HospitalInspections.org

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

1. The facility failed to ensure for four of 31 sampled patients (Patients 22, 27, 29, and 30) the following:

1.a. Patient 22 and/or the patient's representative was provided a copy of the Conditions of Admission (COA, contract between the hospital and patient explaining patient's right and responsibilities) and the Important Message from Medicare letter (IMM, given to all Medicare [federal health insurance for people at a certain age or with specific medical disabilities] beneficiaries, notifying them of their hospital discharge appeal rights) upon admission to the facility.

1.b. Patient 27 and/or the patient's representative was provided a copy of the "Consent for Treatment (COT - a patient's permission to receive medical treatment, tests, or examinations) and Conditions of Admission (COA - a contract between a patient and a hospital that outlines the patient's responsibilities for the hospital services they receive)" and the IMM letter upon admission to the facility.

1.c. Patient 29's "COT (Consent for Treatment) and COA (Conditions of Admission)" was provided in Patient 29's preferred language (Mandarin).

1.d. Patient 30's "COT (Consent for Treatment) and COA (Conditions of Admission)" and IMM (Important Message from Medicare) letter was provided in Patient 30's preferred language (Spanish).

These deficient practices resulted in Patients 22, 27, 29, 30 and/or the patients' representative to not be informed of their rights as a patient and their rights to appeal for discharge from the hospital, which may lead in Patients 22, 27, 29, and 30's inability to effectively make decisions regarding their care and treatment. (Refer to A-0117)

2. The facility failed to ensure the patient's rights requirement was met for one of 31 sampled patients (Patient 12), in accordance with the facility's policy and procedure regarding Patients Rights (Example: the right to considerate, respectful care at all times and under all circumstances), when Patient 12 was placed on an involuntary hold (detain a person for treatment against their will) in the facility's Emergency Department (ED, provides immediate care to patients arriving at the hospital) without evidence of a 5150 form (The 5150 form, also known as the "Application for Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment" or 5150," is a legal document that must be signed by an authorized professional person to initiate an involuntary detention [for evaluation and treatment], for someone who is showing signs of severe mental distress.) filled out and completed.

This deficient practice had the potential of violating patient's rights by placing Patient 12 on an involuntary hold without proper documentation and justification of the 5150 hold (a law that allows for the involuntary psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders] hospitalization of an adult experiencing a mental health crisis) by an authorized professional person. (Refer to A-0129)

3. The facility failed to ensure for one of 31 sampled patients (Patient 22), Patient 22 and/or the patient's representative was provided a "Blood Transfusion (used for low blood levels, and is an important procedure that moves blood or blood products into a person's body through the bloodstream, and can carry risks such as an allergic reaction, heart, or lung problems) Information and Consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered)," prior to Patient 22 receiving blood transfusion, in accordance with the physician's order and the facility's policy and procedure regarding blood transfusion.

This deficient practice resulted in Patient 22 and the patient's representative to not exercise their right to make an informed decision regarding Patient 22's care, as well as understand the risks and benefits of blood transfusion. (Refer to A-0131)

4. The facility failed to ensure for four of 31 sampled patients (Patients 22, 26, 27, and 29) the following:

4.a. Patients 22's Advance Directive (AD, legal document a patient makes in case they are no longer able to communicate their instructions for care) copy was obtained by the facility upon admission.

4.b. Patient 26's AD (Advance Directive) copy was obtained by the facility upon admission.

4.c. Patient 27 and/or the patient's representative was provided information on how to formulate an AD (Advance Directive) upon admission.

4.d. Patient 29's AD (Advance Directive) copy was obtained by the facility upon admission.

These deficient practices had the potential to negatively affect Patients 22, 26, 27, and 29's rights and wishes for treatment when the patient receives medical care that was not in accordance with the patients' AD (Advance Directive). (Refer to A-0132)

5. The facility failed to ensure for one of 30 sampled patients (Patient 23), Patient 23's care plan (part of the nursing process, and is a set of goals, assessments, and interventions for each problem) for the use of restraint (chemical or physical device that prevents a person from freely moving), was developed, in accordance with the facility's policy and procedure regarding restraints use.

This deficient practice had the potential to result in delayed provision of care to the patients by not identifying Patient 23's needs and risks. (Refer to A-0166)

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

Based on observation, interview, and record review, the facility failed to ensure for four of 31 sampled patients (Patients 22, 27, 29, and 30) the following:

1. Patient 22 and/or the patient's representative was provided a copy of the Conditions of Admission (COA, contract between the hospital and patient explaining patient's right and responsibilities) and the Important Message from Medicare letter (IMM, given to all Medicare [federal health insurance for people at a certain age or with specific medical disabilities] beneficiaries, notifying them of their hospital discharge appeal rights) upon admission to the facility.

2. Patient 27 and/or the patient's representative was provided a copy of the "Consent for Treatment (COT - a patient's permission to receive medical treatment, tests, or examinations) and Conditions of Admission (COA - a contract between a patient and a hospital that outlines the patient's responsibilities for the hospital services they receive)" and the IMM letter upon admission to the facility.

3. Patient 29's "COT (Consent for Treatment) and COA (Conditions of Admission)" was provided in Patient 29's preferred language (Mandarin).

4. Patient 30's "COT (Consent for Treatment) and COA (Conditions of Admission)" and IMM (Important Message from Medicare) letter was provided in Patient 30's preferred language (Spanish).

These deficient practices resulted in Patients 22, 27, 29, 30 and/or the patients' representative to not be informed of their rights as a patient and their rights to appeal for discharge from the hospital, which may lead in Patients 22, 27, 29, and 30's inability to effectively make decisions regarding their care and treatment.

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 9/17/2024, the H&P indicated Patient 22 was admitted for low oxygen levels. Patient 22 had a history of End Stage Renal Disease (ESRD, poor kidney function), on dialysis (procedure that cleans the blood and removes wastes and extra fluids through a machine), and was in a vegetative state (unable to intentionally move or speak and is unaware of surroundings).

During a review of Patient 22's "Face sheet" (document containing basic patient information including emergency contact), the record indicated Patient 22 had an emergency contact listed.

During a concurrent interview and record review on 10/3/2024 at 11:20 a.m. with the Clinical Educator (CE) and the Clinical Informatics Manager (CIM), the CE and the CIM verified Patient 22's record did not have a copy of Conditions of Admission (COA, contract between the hospital and patient explaining patient's right and responsibilities) and the Important Message from Medicare letter (IMM, given to all Medicare [federal health insurance for people at a certain age or with specific medical disabilities] beneficiaries, notifying them of their hospital discharge appeal rights).

During an interview on 10/3/2024 at 10:17 a.m. with the Admitting Director (AD), the AD stated the process for providing a copy and obtaining a signature of the patient for the COA and IMM letter included visiting the unit the patient was admitted to and see if the patient was alert to receive and sign the document. The AD further stated the patient's representative should be called if the patient was not alert or unable to sign.

During a concurrent interview and record review on 10/3/2024 at 11:35 a.m. with the AD, the AD verified Patient 22's record did not have a COA and IMM letter. The AD stated there were two attempts made for Patient 22 to sign the COA and IMM letter. The AD said it was documented that Patient 22 was unable to sign and there was no family at the bedside. The AD stated there was no documentation Patient 22's representative was contacted. The AD said Patient 22 had an emergency contact listed and should have been called to discuss Patient 22's COA and IMM Letter.

During a review of the facility's policy and procedure (P&P) titled, "Medicare Beneficiary Appeal Rights," dated 7/2022, the P&P indicated, "Hospitals must issue the Important Message for Medicare (IM) within two (2) days of admission and must obtain the signature of the beneficiary or his or her representative ... When a beneficiary is unable to understand the notice, the hospital may have the beneficiary's representative receive and sign the notice in accordance with state or other applicable law. If the hospital is unable to personally deliver a notice to a representative, then the hospital should telephone the representative to advise him or her of the beneficiary's rights as a hospital patient, including the right to appeal a discharge decision."

During a review of the facility's policy and procedure (P&P) titled, "Completion of Admitting Forms," dated 2/22/2023, the P&P indicated, "If a patient is unable to sign due to mental or physical capacity at time of admission and a patient representative is not available to sign, documentation shall include "Patient unable to sign." Registration staff shall make an additional attempt to obtain signatures at least 2 times."

2. During a review of Patient 27's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/27/2024, the H&P indicated, Patient 27 was admitted to the facility on 9/25/2024 for a leaking gastrostomy tube (G-tube - a tube that's surgically inserted through the abdominal wall and into the stomach; allows for nutrition, fluids, and medications to be delivered directly to the stomach).

The H&P further indicated, Patient 27 had a past medical history of a chronic (long term) tracheostomy (a surgical procedure that creates an opening in the neck to allow air to reach the lungs) and ventilator (a machine or device used medically to support or replace the breathing of a person) dependence.

During a review of Patient 27's face sheet (document containing basic patient information including emergency contact), , dated 9/26/2024, the face sheet indicated Patient 27 was admitted on 9/25/2024 at 10:06 p.m. and that Patient 27 had an emergency contact listed.

2.a. During a concurrent interview and record review on 10/3/2024 at 10:19 a.m. with the Admitting Director (AD), the AD verified Patient 27's "Consent for Treatment (COT - a patient's permission to receive medical treatment, tests, or examinations) and Conditions for Admission (COA - a contract between a patient and a hospital that outlines the patient's responsibilities for the hospital services they receive)," indicated a verbal consent was provided by Patient 27's listed emergency contact on 10/3/2024 (8 days after Patient 27 was admitted to the facility).

During the same interview and record review on 10/3/2024 at 10:19 a.m., the AD stated a copy of the "COT and COA" was not provided to Patient 27 and the patient's representative at the time of admission. The AD said Patient 27's record had a documentation of an attempt to provide the "COT and COA" on admission and indicated Patient 27 was unable to sign. The AD stated Patient 27's representative should have been contacted when Patient 27 was unable to sign.

During a review of the facility's policy and procedure (P&P) titled, "Medicare Beneficiary Appeal Rights," dated 7/2022, the P&P indicated, "Hospitals must issue the Important Message for Medicare (IM) within two (2) days of admission and must obtain the signature of the beneficiary or his or her representative ... When a beneficiary is unable to understand the notice, the hospital may have the beneficiary's representative receive and sign the notice in accordance with state or other applicable law. If the hospital is unable to personally deliver a notice to a representative, then the hospital should telephone the representative to advise him or her of the beneficiary's rights as a hospital patient, including the right to appeal a discharge decision."

During a review of the facility's policy and procedure (P&P) titled, "Completion of Admitting Forms," dated 2/22/2023, the P&P indicated, "If a patient is unable to sign due to mental or physical capacity at time of admission and a patient representative is not available to sign, documentation shall include "Patient unable to sign." Registration staff shall make an additional attempt to obtain signatures at least 2 times."


