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Based on interview and record review, the facility failed to ensure for two of 36 sampled patients (Patients 16 and 22), the following:

1. Patient 16 and/or the patient's representative was provided a Conditions of Admission (CoA, contract between the hospital and patient explaining patient's right and responsibilities) upon admission to the facility.

2. For Patient 22, the CoA provided was in Patient 22's preferred language of Spanish.

These deficient practices resulted in Patients 16 and 22, and/or the patients' representatives, to not be informed of their rights as a patient, which may lead in Patients 16 and 22's inability to effectively make decisions regarding their care and treatment.

Findings:

1. During a review of Patient 16's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 10/28/2024, the H&P indicated Patient 16 was admitted to the facility on 10/28/2024 for cardiac arrest (heart stops beating, which leads to emergency life saving measures) and respiratory failure (lungs are poorly functioning).

During a review of Patient 16's "Facesheet (front page of the chart that contains a summary of basic information about the patient)," the record indicated Patient 16 had an emergency contact listed.

During a concurrent interview and record review on 10/31/2024 at 1:47 p.m. with the Patient Access Manager (PAM), the PAM stated the purpose of the CoA was to discuss patient rights and admission. The PAM verified Patient 16 had a Conditions of Admission (CoA) dated 10/28/2024 (date of admission), indicating "Pt unable to sign due to medical condition" and was signed by two Patient Access Representatives (PAR).

In the same interview and record review on 10/31/2024 at 1:47 p.m., the PAM verified Patient 16's "Electronic Medical Record (EMR, digital version of the chart)," indicated that Patient 16 had an emergency contact listed. The PAM stated Patient 16's record had a note written on 10/28/2024 by the PAR, who made one attempt to contact Patient 16's emergency contact and was unavailable. The PAM verified there was no documentation a second attempt was made to contact Patient 16's emergency contact to provide the patient's CoA.

The PAM further stated on 10/31/2024 at 1:47 p.m., that the facility's process for providing CoA was to make two attempts in reaching out to the patient and/or the patient's representative. The PAM stated there should have been a second attempt to reach out to the patient's emergency contact to provide Patient 16's CoA.

During a review of the facility's "Policy and Procedure (P&P)" titled, "Conditions of Admission," dated 2/28/2024, the P&P indicated, "The Patient and/or the patient's legal representative ... must sign a Conditions of Admission form upon registering or being admitted as a patient ...In the event that the patient's medical/mental condition does not allow the patient to sign, the patient's legal representative may sign."

2. During a concurrent observation and interview on 10/30/2024 at 10:18 a.m. with the Chief Nursing Officer (CNO), Patient 22 was observed in her room, sitting in a chair, watching the television in Spanish. Patient 22 stated she (Patient 22) only speaks Spanish, and the CNO translated Patient 22's responses about her care.

During a review of Patient 22's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 10/19/2024, the H&P indicated, Patient 22 was admitted on 10/19/2024 for left groin pain.

During a review of Patient 22's "Facesheet (front page of the chart that contains a summary of basic information about the patient)," the record indicated Patient 22's preferred language was Spanish.

During a concurrent interview and record review on 10/31/2024 at 1:40 p.m. with the Patient Access Manager (PAM), the PAM verified Patient 22's "Electronic Medical Record (EMR)," indicated Patient 22's preferred spoken and written language was Spanish. The PAM also verified Patient 22's CoA, written in English, was signed by Patient 22 on 10/19/2024. The PAM stated there was no documentation a language interpreter (helps bridge the communication gap between patients who do not speak the same language as the healthcare providers) was used when the English version of the CoA was provided to the patient.

In the same interview on 10/31/2024 at 1:40 p.m., the PAM stated Patient 22 should have been given a CoA in Spanish or a language interpreter should have been used and documented when the CoA was given in English.

During a review of the facility's "Policy and Procedure (P&P)" titled, "Admission of a Patient," dated 12/2/2023, the P&P indicated, " Patient Access Representative is responsible for obtaining the appropriate demographic information and providing the standard admission packet...If the patient or patient representative's preferred language is not English, interpreter service should be used."

Based on interview and record review, the facility failed to ensure registered nurses (RNs) were competent in the hemodialysis (HD - the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) emergency termination procedure (safe process of disconnecting a patient from the dialysis machine in case of an emergency), in the event a HD RN (a RN who was trained in HD) became incapacitated (a state of not having the necessary ability, qualification, r strength to perform a specified act or function) while providing HD to a patient in the facility.

