept that effective pain relief is an important part of treatment and that health professionals will respond to reports of pain ... G. All assessments, reassessments and interventions for pain management are to be documented appropriately in the electronic medical record ...".

Review of Registered Nursing.org Professional Reference titled, "Does a Nurse Always Have to follow a Doctor's Orders?" dated 1/30/23, (found at https://www.registerednursing.org/does-nurse-always-follow-doctors-orders/) indicated, " ...nurses cannot just randomly decide which order to follow and which not to follow. Unless there is a safety concern (I.E., medication not indicated for patient and/or task conflicts with facility policy/protocol) or an order that conflicts with personal or religious beliefs, failing to carry out orders can be grounds for discipline by the employer as well as the board of nursing, as it could be deemed "neglect."
Review of Nursing World.org Professional Reference titled, "The American Nurses Association- Nursing: Scope and Standards of Practice, Third Edition", dated July 2015, (found at https://www.nursingworld.org/~4af71a/globalassets/catalog/book-toc/nssp3e-sample-chapter.pdf) indicated, " ...Standards of Practice The Standards of Practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Accordingly, the nursing process encompasses significant actions taken by registered nurses and forms the foundation of the nurse's decision-making ... Standard 1. Assessment The registered nurse collects pertinent data and information relative to the healthcare consumer's health or the situation ...".