2.b. During a concurrent interview and record review on 10/3/2024 at 10:19 a.m. with the Admitting Director (AD), The AD verified Patient 27's "Important Message from Medicare letter (IMM, given to all Medicare [federal health insurance for people at a certain age or with specific medical disabilities] beneficiaries, notifying them of their hospital discharge appeal rights)," indicated a verbal consent was provided by Patient 27's listed emergency contact on 10/3/2024 (8 days after Patient 27 was admitted to the facility).

During the same interview and record review, on 10/3/2024 at 10:19 a.m., the AD stated the IMM letter was not provided to Patient 27 and the patient's representative at the time of admission. The AD stated Patient 27's record had a documentation of an attempt to provide the IMM letter on admission and indicated Patient 27 was unable to sign. The AD stated Patient 27's representative should have been contacted when Patient 27 was unable to sign.

During a review of the facility's policy and procedure (P&P) titled, "Medicare Beneficiary Appeal Rights," dated 7/2022, the P&P indicated, "Hospitals must issue the Important Message for Medicare (IM) within two (2) days of admission and must obtain the signature of the beneficiary or his or her representative ... When a beneficiary is unable to understand the notice, the hospital may have the beneficiary's representative receive and sign the notice in accordance with state or other applicable law. If the hospital is unable to personally deliver a notice to a representative, then the hospital should telephone the representative to advise him or her of the beneficiary's rights as a hospital patient, including the right to appeal a discharge decision."

During a review of the facility's policy and procedure (P&P) titled, "Completion of Admitting Forms," dated 2/22/2023, the P&P indicated, "If a patient is unable to sign due to mental or physical capacity at time of admission and a patient representative is not available to sign, documentation shall include "Patient unable to sign." Registration staff shall make an additional attempt to obtain signatures at least 2 times."

3. During a concurrent observation and interview on 10/2/2024 at 10:25 a.m. with Registered Nurse (RN) 12, in Patient 29's room, Patient 29 was observed resting in bed with his eyes closed. RN 12 stated Patient 29 only speaks Mandarin. RN 12 stated she communicated with Patient 29 using a language interpreter (translates medical information between patients and healthcare providers) via the electronic tablet.

During a review of Patient 29's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 10/1/2024, the H&P indicated, Patient 29 was admitted to the facility for fever (a body temperature that is higher than normal) with vomiting and productive cough.

During a concurrent interview and record review on 10/3/2024 at 3:10 p.m. with the Clinical Manager of Medical Surgical (CMMS), the CMMS verified Patient 29's face sheet (document containing basic patient information including emergency contact), dated 10/2/2024, indicated Patient 29's preferred language was English. Subsequently, the CMMS called the nursing unit, and the CMMS verified Patient 29's preferred language was Mandarin, and not English. The CMMS stated the face sheet would be updated to reflect that Patient 29's preferred language was Mandarin.

During a concurrent interview and record review on 10/3/2024 at 3:45 p.m. with the CMMS, the CMMS verified Patient 29's "Consent for Treatment (COT - a patient's permission to receive medical treatment, tests, or examinations) and Conditions for Admission (COA - a contract between a patient and a hospital that outlines the patient's responsibilities for the hospital services they receive)," dated 10/1/2024, was written in English (Patient 29's preferred language was Mandarin). The CMMS stated Patient 29's "COT and COA" did not have an information if a language interpreter was used. The CMMS stated Patient 29's "COT and COA" should have been written in the patient's preferred language or an interpreter was used to ensure the patient understood his rights as a patient.

During a review of the facility's policy and procedure (P&P) titled, "Interpreters - Translation of Documents," dated 03/2024, the P&P indicated:

- "Documents requiring patient's signature whenever possible will be in the language the patient speaks. If the document is not available in their primary language the interpreter service should be used and information recorded in the document."
- "Consents are available in English and Spanish; Other languages require the use of the interpreter service. The name of the interpreter or the interpreter ID number must be documented on the consent."

4. During a review of Patient 30's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/26/2024, the H&P indicated Patient 30 was admitted to the facility for fever (a body temperature that is higher than normal) of three days, nausea (a feeling of sickness with an inclination to vomit), vomiting, dysuria (a symptom that describes the sensation of pain, burning, stinging, or itching when urinating), and increased urinary frequency related to sepsis (a life-threatening medical emergency that occurs when the body's immune system has an extreme response to an infection or injury) and pyelonephritis (a kidney infection).

During a concurrent interview and record review on 10/3/2024 at 4:12 p.m. with the Clinical Manager of Medical Surgical (CMMS), the CMMS verified Patient 30's face sheet (document containing basic patient information including emergency contact), dated 9/26/2024, indicated Patient 30's preferred language was Spanish.

4.a. During a concurrent interview and record review on 10/3/2024 at 4:48 p.m. with the Patient Safety Officer (PSO), the PSO verified Patient 30's "Consent for Treatment (COT - a patient's permission to receive medical treatment, tests, or examinations) and Conditions of Admission (COA - a contract between a patient and a hospital that outlines the patient's responsibilities for the hospital services they receive)," dated 9/26/2024, indicated the "COT and COA" was written in English (Patient 30's preferred language was Spanish). The PSO stated Patient 30's "COT and COA" did not have an information if a language interpreter was used. The CMMS stated Patient 30's "COT and COA" should have been written in the patient's preferred language or an interpreter was used.

During a review of the facility's policy and procedure (P&P) titled, "Interpreters - Translation of Documents," dated 03/2024, the P&P indicated:

- "Documents requiring patient's signature whenever possible will be in the language the patient speaks. If the document is not available in their primary language the interpreter service should be used and information recorded in the document."

- "Consents are available in English and Spanish; Other languages require the use of the interpreter service. The name of the interpreter or the interpreter ID number must be documented on the consent."

4.b. During a concurrent interview and record review on 10/3/2024 at 4:48 p.m. with the PSO, the PSO verified Patient 30's Important Message from Medicare letter (IMM, given to all Medicare [federal health insurance for people at a certain age or with specific medical disabilities] beneficiaries, notifying them of their hospital discharge appeal rights), dated 9/26/2024, was written in English (Patient 30's preferred language was Spanish). The PSO stated Patient 30's IMM letter did not have an information if a language interpreter was used. The CMMS said Patient 30's IMM letter should have been written in the patient's preferred language or an interpreter was used.

During a review of the facility's policy and procedure (P&P) titled, "Interpreters - Translation of Documents," dated 03/2024, the P&P indicated:

- "Documents requiring patient's signature whenever possible will be in the language the patient speaks. If the document is not available in their primary language the interpreter service should be used and information recorded in the document."

- "Consents are available in English and Spanish; Other languages require the use of the interpreter service. The name of the interpreter or the interpreter ID number must be documented on the consent."

Based on interview and record review, the facility failed to ensure the patient's rights requirement was met for one of 31 sampled patients (Patient 12), in accordance with the facility's policy and procedure regarding Patients Rights (Example: the right to considerate, respectful care at all times and under all circumstances), when Patient 12 was placed on an involuntary hold (detain a person for treatment against their will) in the facility's Emergency Department (ED, provides immediate care to patients arriving at the hospital) without evidence of a 5150 form (The 5150 form, also known as the "Application for Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment" or 5150," is a legal document that must be signed by an authorized professional person to initiate an involuntary detention [for evaluation and treatment], for someone who is showing signs of severe mental distress.) filled out and completed.

This deficient practice had the potential of violating patient's rights by placing Patient 12 on an involuntary hold without proper documentation and justification of the 5150 hold (a law that allows for the involuntary psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders] hospitalization of an adult experiencing a mental health crisis) by an authorized professional person.

Findings:

During a concurrent interview and record review on 10/3/2024 at 2:17 p.m. with the Clinical Informatics Manager (CIM), Patient 12's Electronic Medical Record ([EMR], digital version of paper chart), was reviewed. The EMR indicated that Patient 12 was seen by an ED (Emergency Department, where patients in need of immediate care are seen upon arrival at the hospital) Provider on 9/22/2024 at 11:50 p.m. The EMR indicated that Patient 12 was a 25 years old female brought in by ambulance from home for evaluation after drinking cleaning fluid with the intention of harming herself. Patient 12 was placed on a 5150 hold (a law that allows for the involuntary psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders] hospitalization of an adult experiencing a mental health crisis) prior to her (Patient 12) arrival in the ED. CIM stated that there were no records of a completed signed 5150 form in Patient's 12 EMR. CIM added that without the 5150 forms, Facility was unable to determine who signed the 5150 form or that person's assessment, evaluation, and justification in placing Patient 12 on a 72-hour hold (temporary detention of a person for evaluation and treatment in a mental health facility against their will).

During a concurrent interview and record review on 10/4/2024 at 10:44 a.m. with the Director of Emergency Department (DED), Patient 12's Electronic Medical Record ([EMR], digital version of paper chart), was reviewed. DED stated that the ED practice for a patient coming in with a completed 5150 form was for staff to scan and keep a copy of the form in the patient's EMR. The original 5150 form will be sent out with the patient upon transfer to a behavioral health facility. For Patient 12, most likely staff may have forgotten to scan the 5150 form into the patient's (Patient 12) EMR. DED further said "It's important that the facility must have a 5150 form."

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights Responsibilities," last approved date 04/2023, the P&P indicated the following: "Respect and Dignity: The patient has the right to considerate, respectful care at all times and under all circumstances, with recognition of his/her personal dignity. Consideration shall be given to the psychosocial, spiritual and cultural variables influencing the patient. The patient has the right to express spiritual beliefs and cultural practices that do not harm others or interfere with the planned course of medical therapy for the patient.

During a review of the facility's policy and procedure (P&P) titled, "Psychiatric Patients in the ED," last approved date 01/2022, the P&P indicated the following: "PURPOSE: To protect the patient who is compromised and act in the patients' best interest while the patient's judgment may be impaired. Psychiatric patients who are a danger to themselves, to others, or gravely disabled, under California Welfare and Institutions Code 5150, may be placed in protective custody either by a peace office or qualified individual. When this occurs, the patient MUST be placed in a designated psychiatric facility. The ED Physician is not considered a qualified individual unless he/she has received specific training regarding 5150 placement."

Based on interview and record review, the facility failed to ensure for one of 31 sampled patients (Patient 22), Patient 22 and/or the patient's representative was provided a "Blood Transfusion (used for low blood levels, and is an important procedure that moves blood or blood products into a person's body through the bloodstream, and can carry risks such as an allergic reaction, heart, or lung problems) Information and Consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered)," prior to Patient 22 receiving blood transfusion, in accordance with the physician's order and the facility's policy and procedure regarding blood transfusion.

This deficient practice resulted in Patient 22 and the patient's representative to not exercise their right to make an informed decision regarding Patient 22's care, as well as understand the risks and benefits of blood transfusion.