This deficient practice resulted in the RNs, who provides direct nursing care to HD patients, to not have the knowledge to safely shut off the HD machine in case of an emergency which may cause harm and/or death to the patients during HD.

Findings:

During a concurrent observation and interview on 10/29/24 at 2:42 p.m. with Registered Nurse 6 (RN 6), outside of room 403, RN 6 (a HD RN) was observed at the bedside providing HD to the patient. A written instruction titled, "emergency procedure if RN incapacitated" was hanged on the HD machine. RN 6 stated she (RN 6) was a contracted employee for HD. RN 6 stated she was not sure if the facility gave an in-service to the nurses regarding an emergency procedure if the HD RN became incapacitated.

During an interview on 10/29/2024 at 2:50 p.m. with RN 7, RN7 stated she was the primary nurse assigned to the patient in room 403. RN 7 stated the patient was on HD and a nurse-to-nurse verbal handoff communication would be conducted before and after HD treatment. RN 7 stated they were not given an in-service regarding an emergency procedure if the HD RN became incapacitated while providing HD to the patient.

During an interview on 10/29/2024 at 2:55 p.m., with the Director of Service and Support (DSS), the DSS stated the primary nurse and HD nurse would verbally communicate and there was instruction on the HD machine. DSS was questioned by surveyor how to verify or validate the nurses were competent on how to handle an emergency situation if the HD nurse was incapacitated, DSS stated should have a in-service for that.

During an interview on 10/31/2024 at 12:07 p.m. with the Director of Quality (DQ), the DQ stated the facility did not have a Policy and Procedure (P&P) regarding emergency termination of dialysis by a non-dialysis staff. The DQ verified there was no record of the RNs having a training or in-service for emergencies during HD including safely shutting shut off HD machine in case of an emergency. The DQ stated there should have a training for the RNs on proper handling of HD machine for the patient's receiving HD treatment in an emergency situation case as needed.

Based on observation, interview, and record review, the facility failed to ensure for one of 36 sampled patients (Patient 24), safe care was provided when Patient 24 was not wearing an identification arm band (facility armband that contains information such as name, date of birth and medical record number) in accordance with the facility's policy and procedure.

This deficient practice resulted in Patient 24 to not to be accurately identified and had the potential for the patient's safety to be compromised, while in the facility, such as with medication errors, etc. due to lack of proper identification.

Findings:

During a concurrent observation and interview, on 10/29/24 at 3:10 PM, with Charge Nurse 1 (CN 1), Patient 24 was observed lying in bed, awake, and oriented (a mental state marked by knowing time, place, or who one is). Patient 24 was not wearing an identification armband. CN 1 stated Patient 24 should wear an identification armband at all times. CN 1 stated the risk of Patient 24 not having an identification armband attached would be the possibility of falsely identifying a patient and causing medical errors.

During a review of Patient 24's "History and Physical (H&P)," dated 9/26/2024, the H&P indicated, Patient 24 was admitted to the facility for complaints of chest pressure, right sided facial paresthesia (the feeling of tingling, numbness or "pins and needles"), and right arm and leg weakness and bilateral (both side) hand paresthesia along with slurred speech.

During a review of the facility's policy and procedure (P&P) titled, "Patient Armband Replacement: Guidelines," dated 11/3/2023, the P&P indicated, "Every patient will have an armband placed on their person upon entrance to the hospital. Said armband must remain on their person at all times while on the premises of the hospital."

Based on interview and record review, the facility failed to ensure for two of 36 sampled patients (Patients 22 and 28), the following:

1. Patient 22's Hydralazine (medication used to lower blood pressure [BP, amount of force blood uses to move through the body, with a normal range less than 120/80 mmHg]) was given as ordered by the physician.

This deficient practice had the potential to worsen Patient 22's condition due to uncontrolled Hypertension which can lead to complications such as stroke (clot in the brain), seizures (abnormal electrical activity in the brain that can cause abnormal behavior, movements, etc.) , prolonged hospitalization and/or death.

2. Patient 28's cefepime (antibiotic, use for treatment of an infection) and azithromycin (antibiotic, use for treatment of an infection) were given in accordance with the physician's order and the facility's policy and procedure regarding medication administration.

This deficient practice resulted in delay of treatment and had the potential for the antibiotic to be ineffective in the treatment of Patient 28's infection.

Findings:

1. During a review of Patient 22's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 10/19/2024, the H&P indicated Patient 22 was admitted for left groin pain. Patient 22 had a history of high blood pressure, kidney failure (when the kidneys can no longer function properly to remove waste and excess water from the blood) requiring hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing).