Findings:

During a review of Patient 22's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/17/2024, the "H&P" indicated, Patient 22 was admitted for low oxygen levels, with bilateral (both sides) pleural effusions (fluid buildup in the space between the lungs and chest wall), and had a thoracentesis (procedure to remove fluid or air in the space between the lungs and chest wall). Patient 22's medical history included End Stage Renal Disease (ESRD, poor kidney function), on dialysis (procedure that cleans the blood by removing extra fluids and waste).

During a review of Patient 22's "Transfuse Red Blood Cells (RBC, blood) Active Bleed-Adult/Adolescent (RBC transfusion order)," dated 9/21/2024, the order indicated for Patient 22 to have 1 unit (bag) of RBC given for a low Hemoglobin (Hgb, part of the red blood cell that carries oxygen) level of 7.1 (normal is at 12 g/dl [a unit of measurement]).

During a review of Patient 22's RBC transfusion order, dated 9/26/2024, the order indicated for Patient 22 to have 1 unit (bag) of RBC given for a Hgb level less than 7.

During a review of Patient 22's "Verify (confirm) Consent" order, dated 9/21/2024, the order indicated to verify Patient 22's consent for blood transfusion.

During a concurrent interview and record review on 10/1/2024 at 12:37 p.m. with the Director of ICU (DICU), Patient 22's "Transfusion Record," dated 9/21/2024 and 9/26/2024, indicated Patient 22 received blood transfusions. The DICU verified Patient 22's record did not have a blood transfusion consent when Patient 22 received blood transfusion on 9/21/2024 and 9/26/2024. The DICU stated Patient 22 should have a blood transfusion consent prior to receiving blood transfusion.

During a review of the facility's policy and procedure (P&P) titled, "Administration of Blood and Components," dated 09/2022, the P&P indicated, "The process of blood administration should begin and end with patient's safety in mind ...and maintenance of appropriate records ...Blood transfusion will occur only when the following criteria are met ...The patient has signed consent for transfusion, and the physician must document informed consent in the medical record ...Pre-Transfusion Requirements (Nursing): The patient or an authorized representative must read and sign the required consent form to receive blood."

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights Responsibilities," dated 02/2023, the P&P indicated, "The patient has the right to receive as much information about any proposed treatment or procedure as the patient may need in order to give informed consent, or refuse this course of treatment...This information shall include a description of the procedure or treatment, the medically significant risks involved in this treatment, alternative courses of treatment or non-treatment and the risks involved in each, and to know the name of the person who will carry out the procedure or treatment."

Based on interview and record review, the facility failed to ensure for four of 31 sampled patients (Patients 22, 26, 27, and 29) the following:

1. Patients 22's Advance Directive (AD, legal document a patient makes in case they are no longer able to communicate their instructions for care) copy was obtained by the facility upon admission.

2. Patient 26's AD (Advance Directive) copy was obtained by the facility upon admission.

3. Patient 27 and/or the patient's representative was provided information on how to formulate an AD (Advance Directive) upon admission.

4. Patient 29's AD 9Advance Directive) copy was obtained by the facility upon admission.

These deficient practices had the potential to negatively affect Patients 22, 26, 27, and 29's rights and wishes for treatment when the patient receives medical care that was not in accordance with the patients' AD.

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 9/17/2204, the H&P indicated Patient 22 was admitted for low oxygen levels. Patient 22 had a history of End Stage Renal Disease (ESRD, poor kidney function), on dialysis, and was in a vegetative state (unable to intentionally move or speak and is unaware of surroundings).

During a concurrent interview and record review on 10/3/2024 at 11:20 a.m. with the Clinical Educator (CE) and the Clinical Informatics Manager (CIM), Patient 22's questionnaire for having an Advance Directive (AD, legal document a patient makes in case they are no longer able to communicate their instructions for care) was marked, "Yes." The CE and CIM verified Patient 22's medical record did not have a copy of Patient 22's AD.

During a concurrent interview and record review on 10/3/24 at 12:21 p.m. with Charge Nurse 5 (CN) 5, CN 5 stated the facility did not have a copy of Patient 22's AD. CN 5 stated the patient's primary nurse, unit secretary, and/or charge nurse should follow up in getting a copy of the patient's AD if the patient had an AD.

During a review of the facility's policy and procedure (P&P) titled, "Advanced Healthcare Directives," dated 5/2022, the "P&P" indicated, "This hospital shall provide each adult patient over 18 years of age, at the time of his/her admission as an inpatient, written information describing ...The hospital's policies regarding these rights to make healthcare decisions and to formulate AHCD (Advanced Healthcare Directives) and regarding the way such decisions and directives will be implemented in the hospital ... Nursing will confirm the information on the AHCD Questionnaire Form with the patient when completing the Initial Assessment. If the AHCD Questionnaire Form indicates that an AHCD exists but there is no copy available, the nurse must attempt to obtain a copy from the patient's family/significant other and document the attempt in the chart.

2. During a review of Patient 26's "Discharge Summary (a narrative document for communicating clinical information about what happened to the patient in the hospital)," dated 10/2/2024, the summary indicated, Patient 26 was admitted on 9/23/2024 for back pain.

During a concurrent interview and record review on 10/3/2024 at 4:00 p.m. with the Clinical Educator (CE) and ST Segment Elevation Myocardial Infarction (STEMI, deadly type of heart attack) Coordinator (SC), The CE verified Patient 26's questionnaire for having an Advance Directive (AD, legal document a patient makes in case they are no longer able to communicate their instructions for care) was marked, "Yes." The SC stated she (SC) could not recall seeing a copy of Patient 26's AD on the patient's medical record.

During a concurrent interview and record review on 10/4/2024 at 11:07 a.m. with the Clinical Manager of Med-Surg (CMMS), the CMMS stated if patient stated "Yes," to having an AD, the nurse should follow up in getting a copy of the patient's AD.

During a review of the facility's policy and procedure (P&P) titled, "Advanced Healthcare Directives," dated 5/2022, the "P&P" indicated, "This hospital shall provide each adult patient over 18 years of age, at the time of his/her admission as an inpatient, written information describing ... The hospital's policies regarding these rights to make healthcare decisions and to formulate AHCD (Advanced Healthcare Directives) and regarding the way such decisions and directives will be implemented in the hospital ...The hospital shall document in the individual's medical record whether or not the individual has executed an AHCD ... Nursing will confirm the information on the AHCD Questionnaire Form with the patient when completing the Initial Assessment. If the AHCD Questionnaire Form indicates that an AHCD exists but there is no copy available, the nurse must attempt to obtain a copy from the patient's family/significant other and document the attempt in the chart.

3. During a review of Patient 27's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/27/2024, the H&P indicated Patient 27 was admitted to the facility on 9/25/2024 for a leaking gastrostomy tube (G-tube - a tube that's surgically inserted through the abdominal wall and into the stomach; allows for nutrition, fluids, and medications to be delivered directly to the stomach). The H&P further indicated, Patient 27 had a past medical history of a chronic (long term) tracheostomy (a surgical procedure that creates an opening in the neck to allow air to reach the lungs) and ventilator (a machine or device used medically to support or replace the breathing of a person) dependence.

During a review of Patient 27's face sheet (a document that summarizes a person's personal and demographic information), dated 9/26/2024, the face sheet indicated Patient 27 was admitted on 9/25/2024 at 10:06 p.m. and that Patient 27 had an emergency contact listed.

During a concurrent interview and record review on 10/3/2024 at 9:52 a.m. with the Clinical Informatics Manager (CIM), the CIM verified Patient 27's "Admission History Adult," indicated Patient 27 did not have an Advance Directive (AD, legal document a patient makes in case they are no longer able to communicate their instructions for care) and that "information was requested." The CIM stated upon admission on 9/25/2024, Patient 27 did not have an AD.

During a concurrent interview and record review on 10/3/2024 at 10:23 a.m. with the Medical Social Worker (MSW), the MSW confirmed that Patient 27 had an order for Social Services Advance Directive Consult on 9/26/2024 at 7:33 a.m. . The MSW verified the consult order was completed by the MSW on 9/26/2024 at 8:43 a.m. without the MSW note regarding the consult visit.

During the same interview on 10/3/2024 at 10:23 a.m., the MSW stated "order completed" means the consult occurred and that she (MSW) completed the task needed as indicated on the order. The MSW stated Patient 27's record did not have the MSW note to indicate the consult occurred with Patient 27 regarding AD.

During a review of the facility's policy and procedure (P&P) titled, "Advanced Healthcare Directives (AHCD)," dated 05/2022, the P&P indicated the following:

-"If the Advanced Healthcare Directives (AHCD) Questionnaire Form indicates that an AHCD exists but there is no copy available, the nurse must attempt to obtain a copy from the patient's family/significant other and document the attempt in the chart."

-"Social Services will follow-up with patients indicating an interest in further information regarding AHCD."

-"When a patient who lacks present decision-making capacity is admitted to the hospital, family or friend will be asked if the patient has an AHCD."

-"If the patient is unaccompanied information about AHCD will be asked of the surrogate decision-maker as soon as possible."

4. During a review of Patient 29's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 10/1/2024, the H&P indicated, Patient 29 was admitted to the facility for fever with vomiting and productive cough.

During a concurrent interview and record review on 10/3/2024 at 4:47 p.m. with the Admitting Director, Patient 29's "Consent for Treatment (COT - patient's permission to receive medical treatment, tests, or examinations)) and Conditions of Admission (COA - a contract between a patient and a hospital that outlines the patient's responsibilities for the hospital services they receive)," dated 10/1/2024, indicated Patient 29 had an Advance Directive (AD, legal document a patient makes in case they are no longer able to communicate their instructions for care) and that a copy of AD was provided to the facility. The Admitting Director verified the facility did not have a copy of Patient 29's AD. The Admitting Director stated there was no documentation of an attempt to obtain Patient 29's AD.

During a review of the facility's policy and procedure (P&P) titled, "Advanced Healthcare Directives," dated 5/2022, the "P&P" indicated, "This hospital shall provide each adult patient over 18 years of age, at the time of his/her admission as an inpatient, written information describing ...The hospital's policies regarding these rights to make healthcare decisions and to formulate AHCD (Advanced Healthcare Directives) and regarding the way such decisions and directives will be implemented in the hospital ... Nursing will confirm the information on the AHCD Questionnaire Form with the patient when completing the Initial Assessment. If the AHCD Questionnaire Form indicates that an AHCD exists but there is no copy available, the nurse must attempt to obtain a copy from the patient's family/significant other and document the attempt in the chart.

Based on observation, interview, and record review, the facility failed to ensure for one of 30 sampled patients (Patient 23), Patient 23's care plan (part of the nursing process, and is a set of goals, assessments, and interventions for each problem) for the use of restraint (chemical or physical device that prevents a person from freely moving) was developed in accordance with the facility's policy and procedure regarding restraints use.

This deficient practice had the potential to result in in delayed provision of care to the patients by not identifying Patients 23's needs and risks.

Findings:

During a concurrent observation and interview on 10/2/2024 at 10:20 a.m. with Registered Nurse 6 (RN) 6, Patient 23 was observed in bed with bilateral (both sides) wrist restraints (chemical or physical device that prevents a person from freely moving). RN 6 stated Patient 23 was confused but aware of herself.

During a review of Patient 23's "Discharge Summary (a narrative document for communicating clinical information about what happened to the patient in the hospital)," dated 10/2/2024, the discharge summary indicated Patient 23 was admitted on 9/27/2024, for shortness of breath (difficulty breathing), urinary tract infection (UTI, urine infection), agitation (mix of emotions that can make someone feel irritable, tense, or confused) and had a history of depression (constant feelings of sadness and/or loss of interest in usual activities) and fibular fracture (broken lower leg bone).

During a concurrent interview and record review on 10/3/2024 at 2:13 p.m. with the Clinical Educator (CE), the CE verified Patient 23 had an order for bilateral soft wrist restraints from 9/29/2024 through 10/2/2024. The CE stated the record indicated Patient 23 was on bilateral wrist restraints for interfering with incision wound healing, and for pulling on medical devices (intravenous [IV, through the vein] lines, tubes). The CE stated Patient 23 was on bilateral wrist restraints from 9/29/2024 to 10/2/2024.

During the same interview and record review on 10/3/2024 at 2:13 p.m., with the CE and the ST Segment Elevation Myocardial Infarction (STEMI, deadly type of heart attack) Coordinator (SC), the SC verified Patient 23 did not have a care plan (part of the nursing process, and is a set of goals, assessments, and interventions for each problem) for the use of restraints when it was initiated on 9/29/2024. The CE stated Patient 23's restraint care plan was developed on 10/1/2024 (2 days after Patient 23's restraint was applied).

During an interview on 10/3/2024 at 5:20 p.m. with the Director of Telemetry (DT), the DT stated Patient 23's care plan for the use of restraint was important for the nurses to know what needed to be managed, such as looking at skin integrity, and evaluating the need for restraints. The DT stated Patient 23's restraint care plan should have been started within four to six hours after the patient's restraint application.

During a review of the facility's policy and procedure (P&P) titled, "Restraints and Seclusion (involuntary confinement of a patient alone in a room or an area from which the patient is physically prevented from leaving)," dated 6/2024, the P&P indicated, "When Restraint or Seclusion is used, there must be documentation in the patient's medical record of the following ...Use of Restraint or Seclusion in the Plan of Care."

During a review of the facility's P&P titled, "Planning of Care," dated 2/2022, the P&P indicated, "Nursing assessments and associated care plans should be documented in the medical record within 24 hours of inpatient admission or the initiation of observation status."

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

1. The facility failed to ensure three of five sampled patients (Patients 1, 11, and 12) were screened, in accordance with the facility's policy and procedure using the Columbia Suicide Severity Rating Scale Pre-Screener (C-SSRS, supports suicide risk screening in which the answers help users identify whether someone is at risk for suicide [death caused by injuring oneself with the intent to die], determine the severity and immediacy of that risk, and gauge the level of support that the person needs) tool:

1.a. For Patient 1, there was no C-SSRS completed during triage (a system to determine who needs to be seen first by evaluating the severity of patient symptoms); C-SSRS was answered by Registered Nurse (RN) 1 as "no" but should have been answered "yes," and no C-SSRS was completed when Patient 1's mental status condition worsened.

This deficient practice led to undetected suicidal ideation (thoughts of killing oneself) and/or plans, delayed treatment, and compromised Patient 1's safety. Patient 1 eloped (when a patient leaves an area they are expected to stay within, for their safety) from the facility and jumped from the second floor of the parking structure and sustained injury. (Refer to A-0395)

1.b. For Patient 11, a C-SSRS was not properly completed during triage (a system to determine who needs to be seen first by evaluating the severity of patient symptoms); C-SSRS was answered as "no" but should have been answered "yes."

This deficient practice led to incomplete screening of Patient 11 who was diagnosed with suicide ideation (thoughts of killing oneself) in the ED (Emergency Department, where immediate care is provided for patients arriving at the hospital). This deficient practice also had the potential for undetected suicidal ideation and/or plans, delayed treatment, which may compromise Patient 11's safety. (Refer to A-0395)

1.c. For Patient 12, a C-SSRS was not properly completed during triage (a system to determine who needs to be seen first by evaluating the severity of patient symptoms); C-SSRS was answered as "no" but should have been answered "yes."

This deficient practice led to incomplete screening of Patient 12 who was diagnosed with suicide ideation (thoughts of killing oneself) in the ED (Emergency Department, where immediate care is provided for patients arriving at the hospital). This deficient practice also had the potential for undetected suicidal ideation and/or plans, delayed treatment, which may compromise Patient 12's safety. (Refer to A-0395)

2. The facility failed to ensure one of five sampled patient's (Patient 1) change in behavior (emotions and behaviors that affect individual overall well-being) was communicated to the physician, in accordance with the facility's policy and procedure regarding assessment and physician notification about change of condition.

This deficient practice likely led to Patient 1's elopement (when a patient leaves an area they are expected to stay within, for their safety) from the ED (Emergency Department, where immediate care is provided for patients arriving at the hospital) and ran into the facility's parking structure and jumped from the second floor, sustained injuries to the face and forehead and required transport to a trauma specialized hospital (handles the extreme cases where there is an issue immediate survival). (Refer to A-0395)

3. The facility failed to ensure the pain level of two of 31 sampled patients (Patients 6 and Patient 30), was reassessed, after pain medication was administered, in accordance with the facility's policy and procedure regarding pain management standard of care.

This deficient practice had the potential for Patient 6's and Patient 30's pain to not be managed effectively and in a timely manner, and may result in delayed treatment, which could worsen the patients' (Patient 6 and 30) pain level. (Refer to A-0395)

4. The facility failed to ensure one of 31 sampled patients (Patient 25) was reassessed (reevaluated), in accordance with the nursing standard of care and the facility's policy and procedure regarding reassessment, after Ativan (medication used for relaxation), ordered as needed (PRN) for anxiety, was administered, in order to determine the effectiveness of the medication or the patient's (Patient 25) response to the medication (Ativan).

This deficient practice had the potential to cause a delay in determining Patient 25's change of condition and/or a delay in the provision of care needed which could worsen the patient's condition. (Refer to A-0395)

5. The facility failed to ensure one of 31 sampled patients (Patient 26) was reassessed, in accordance with the facility's policy and procedure regarding reassessment, after Hydralazine (medication used for lowering blood pressure [BP, amount of force blood uses to move through the body]), ordered PRN (as needed) 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), was administered.

This deficient practice had the potential to cause a delay in determining Patient 26's change of condition and/or a delay in the provision of care needed which could worsen the patient's condition. (Refer to A-0395)

6. The facility failed to ensure for one of 31 sampled patients (Patient 22), Patient 22's care plan (part of the nursing process, and is a set of goals, assessments, and interventions for each problem) related to dialysis (procedure that cleans the blood by removing extra fluids and waste), was developed, in accordance with the accepted standards of nursing practice and the facility's policy and procedure regarding care planning.

This deficient practice resulted in Patient 22 not having an individualized goal-oriented plan of care to provide a means for interdisciplinary communication for Patient 22's care. In addition, this deficient practice had the potential for Patient 22's needs and risks to not be addressed. (Refer to A-0396)

7. The facility failed to ensure two of 31 sampled patients' (Patients 1 and 2), who were admitted to the facility's Emergency Department (ED, the department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care), focused reassessment at a minimum of every four hours, were completed, in accordance with the facility's policy and procedure regarding frequency of focused reassessment in the ED.

This deficient practice had the potential for missed changes in condition, delay in care, and treatment, which may compromise Patient 1 and Patient 2's safety. (Refer to A-0398)

8. The facility failed to ensure one of 31 sampled patient's (Patient 1's) refusal to take Keppra (Levetiracetam, medication used to treat seizures) medication was properly documented when Patient 1 did not take the medication, in accordance with the facility's policy and procedure regarding medication administration documentation.

This deficient practice had the potential to result in mismanagement of Patient 1's treatment and affect patient's (Patient 1) safety, as Patient 1 was brought into the facility's Emergency Department (ED, the department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care) for suspected seizure (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness). (Refer to A-0398)

9. The facility failed to ensure one of 31 sampled patient's (Patient 3) IV (Intravenous, through the vein) catheter was changed after 96 hours (4 days) instead of 192 hours (8 days), in accordance with the facility's policy and procedure regarding IV catheter management. This deficient practice had the potential to increase Patient 3's risk for catheter-related bloodstream infection, inflammation of the vein due to blood clot (thrombophlebitis), and discomfort. (Refer to A-0398)

10. The facility failed to ensure one of 31 sampled patient's (Patient 8) IV (Intravenous, through the vein) catheter was removed after discovering a hematoma (collection of blood that pools outside the blood vessel) at the catheter site, and notify the physician, in accordance with the facility's policy and procedure regarding IV catheter site maintenance. This deficient practice resulted in Patient 8's left inner arm, from the armpit to above the elbow, to develop swelling and with dark purple discoloration. (Refer to A-0398)

11. The facility failed to ensure one of 31 sampled patient's (Patient 4) medication was not left unattended in the Emergency Department (ED, the department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care) room in the back of a gurney, in accordance with the facility's policy and procedure regarding medications brought from home.

This deficient practice had the potential to compromise Patient 4's safety due to the risk of the patient's (Patient 4) own medications being lost as well as the risk for a mental health patient in the Emergency Department (ED, the department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care) who may unintentionally ingest the medications. (Refer to A-0398)

12. The facility failed to ensure one of 31 sampled patient's (Patient 11) constant observation, due to risk of self-harm, was properly carried out and documented, while Patient 11 was in the Emergency Department (ED, the department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care), in accordance with the facility's policy and procedure regarding Suicide (death caused by injuring oneself with the intent to die) risk assessment and intervention.

This deficient practice had the potential to compromise Patient 11's safety and may result in Patient 11 causing self-harm. (Refer to A-0398)

13. The facility failed to ensure Patients 22 and 31's wound photos were documented, in accordance with the facility's policy and procedure regarding wound care, when Patients 22 and 31's wound photos did not have wound measurement.

This deficient practice had the potential to result in an inaccurate assessment of Patients 22 and 31's wounds and staff may not be able to monitor for signs and symptoms of the patients' wound deterioration. (Refer to A-0398)

14. The facility failed to ensure for two of 31 sampled patients (Patients 26 and 29) the following:

14.a. Patient 26's Hydralazine (medication used to lower blood pressure [BP, amount of force blood uses to move through the body]) was given as ordered by the physician.

This deficient practice had the potential to cause adverse health outcomes (such as continuously elevated blood pressure and complications of stroke [blood clot in the brain]), which could negatively affect Patient 26's health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death of the patient. (Refer to A-0405)

14.b. Patient 29 received the first dose of cefepime (antibiotic, used for treatment of an infection) in a timely manner, in accordance with the facility's Policy and Procedure regarding medication administration.