During a concurrent interview and record review on 10/31/2024 at 11:20 a.m. with the Director of Service and Support (DSS), the DSS verified Patient 22's "Medication Detail," dated 10/22/2024, included a physician's order for Patient 22 to be given Hydralazine 10 milligram (mg, unit of measure) intravenously (IV, through the vein), every four hours as needed (PRN) for systolic (SBP, maximum amount of pressure the blood uses to move through the body) greater than 160 mmHg (millimeters of mercury, a unit of measure).

In the same interview and record review, on 10/31/2024 at 11:20 a.m., the DSS verified Patient 22's "Vital Signs Flowsheet," dated 10/27/2024, Patient 22 had the following BP readings:

-At 7:54 a.m., Patient 22's BP was 166/82 mmHg;
-At 11:42 a.m., Patient 22's BP was 177/79 mmHg;
-At 3:43 p.m., Patient 22's BP was 172/68 mmHg;
-At 9:07 p.m., Patient 22's BP was 186/79 mmHg;
-At 11:50 p.m., Patient 22's BP was 185/78 mmHg.

In addition, the "Vital Signs Flowsheet," dated 10/28/2024 at 3:12 p.m., Patient 22's BP was 173/77 mmHg.

The DSS further stated on 10/31/2024 at 11:20 a.m., Patient 22's "Medication Administration Record" had no documentation of Hydralazine given when Patient 22's BP was greater than 160 mmHg on 10/27/2024 at 7:54 a.m.; at 11:42 a.m.; at 3:43 p.m.; at 9:07 p.m.; at 11:50 p.m., and on 10/28/2024 at 3:12 p.m. The DSS stated it was important to give Patient 22 Hydralazine to lower the patient's BP. The DSS stated not giving Patient 22 Hydralazine as needed could put the patient at risk for stroke and other life-threatening complications.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration and Safety, "dated 2/2/2024, the P&P indicated, "The RN will administer medications using the nursing process assessment, planning, implementation, evaluation ..."

2. During a review of Patient 28's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 10/23/2024, the H&P indicated Patient 28 was admitted to the facility for failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity) and pneumonia (lung infection).

2.a. During a concurrent interview and record review, on 10/31/2024 at 10:30 a.m., with the Clinical Manager, the CM verified Patient 28's "Medication Administration Record (MAR)," dated 10/23/2024, included a physician's order for Patient 28 to be given cefepime (antibiotic, use for treatment of an infection) 1 gram intravenous (IV - within the veins), to be given every 12 hours, with a start date of 10/23/2024 at 9:00 PM.

In the same interview and record review, on 10/31/2024 at 10:30 a.m., the CM stated Patient 28's MAR indicated Patient 28 was given cefepime on 10/24/2024 at 8:36 a.m.. The next cefepime dose was given at 10:02 p.m. (13 hours and 27 minutes since the last dose was given).

The CM stated Patient 28's cefepime dose given on 10/24/2024 at 10:02 p.m. was 1 hour and 27 minutes late. The CM stated the antibiotic should have been given within one hour of scheduled dose.

2.b. During a concurrent interview and record review, on 10/31/2024 at 10:40 a.m., with the CM, the CM verified Patient 28's "Medication Administration Record (MAR)," dated 10/23/2024, included a physician's order for Patient 28 to receive azithromycin (antibiotic, use for treatment of an infection) 500 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) IV, to be given once a day, with a start date of 10/23/2024 at 9:00 a.m.

In the same interview and record review, on 10/31/2024 at 10:40 a.m., the CM stated Patient 28's MAR indicated Patient 28 was given azithromycin 500 mg IV on 10/23/2024 at 11:13 a.m. (2 hours and 13 minutes after the initial dose of antibiotic was ordered to be given). The CM stated the azithromycin should have been given to Patient 28 within an hour of scheduled dose.

In a follow up interview on 10/31/2024 at 10:45 a.m., the CM stated antibiotic dose should be given within one hour of scheduled time to make sure a therapeutic level of antibiotics remains in the bloodstream to treat the infection.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration and Safety," dated 2/2/2024, the P&P indicated the following:

-"Before administering a medication the licensed nurse must...Verify that the medication is being given at the proper time, in the prescribed dose and by the correct route.

-"Non-time-critical scheduled medications are to be administered within 60 minutes before or after the schedule dose time. Scheduled time will be indicated in the electronic-MAR (e-MAR)".