This deficient practice resulted in a delay in treatment and had the potential for the antibiotic to be ineffective in the treatment of Patient 29's infection. (Refer to A-0405)

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

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

1. Ensure three of five sampled patients (Patients 1, 11, and 12) were screened, in accordance with the facility's policy and procedure using the Columbia Suicide Severity Rating Scale Pre-Screener (C-SSRS, supports suicide risk screening in which the answers help users identify whether someone is at risk for suicide [death caused by injuring oneself with the intent to die], determine the severity and immediacy of that risk, and gauge the level of support that the person needs) tool:

1.a. For Patient 1, there was no C-SSRS completed during triage (a system to determine who needs to be seen first by evaluating the severity of patient symptoms); C-SSRS was answered by Registered Nurse (RN) 1 as "no" but should have been answered "yes," and no C-SSRS was completed when Patient 1's mental status condition worsened.

This deficient practice led to undetected suicidal ideation (thoughts of killing oneself) and/or plans, delayed treatment, and compromised Patient 1's safety. Patient 1 eloped (when a patient leaves an area they are expected to stay within, for their safety) from the facility and jumped from the second floor of the parking structure and sustained injury.

1.b. For Patient 11, a C-SSRS was not properly completed during triage (a system to determine who needs to be seen first by evaluating the severity of patient symptoms); C-SSRS was answered as "no" but should have been answered "yes." This deficient practice led to incomplete screening of Patient 11 who was diagnosed with suicide ideation (thoughts of killing oneself) in the ED (Emergency Department, where immediate care is provided for patients arriving at the hospital). This deficient practice had the potential for undetected suicidal ideation and/or plans, delayed treatment, which may compromise Patient 11's safety.

1.c For Patient 12, a C-SSRS was not properly completed during triage (a system to determine who needs to be seen first by evaluating the severity of patient symptoms); C-SSRS was answered as "no" but should have been answered "yes." This deficient practice led to incomplete screening of Patient 12 who was diagnosed with suicide ideation (thoughts of killing oneself) in the ED (Emergency Department, where immediate care is provided for patients arriving at the hospital). This deficient practice also had the potential for undetected suicidal ideation and/or plans, delayed treatment, which may compromise Patient 12's safety.

2. Ensure one of five sampled patient's (Patient 1) change in behavior (emotions and behaviors that affect individual overall well-being) was communicated to the physician, in accordance with the facility's policy and procedure regarding assessment and physician notification about change of condition.

This deficient practice likely led to Patient 1's elopement (when a patient leaves an area they are expected to stay within, for their safety) from the ED (Emergency Department, where immediate care is provided for patients arriving at the hospital) and ran into the facility's parking structure and jumped from the second floor, sustained injuries to the face and forehead and requiring transport to a trauma specialized hospital.

3. Ensure the pain level of two of 31 sampled patients (Patients 6 and Patient 30) was reassessed after pain medication was administered, in accordance with the facility's policy and procedure regarding pain management standard of care.

This deficient practice had the potential for Patient 6's and Patient 30's pain to not be managed effectively and in a timely manner and may result in delayed treatment, which could worsen the patients (Patient 6 and 30) pain level.

4. Ensure one of 31 sampled patients (Patient 25) was reassessed (reevaluated), in accordance with the nursing standard of care and the facility's policy and procedure regarding reassessment, after Ativan (medication used for relaxation), ordered as needed (PRN) for anxiety, was administered, in order to determine the effectiveness of the medication or the patient's (Patient 25) response to the medication (Ativan).

This deficient practice had the potential to cause a delay in determining Patient 25's change of condition and/or a delay in the provision of care needed which could worsen the patient's condition.

5. Ensure one of 31 sampled patients (Patient 26) was reassessed, in accordance with the facility's policy and procedure regarding reassessment, after Hydralazine (medication used for lowering blood pressure [BP, amount of force blood uses to move through the body]), ordered PRN (as needed) 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), was administered. This deficient practice had the potential to cause a delay in determining Patient 26's change of condition and/or a delay in the provision of care needed which could worsen the patient's condition.


Findings:

1a. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/12/2024, the "H&P" indicated, Patient 1 "presented status post (after) seizure (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness). Patient (Patient 1) had not been taking his Keppra (Levetiracetam, medication used to treat seizures). The patient was seen in the ED (Emergency Department, department of a hospital responsible for the provision of medical and surgical care to patients in need of immediate care) and ready for discharge. At that time, he (Patient 1) became more emotional and complained of having feelings of wanting to hurt himself. For that reason, a psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders) clearance workup (a medical exam to make sure that a patient's psychiatric symptoms are not caused by a medical condition) was initiated, and at the time of elopement (when a patient leaves an area they are expected to stay within, for their safety), the patient (Patient 1) was pending psychiatric evaluation." The H&P further indicated that "on reevaluation/repeat exam, the current time (when Patient 1 eloped) the patient is pending psychiatric evaluation for suicidal ideation."

During a review of Patient 1's "Neurologic Assessment (evaluate function of the brain, involves a series of tests that assesses mental status, reflexes, and movements)," dated 9/11/2024 at 5:45 p.m., the exam indicated Patient 1 was "calm, stares into space, flat affect (emotional flattening, not expressing emotions), coherent (is logical and clear), and alert." The following exam on 9/12/2024 at 6:30 a.m. indicated, "patient (Patient 1) is now euphoric [intense happiness and excitement], not oriented to the situation [the inability to correctly acknowledge the current time, place, one's role, and personal identity], confused [disturbed in mind or purpose], disjointed [unorganized or disconnected thoughts], and easily distracted."

During a concurrent interview and record review on 10/1/2024 at 2:56 p.m. with the Clinical Informatics Manager (CIM), Patient 1's "ED Triage (a system to determine who needs to be seen first by evaluating the severity of patient symptoms)," dated from 9/11/2024 through 9/12/2024, was reviewed. The triage indicated Patient 1 arrived at the ED on 9/11/2024 at 4:53 p.m. Patient 1 received a C-SSRS pre-screener (C-SSRS, supports suicide risk screening in which the answers help users identify whether someone is at risk for suicide [death caused by injuring oneself with the intent to die], determine the severity and immediacy of that risk, and gauge the level of support that the person needs) on 9/12/2024 at 12:17 a.m., seven hours and 24 minutes after admission to the ED. CIM confirmed that there was only one C-SSRS completed for Patient 1, and likewise, Patient 1 did not have a C-SSRS pre-screener completed during initial triage. The CIM confirmed that Patient 1's triage report did not indicate at the time of triage that Patient 1 was not able to answer questions.

During an interview on 10/1/2024 at 4:00 p.m. with Registered Nurse (RN) 1, RN 1 stated that Patient 1's behavior was initially calm and quiet and progressed to becoming strange and asking strange questions. RN 1 stated, Patient 1's behavior worsened towards the end of the shift, it became more frequent when he (Patient 1) would say things like "are we on a space station?" RN 1 stated the C-SSRS Pre-Screen question indicating "Patient present with self-harm intent or signs and/or symptoms of self-harm in the initial assessment or a behavioral health chief complaint," was answered with "no." RN 1 stated, "I should have answered "yes" because the patient has behavioral health as chief compliant." RN 1 further stated when a patient's mental status changed, the RN has to do another CSSRS. During an interview on 10/1/2024 at 5:15 p.m. with Registered Nurse (RN) 2, RN 2 stated, "The patient (Patient 1) has mood swing, up and down, and around 6:30 he sprinted to the bathroom. Closed his eyes and talked to himself."

During the same interview on 10/1/2024 at 4:00 p.m., RN 2 stated around 8:00 a.m. a code gray (a rapid response in the event a need occurs to help control a combative patient, or incident involving violence or impending violence where assistance in the part of other hospital employees may be necessary) was called because Patient 1 was standing up at the edge of the bed." RN 1 confirmed that after the code gray, another psychiatric assessment (assess the individual to establish a diagnosis and formulation of the individual's problems, and to plan their care and treatment) and neurological assessment (collecting subjective and objective data through an interview and detailed physical examination of the individual's function) were to be completed. However, these (referring to another psychiatric assessment and neurological assessment) were not completed.

During a concurrent interview and record review on 10/2/2024 at 10:24 a.m. with the Emergency Department Director (DED), the Columbia Suicide Severity Rating Scale Pre-Screener (C-SSRS, supports suicide risk screening. The answers help users identify whether someone is at risk for suicide, determine the severity and immediacy of that risk, and gauge the level of support that the person needs), was reviewed. The DED stated answering yes to the prescreen question will prompt the staff to complete CSSR questions 1-7, and answering yes to questions 3,4,5,or 7 will trigger interventions such as to initiate a self-harm observation, initiate suicide precaution (set of interventions to reduce access to lethal means of suicide among individuals with identified suicide risk), initiate environment checklist, and notify QMP (a provider approved by the governing body to complete the medical screening exam to determine if an emergency medical condition exists) or QMHP (Qualified Mental Health Professional, an individual who is trained and experienced in providing psychiatric or mental health services to individuals who have a mental illness) for a full suicide assessment, and notify provider. The DED confirmed that for Patient 1, the interventions were not triggered because the answer provided by RN 1 was "no."

During a review of the facility's policy and procedure (P&P) titled, "Suicide Risk Assessment and Intervention," dated November 2022, the P&P indicated, "(name of the facility) will provide for the proper assessment and plan of care for patients with suicidal/self-harm ideation in accordance with this policy ...A registered nurse will pre-screen all patients, >= 12 years of age upon admission. If a registered nurse cannot assess the patient upon arrival due to the patient's medical status, they will perform the pre-screening as soon as the patient's condition permits. A registered nurse will complete the Columbia Suicide Severity Rating Scale (C-SSRS) screening tool for patients requiring a suicide risk screening. If the patient screens positive using C-SSRS, which is defined as providing a "Yes" response to questions 3,4,5, or 7, the nursing staff will complete the following:

1. Send an order request for one-to-one observation to the attending physician.
2. Send a referral for consult to case management, social services, and a BHP.
3. Immediately place the patient on a one-to-one observation by a CHP and obtains a physician's order as soon as possible.
4. Implement at a minimum the following precautions:
a. Place patient in safe hospital attire, preferably green safety scrubs.
b. Provide safe patient food trays.
c. Complete environmental checklist.
d. Where practical, place patient in a preferred room or closest to the main nurse's station.
The nursing staff will use the Constant Observation Flowsheet to document observation. Using the Environment Patient Safety Checklist, the Constant Observer will maintain visualization of identified risks which are not able to be removed. If the patient screens positive using C-SSRS, then the facility designated QMHP will complete an evidenced based full suicide risk assessment within 24 hours... (name of the facility) will require an initial C-SSRS suicide screening if, at any time, a patient who has screened negative for suicide ideations expresses new thoughts of self-harm or suicidal ideation."
1.b During a review of Patient 11's "ED (Emergency Department) Note," dated 9/7/2024, the "ED Note" indicated, Patient 11 was presented for an evaluation of auditory hallucination (the perception of hearing sounds or voices that are not there). The ED Note also indicated that patient (Patient 1) stated he had been hearing voices, felt depressed, thought people want to hurt him (Patient 1), and had suicidal ideations (thoughts of killing oneself). The patient (Patient 1) had attempted to hurt himself in the past by cutting his wrists. He was willing to go voluntarily to a psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders) facility.

During a concurrent interview and record review on 10/2/2024 at 10:24 a.m. with the Emergency Department Director (DED), the "Columbia Suicide Severity Rating Scale Pre-Screener (C-SSRS, supports suicide risk screening. The answers help users identify whether someone is at risk for suicide, determine the severity and immediacy of that risk, and gauge the level of support that the person needs), was reviewed.
The DED stated answering yes to the prescreen question will prompt the staff to complete CSSR questions 1-7, and answering yes to questions 3,4,5,or 7 will trigger interventions such as to initiate a self-harm observation, initiate suicide precaution (set of interventions to reduce access to lethal means of suicide among individuals with identified suicide risk), initiate environment checklist, and notify QMP (a provider approved by the governing body to complete the medical screening exam to determine if an emergency medical condition exists) or QMHP (Qualified Mental Health Professional, an individual who is trained and experienced in providing psychiatric or mental health services to individuals who have a mental illness) for a full suicide assessment, and notify provider.

During a concurrent interview and record review on 10/3/2024 at 2:17 p.m. with the Clinical Informatics Manager (CIM), Patient 11's "ED Triage (a system to determine who needs to be seen first by evaluating the severity of patient symptoms)," dated 9/7/2024, was reviewed. The triage indicated Patient 11 arrived at the ED on 9/7/2024 at 10:34 a.m. Patient 11 received a C-SSRS pre-screener on 9/7/2024 at 10:37 a.m. CIM confirmed that the C-SSRS Pre-Screen question indicating "Patient present with self-harm intent or signs and/or symptoms of self-harm in the initial assessment or a behavioral health chief complaint" was answered with "no." CIM stated, "it should have been answered "yes" because the patient presented with self-harm intent and was diagnosed with suicidal ideation.

During a review of the facility's policy and procedure (P&P) titled, "Suicide Risk Assessment and Intervention," dated November 2022, the P&P indicated, "(name of the facility) will provide for the proper assessment and plan of care for patients with suicidal/self-harm ideation in accordance with this policy ...A registered nurse will pre-screen all patients, >= 12 years of age upon admission. If a registered nurse cannot assess the patient upon arrival due to the patient's medical status, they will perform the pre-screening as soon as the patient's condition permits. A registered nurse will complete the Columbia Suicide Severity Rating Scale (C-SSRS) screening tool for patients requiring a suicide risk screening. If the patient screens positive using C-SSRS, which is defined as providing a "Yes" response to questions 3,4,5, or 7, the nursing staff will complete the following:
1. Send an order request for one-to-one observation to the attending physician.
2. Send a referral for consult to case management, social services, and a BHP.
3. Immediately place the patient on a one-to-one observation by a CHP and obtains a physician's order as soon as possible.
4. Implement at a minimum the following precautions:
a. Place patient in safe hospital attire, preferably green safety scrubs.
b. Provide safe patient food trays.
c. Complete environmental checklist.
d. Where practical, place patient in a preferred room or closest to the main nurse's station.
The nursing staff will use the Constant Observation Flowsheet to document observation. Using the Environment Patient Safety Checklist, the Constant Observer will maintain visualization of identified risks which are not able to be removed. If the patient screens positive using C-SSRS, then the facility designated QMHP will complete an evidenced based full suicide risk assessment within 24 hours... (name of the facility) will require an initial C-SSRS suicide screening if, at any time, a patient who has screened negative for suicide ideations expresses new thoughts of self-harm or suicidal ideation."

1.c. During a review of Patient 12's "ED (Emergency Department) Note," dated 9/22/24, the "ED Note" indicated, Patient 12 was a 25 years old female, was brought in by ambulance from home for evaluation after drinking cleaning fluid. "Patient did ingest the cleaning fluid with the intention of harming herself." Patient (Patient 12) was placed on a 5150 hold (a law that allows for the involuntary psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders] hospitalization of an adult experiencing a mental health crisis) prior to arrival.

During a concurrent interview and record review on 10/2/2024 at 10:24 a.m. with the Emergency Department Director (DED), the "Columbia Suicide Severity Rating Scale Pre-Screener (C-SSRS, supports suicide risk screening. The answers help users identify whether someone is at risk for suicide, determine the severity and immediacy of that risk, and gauge the level of support that the person needs), was reviewed.

The DED stated answering yes to the prescreen question will prompt the staff to complete CSSR questions 1-7, and answering yes to questions 3,4,5,or 7 will trigger interventions such as to initiate a self-harm observation, initiate suicide precaution (set of interventions to reduce access to lethal means of suicide among individuals with identified suicide risk), initiate environment checklist, and notify QMP (a provider approved by the governing body to complete the medical screening exam to determine if an emergency medical condition exists) or QMHP (Qualified Mental health Professional, an individual who is trained and experienced in providing psychiatric or mental health services to individuals who have a mental illness) for a full suicide assessment, and notify provider.

During a concurrent interview and record review on 10/3/2024 at 3:31 p.m. with the Clinical Informatics Manager (CIM), Patient 12's "ED Triage (a system to determine who needs to be seen first by evaluating the severity of patient symptoms)," dated 9/22/2024, was reviewed. The triage indicated Patient 12 arrived at the ED on 9/22/2024 at 11:22 p.m. Patient 12 received a C-SSRS pre-screener on 9/22/2024 at 11:30 p.m. CIM confirmed that the C-SSRS Pre-Screen question indicating "Patient present with self-harm intent or signs and/or symptoms of self-harm in the initial assessment or a behavioral health chief complaint," was answered with "no." CIM stated, "it should have been answered "yes" because the patient presented with self-harm intent and was diagnosed with suicidal ideation.

During a review of the facility's policy and procedure (P&P) titled, "Suicide Risk Assessment and Intervention," dated November 2022, the P&P indicated, "(name of the facility) will provide for the proper assessment and plan of care for patients with suicidal/self-harm ideation in accordance with this policy ...A registered nurse will pre-screen all patients, >= 12 years of age upon admission. If a registered nurse cannot assess the patient upon arrival due to the patient's medical status, they will perform the pre-screening as soon as the patient's condition permits. A registered nurse will complete the Columbia Suicide Severity Rating Scale (C-SSRS) screening tool for patients requiring a suicide risk screening. If the patient screens positive using C-SSRS, which is defined as providing a "Yes" response to questions 3,4,5, or 7, the nursing staff will complete the following:
1. Send an order request for one-to-one observation to the attending physician.
2. Send a referral for consult to case management, social services, and a BHP.
3. Immediately place the patient on a one-to-one observation by a CHP and obtains a physician's order as soon as possible.
4. Implement at a minimum the following precautions:
a. Place patient in safe hospital attire, preferably green safety scrubs.
b. Provide safe patient food trays.
c. Complete environmental checklist.
d. Where practical, place patient in a preferred room or closest to the main nurse's station.
The nursing staff will use the Constant Observation Flowsheet to document observation. Using the Environment Patient Safety Checklist, the Constant Observer will maintain visualization of identified risks which are not able to be removed. If the patient screens positive using C-SSRS, then the facility designated QMHP will complete an evidenced based full suicide risk assessment within 24 hours ... (name of the facility) will require an initial C-SSRS suicide screening if, at any time, a patient who has screened negative for suicide ideations expresses new thoughts of self-harm or suicidal ideation."

2. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/12/2024, the "H&P" indicated, Patient 1 "presented status (after) post seizure (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness). Patient (Patient 1) had not been taking his Keppra (Levetiracetam, medication used to treat seizures). The patient was seen in the ED (Emergency Department, department of a hospital responsible for the provision of medical and surgical care to patients in need of immediate care) and ready for discharge.

At that time, he (Patient 1) became more emotional and complained of having feelings of wanting to hurt himself. For that reason, a psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders] hospitalization of an adult experiencing a mental health crisis) clearance workup (a medical exam to make sure that a patient's psychiatric symptoms are not caused by a medical condition), was initiated, and at the time of elopement (an act or instance of running off secretly against medical advice), the patient was pending psychiatric evaluation." The H&P further indicated that on reevaluation/repeat exam, the current time (when Patient 1 eloped) the patient (Patient 1) was pending psychiatric evaluation for suicidal ideation (thoughts of killing oneself).

During a review of Patient 1's "Neurologic Exam (evaluate function of the brain, involves a series of tests that assesses mental status, reflexes, and movements)," dated 9/11/2024 at 5:45 p.m., the exam indicated Patient 1 was "calm, stares into space, flat affect (emotional flattening, not expressing emotions), coherent (is logical and clear), and alert." The following exam on 9/12/2024 at 6:30 a.m. indicated Patient 1 was euphoric (intense happiness and excitement), not oriented to the situation (the inability to correctly acknowledge the current time, place, one's role, and personal identity), confused (disturbed in mind or purpose), disjointed (unorganized or disconnected thoughts), and easily distracted.

During an interview on 10/1/2024 at 3:10 p.m. with the certified nursing assistant (CNA, an entry-level role that provides vital support to both patients and nurses) 1, CNA 1 stated, he (CNA 1) received report from RN 1 that the patient (Patient 1) was suicidal. CNA 1 further stated that on 9/12/2024 at about 8:00 a.m. "because the Patient (Patient 1) was standing on top of the gurney with his eyes closed, a code gray (a rapid response in the event a need occurs to help control a combative patient, or incident involving violence or impending violence where assistance in the part of other hospital employees may be necessary) was called." CNA 1 stated, "the charge nurse and I have to hold the patient shoulder, we put him back to bed."

During an interview on 10/1/2024 at 4:00 p.m. with Registered Nurse (RN, a licensed medical professional who provides hands-on care in different medical and community settings) 1, RN 1 stated that Patient 1's behavior was initially calm and quiet and progressed to becoming strange and asking strange questions. RN 1 stated, Patient 1's behavior worsened towards the end of the shift, it became more frequent when he (Patient 1) would say things like "are we on a space station?" RN 1 stated on 9/11/2024 at around 10:00 p.m. the physician (MD)1 spoke to the patient (Patient 1) for about 25 minutes. RN 1 stated the physician came back and informed RN 1 that now the patient was "Passive SI (when an individual's thinks about or wishes for death without actually planning to end their life) and we will hold him overnight and need to do PET (Psychiatric Emergency Team, perform evaluations for involuntary detention of individuals determined to be at risk of harming themselves or others as a result of mental disorder) eval (evaluation)." RN 1 stated, "The patient behavior worsens toward the end of the shift. The doctor (name of MD 1) was aware of this, but he (MD 1) left a few hours after we decided to keep the patient (Patient 1) that night after we started to take over. The doctor (name of MD 2) took over care, I did not report this (change in Patient 1's behavior) to him."

During an interview on 10/2/2024 at 11:15 a.m. with the Emergency Department Medical Director (MD) 3, MD 3 stated, "If the patient become more aggressive, and behavior changes, the nurse will communicate to the physician and the physician would assess the patient, may give medication to control behavior issues, and may call PET (Psychiatric Emergency Team) and give (discuss) situation that patient is not giving urine for test and the patient's condition changed."

During a review of the facility's policy and procedure (P&P) titled, "Assessment and Reassessment Patient Care," dated November 2023, the P&P indicated, "To ensure that each patient's physical, psychological and social status is assessed to determine the patient's care needs and to ensure patient's changing needs are reassessed in response to treatment and care provided. All patients at (name of the facility) receiving inpatient, outpatient, or emergency services will have a timely, initial assessment of pertinent medical and psychosocial variables by qualified, privileged, interdisciplinary health care providers. The scope of assessment performed is dependent upon the patient's status, diagnosis, location, response to treatment, and the assessing discipline ... Reporting Abnormal Guidelines for calling MD: Reporting Abnormal Guidelines for calling MD: Any changes in patient baseline vital signs that may cause concerns. All abnormal vital signs should be reported following the guidelines below to the patient's physician unless the physician has ordered specific notification parameters. All interventions should be documented in the outcome notes: Failure to respond to treatment for an acute problem/symptom; Any other concern when there is a change from the patient's baseline or change in condition ..."

3.a. During a review of Patient 6 's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 10/1/2024, the "H&P" indicated, Patient 6's past medical history included hip surgery in 2023. The H&P further indicated, "Patient 6 came in with abdominal pain ...patient underwent incarceration (the contents of the hernia cannot be reduced) right hernia (a condition in which part of an organ is displaced and protrudes through the wall of the cavity containing it) repair."
During a concurrent interview and record review on 10/3/2024 at 3:44 p.m. with the Director of Clinical Quality Improvement (DCQI), Patient 6's "Medication Administration Records (MAR)," was reviewed. The MAR indicated a physician order of Morphine (Morphine sulfate, a drug used to treat moderate to severe pain) 2 milligrams (mg, a unit of measurement) per 1 milliliter (mL, unit of fluid measurement) injection, PRN (as needed) for severe pain (pain scale 8-10). DCQI verified in the MAR that Patient 6 was administered Morphine 2 mg on 10/2/2024 at 9:02 p.m. The DCQI stated there was no documentation of Patient 6's pain re-assessment after the pain medication was given.

During an interview on 10/4/2024 at 10:20 a.m. with the Director of the Emergency Department (DED), DED stated pain medication after it was given should be reassessed; "there is no policy, but this is a nursing standard of care to see if the medication is effective."

During a review of the facility's policy and procedure (P&P) titled, "Pain management," dated July 2022, the P&P indicated, "Provide guidelines for the effective relief and management of acute pain for all patients using an individualized interdisciplinary approach to pain management. Enhance patient comfort and satisfaction. Reduce acute pre-procedure, post-procedure, and post-traumatic pain severity and incidence. Educate patients and staff about the process of pain assessment, evaluation, and treatment ...If interventions are ineffective, alternative measures must be considered. Alternative measures may include but are not limited to: Dosage adjustment and/or new medications. Notification of the physician for new or alternate orders. Implementation of other non-pharmacological measures such as responding, music therapy, massage or immobilization. A reassessment for the presence and intensity of pain shall be performed as a component of the shift assessment for inpatients and following any intervention intended to lessen the patient's pain (e.g., administration of pain medications, application of cold packs, repositioning). Such reassessment is a dynamic and ongoing process which shall take place within a clinically appropriate time frame, depending on the type of intervention, the route of medication administration and the clinical condition of the patient. Staff should document the reassessment of a pain intervention must occur by the end of shift."

3.b. During a review of Patient 30s "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/26/2024, the H&P indicated Patient 30 was admitted to the facility for fever (a body temperature that is higher than normal) of three days, nausea (a feeling of sickness with an inclination to vomit), vomiting, dysuria (a symptom that describes the sensation of pain, burning, stinging, or itching when urinating), and increased urinary frequency related to sepsis (a life-threatening medical emerg

Based on interview and record review, the facility failed to ensure for one of 31 sampled patients (Patient 22), Patient 22's care plan (part of the nursing process, and is a set of goals, assessments, and interventions for each problem) related to dialysis (procedure that cleans the blood by removing extra fluids and waste), was developed in accordance with the accepted standards of nursing practice and the facility's policy and procedure regarding care planning.

This deficient practice resulted in Patient 22 not having an individualized goal-oriented plan of care to provide a means for interdisciplinary communication for Patient 22's care. In addition, this deficient practice had the potential for Patient 22's needs and risks to not be addressed.

Findings:

During a review of Patient 22's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/17/2024, the H&P indicated Patient 22 was admitted for low oxygen levels. Patient 22 had a history of End Stage Renal Disease (ESRD, poor kidney function) and was on dialysis (procedure that cleans the blood by removing extra fluids and waste).

During a review of Patient 22's "Hemodialysis (procedure that cleans the blood by removing extra fluids and waste) Treatment," dated 10/1/2024, the record indicated Patient 22 had an order to receive dialysis.

During a concurrent interview and record review on 10/3/2024 at 12:21 p.m. with Charge Nurse 5 (CN) 5, CN 5 stated Patient 22's "Care Plans" did not include a plan addressing Patient 22's dialysis. CN 5 stated Patient 22 should have a developed care plan that addressed the patient's goals and needs for dialysis treatment.

During a review of the facility's policy and procedure (P&P) titled, "Planning of Care," dated 2/2022, the P&P indicated, "Nursing assessments and associated care plans should be documented in the medical record within 24 hours of inpatient admission or the initiation of observation status."

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

1. Ensure two of 31 sampled patients' (Patients 1 and 2), who were admitted to the facility's Emergency Department (ED, the department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care), focused reassessment at a minimum of every four hours, were completed, in accordance with the facility policy and procedure regarding frequency of focused reassessment in the ED.

This deficient practice had the potential for missed changes in condition, delay in care, and treatment which may compromise Patient 1 and Patient 2's safety.

2. Ensure one of 31 sampled patient's (Patient 1's) refusal to take Keppra (Levetiracetam, medication used to treat seizures) medication was properly documented when Patient 1 did not take the medication, in accordance with the facility's policy and procedure regarding medication administration documentation.

This deficient practice had the potential to result in mismanagement of Patient 1's treatment and affect patient's (Patient 1) safety, as Patient 1 was brought into the facility's Emergency Department (ED, the department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care) for suspected seizure (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness).

3. Ensure one of 31 sampled patient's (Patient 3) IV (Intravenous, through the vein) catheter was changed after 96 hours (4 days) instead of 192 hours (8 days), in accordance with the facility's policy and procedure regarding IV catheter management. This deficient practice had the potential to increase Patient 3's risk for catheter-related bloodstream infection, inflammation of the vein due to blood clot (thrombophlebitis), and discomfort.

4. Ensure one of 31 sampled patient's (Patient 8) IV (Intravenous, through the vein) catheter was removed after discovering a hematoma (collection of blood that pools outside the blood vessel) at the catheter site, and notify the physician, in accordance with the facility's policy and procedure regarding IV catheter site maintenance. This deficient practice resulted in Patient 8's left inner arm, from the armpit to above the elbow, to develop swelling and with dark purple discoloration.

5. Ensure one of 31 sampled patient's (Patient 4) medication was not left unattended in the Emergency Department (ED, the department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care) room in the back of gurney, in accordance with the facility's policy and procedure regarding medications brought from home.

This deficient practice had the potential to compromise Patient 4's safety due to the risk of the medications being lost as well as the risk for a mental health patient in the Emergency Department (ED, the department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care) who may unintentionally ingest the medications.

6. Ensure one of 31 sampled patient's (Patient 11)constant observation, due to risk of self-harm, was properly carried out and documented, while Patient 11 was in the Emergency Department (ED, the department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care), in accordance with the facility's policy and procedure regarding Suicide (death caused by injuring oneself with the intent to die) risk assessment and intervention.

This deficient practice had the potential to compromise Patient 11's safety and may result in Patient 11 causing self-harm.

7. Ensure Patients 22 and 31's wound photos were documented in accordance with the facility's policy and procedure regarding wound care, when Patients 22 and 31's wound photos did not have wound measurement.

This deficient practice had the potential to result in an inaccurate assessment of Patients 22 and 31's wounds and staff may not be able to monitor for signs and symptoms of the patients' wound deterioration.

Findings:

1.a. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/12/2024, the "H&P" indicated, Patient 1 "presented status post (after) seizure (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness). Patient (Patient 1) had not been taking his Keppra (Levetiracetam, medication used to treat seizures). The patient (Patient 1) was seen in the ED (Emergency Department, department of a hospital responsible for the provision of medical and surgical care to patients in need of immediate care) and ready for discharge. At that time, he (Patient 1) became more emotional and complained of having feelings of wanting to hurt himself. For that reason, a psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders] hospitalization of an adult experiencing a mental health crisis) clearance workup (a medical exam to make sure that a patient's psychiatric symptoms are not caused by a medical condition) was initiated, and at the time of elopement (an act or instance of running off secretly against medical advice), the patient was pending psychiatric evaluation." The H&P further indicated that on "reevaluation/repeat exam, the current time the patient is pending psychiatric evaluation for suicidal ideation."

During a concurrent interview and record review on 10/3/2024 at 2:50 p.m. with the ED Manager (EDM) and the ED Director (DED), Patient 1's "ED Neurological Assessment (Neuro assessment, evaluate function of the brain, involves a series of tests that assess mental status, reflexes, and movements)," was reviewed. There was no neuro assessment completed on admission on 9/11/2024 at 4:54 p.m. There was a neuro assessment on 9/11/2024 at 5:45 p.m. and (over 12 hours and 45 minutes later) another assessment done on 9/12/2024 at 6:30 a.m. EDM confirmed that Patient 1 was admitted to the ED on 9/11/2024 at 4:54 p.m. until Patient 1 eloped on 9/12/2024 at 9:00 a.m., only two neuro assessments were completed. The DED stated, "In the ED, we chart by exception, and a focus assessment on the patient chief of complaint is done; it should be completed a minimal q (every) shift (12 hours)."

During a concurrent interview and record review on 10/3/2024 at 2:50 p.m. with the DED, the facility's policy and procedure (P&P) titled, "Assessment and Reassessment Patient Care," dated November 2023, was reviewed. The P&P indicated, "To ensure that each patient's physical, psychological and social status is assessed to determine the patient's care needs and to ensure patient's changing needs are reassessed in response to treatment and care provided ...Emergency Department: An evaluation is initiated by an RN within 10 minutes of arrival for emergent patients, 30 minutes for urgent patients, and 45 minutes for non¿urgent patients utilizing preset triage criteria. Triage and initial assessment will include data related to patient's chief complaint upon entering Emergency Department and shall include ... Glasgow Coma Scale ... Reassessment: Patients are reassessed based upon the triage priority. A focused reassessment occurs minimally every 4 hours and at regular intervals, the frequency and content of which is based on changes in patient condition or diagnosis, standards of care, policies and procedures for ED, response to treatment or procedure, changes in level of care, and progress toward patient outcomes and patient goal attainment." The DED verified that the ED staff are not completing a focused reassessment at a minimal every 4 hours, they are completing every shift.

1.b. During a review of Patient 2's "Medical Screening Exam (MSE, a provider initial exam performed when a patient presents to a dedicated emergency department and requests care)," dated 9/24/2024, the "MSE" indicated, Patient 2 presenting to the ED for complaints of hearing auditory hallucinations (the perception of hearing sounds or voices that are not there) telling him to walk into traffic and to kill himself."
During a concurrent interview and record review on 10/3/2024 at 2:40 p.m. with the ED Manager (EDM) and the ED Director (DED), Patient 2's "ED timeline," was reviewed. The patient (Patient 2) arrived in the ED on 9/24/2024 at 8:22 p.m. The chief complaint indicated, "States he (Patient 2) has been off his psych meds (psychotropic medications are used to treat mental health disorders) for 5 days, and is now hearing voices telling him to jump into traffic."

During a concurrent interview and record review on 10/3/2024 at 2:40 p.m. with the ED Manager (EDM) and the ED Director (DED), Patient 2's "ED Neurological Assessment," was reviewed. The first Neurological assessment was completed on 9/24/2024 at 9:40 p.m. and then a partial assessment of behavior was completed 20 minutes later at 10:00 p.m. there was no other neuro assessment completed until 9 hours later on 9/25/2024 at 7:00 a.m. EDM verified there were no other neuro assessment until the patient was transferred more than 8 hours later.

During a concurrent interview and record review on 10/3/2024 at 2:50 p.m. with the DED, the facility's policy and procedure (P&P) titled, "Assessment and Reassessment Patient Care," dated November 2023, was reviewed. The P&P indicated, "To ensure that each patient's physical, psychological and social status is assessed to determine the patient's care needs and to ensure patient's changing needs are reassessed in response to treatment and care provided ...Emergency Department: An evaluation is initiated by an RN within 10 minutes of arrival for emergent patients, 30 minutes for urgent patients, and 45 minutes for non¿urgent patients utilizing preset triage criteria. Triage and initial assessment will include data related to patient's chief complaint upon entering Emergency Department and shall include ... Glasgow Coma Scale ... Reassessment: Patients are reassessed based upon the triage priority. A focused reassessment occurs minimally every 4 hours and at regular intervals, the frequency and content of which is based on changes in patient condition or diagnosis, standards of care, policies and procedures for ED, response to treatment or procedure, changes in level of care, and progress toward patient outcomes and patient goal attainment." The DED verified that the ED staff are not completing a focused reassessment at a minimal every 4 hours, they are completing every shift.

2. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/12/2024, the "H&P" indicated, Patient 1 "presented status post (after) seizure (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness). Patient (Patient 1) had not been taking his Keppra (Levetiracetam, medication used to treat seizures). The patient (Patient 1) was seen in the ED (Emergency Department, department of a hospital responsible for the provision of medical and surgical care to patients in need of immediate care) and ready for discharge. At that time, he (Patient 1) became more emotional and complained of having feelings of wanting to hurt himself. For that reason, a psychiatric (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders] hospitalization of an adult experiencing a mental health crisis) clearance workup (a medical exam to make sure that a patient's psychiatric symptoms are not caused by a medical condition) was initiated, and at the time of elopement (an act or instance of running off secretly against medical advice), the patient (Patient 1) was pending psychiatric evaluation." The H&P further indicated that "on reevaluation/repeat exam, the current time the patient is pending psychiatric evaluation for suicidal ideation."

During a review of Patient 1's "Medication Administration Record (MAR, a report detailing the drugs administered to a patient)," dated 9/12/2024, the "MAR" indicated, Patient 1 received 750 milligrams (mg, a unit of measurement) of Keppra (Levetiracetam, medication used to treat seizures) by mouth.

During an interview on 10/1/2024 at 5:15 p.m. with Registered Nurse (RN) 2, RN 2 stated, while on break, a nurse (RN 14) that took over the care of Patient 1, administered the Keppra (Levetiracetam, prescription drugs used to treat seizures) medication that is due at 8:00 a.m. but Patient 1 refused to take the Keppra medication that had been scanned by RN 14. The RN 14 reported to RN 2 that the medication was scanned. However, it was not given. RN 14 then handed RN 2 the Keppra medication. RN 2 stated, "I should have modified the medication administration record, but I forgot to do it."

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," dated September 2022, the P&P indicated the following: To provide guidelines for the safe and accurate administration of medications, to provide a permanent documentation of medication administration and to provide a system for licensed personnel to have access to secure, approved floor stock medication, maintain inventory control, narcotic tracking and accurate patient charging. Clinical appropriateness and patient status shall serve as the determining factors for immediacy of order processing, regardless of age ... All medications will be stored in suitable secure locations, and shall be prepared and administered in accordance with Federal and State Laws, under the orders of a licensed practitioner, as per accepted standards of practice ... Any medication(s) obtained from an ADC or secured medication floor stock location but not administered must be returned to an appropriate secured location (ADC return bin, patient cassette, controlled medication drawer) or pharmacy within 30 minutes of acquisition and may not be carried on any person beyond the 30-minute time frame (excluding procedural and operating areas) ... All medications which are refused, not given, "given by other", etc. shall be clearly documented in the patient's medical record (eMar) accordingly. Patients may refuse scheduled medications while admitted to the hospital and will have the risks versus benefits reviewed by the licensed health care professional (HCP) accordingly. If the patient still refuses a medication, then the HCP will document education efforts and patient refusal, chart the medication task as "not given", and indicate the reason as "patient refused".

During a review of the facility's policy and procedure (P&P) titled, "Medication Errors," dated April 2023, the P&P indicated, "Definition of Medication Variance (Error): Anytime a medication is administered includes but is not limited to one of the following ... Omission, unless qualified in nursing notes ... The healthcare provider making or discovering the error is responsible for notifying the attending physician of the error and carrying out any further orders. Notify the Charge Nurse or Nursing Supervisor, Unit Director. Completing an incident report using the Electronic System for Risk Management (ESRM)."

3. During a review of Patient 3's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/9/2024, the "H&P" indicated, Patient 3 presented to the emergency department for left foot pain for three (3 ) weeks. H& P indicated, "Patient states that he notices a blister (fluid fills a space between layers of skin) on his (Patient 30 foot but now thinks his foot is turning gangrenous (occurs when a body tissue dies due to a lack of blood supply or a bacterial infection)." The H&P further indicated the plan was to start the patient (Patient 3) on Intravenous (medication administered into the vein) antibiotic (medication that inhibit or kill microorganisms).

During a concurrent observation and interview on 10/3/2024 at 10:30 a.m. with the Director of Telemetry (DT), in Patient 3's room, Patient 3's skin at the intravenous (IV, into the vein) catheter (a thin, flexible tube is inserted into a vein to administer fluid medication) site was reddened. The catheter site did not have a label (date and initial of staff who inserted the catheter) of when the IV catheter was inserted. Patient 3 stated, "There is a little pain (pointing to the IV catheter site), but not too much." The DT stated she will have the nurse look at the IV catheter site. DT said, generally, the IV catheter site was assessed every shift (within 12 hours) and was changed every 96 hours or as needed.

During an interview on 10/3/2024 at 10:38 p.m. with Registered Nurse (RN) 13, outside the corridor, RN 13 stated, "I did not insert the IV catheter, but we do need to label the IV catheter site with date, so we know when it was inserted. IV catheter need to be replaced every 4-5 days."

During a concurrent interview and record review on 10/3/2024 at 3:45 p.m. with the Director of Clinical Quality Improvement (DCQI), Patient 3's flowsheet (report that outlines the steps involved in managing patient care) dated 9/24/2024 to current, 10/2/2024, was reviewed. The flowsheet indicated Patient 3's IV catheter was inserted on 9/24/2024, more than 192 hours (8 days) old. DCQI stated this was failure on the nurse to not change the IV catheter site.

During a review of the facility's policy and procedure (P&P) titled, "IV Therapy-Central Venous Cath," November 2022, the P&P indicated, "To provide guidelines to achieve the following goals during peripheral IV therapy: Provide standardization of care for continuous or intermittent IV therapy Administer IV Push medications. Reduce the risk of infection due to IV Therapy. Reduce the risk of clotting by establishing a standardized procedure for maintenance of peripheral saline lock therapy. IV Insertion Site Change: Every 96 hours. PRN complications (e.g. infiltration, phlebitis, clotted/resistance to flush). Initiate new venous access before discontinuing old access device. If unable to initiate access at a new site, contact the physician. Label dressings with date and time changed, and initials of person changing. Change the needleless components with routine dressing changes, when residual blood is visible, and at least as frequently as the administration set which should be changed every 96 hours."

4. During a review of Patient 8's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/9/2024, the "H&P" indicated, Patient 8 was admitted to the facility for chest pain and shortness of breath (difficulty breathing). The H&P further indicated "Patient has never had chest pain before. Denies any fever, chills (a feeling of coldness and rapid muscle contractions and relaxations as the body tries to produce heat), nausea (a feeling of sickness with an inclination to vomit), vomiting. However, patient (Patient 8) does state that patient (Patient 8) had melena (black tarry stool that comes from bleeding in your upper) at the skilled nursing facility (is a type of inpatient facility that provides short or long-term skilled nursing care, and rehabilitation services) denies any previous history of melena."

During an observation and interview on 10/3/2024 at 10:30 a.m. with Registered Nurse (RN) 13 in Patient 8' room, Patient 8's left inner arm, from the armpit to above the elbow, was observed to have swelling and dark purple coloration. Patient 8 pointed to the left inner arm and stated, "Last night at 1 or 12, It was here and here no good." RN 13 stated IV (Intravenous, through the vein) to the left upper arm was removed at 4:19 a.m. due to infiltration (when the IV fluid or medication accidentally leaks into the surrounding tissues outside the intended vein). RN 13 stated, "I will call the physician for an order for ultrasound."

During a concurrent interview and record review on 10/3/2024 At 4:35 p.m. with the Director of Clinical Quality Improvement (DCQI), Patient 8's "flowsheet," dated 10/2/2024 and 10/3/2024, was reviewed. The flowsheet indicated an IV catheter to the left upper arm assessed on 10/2/2024 at 8:00 a.m. indicated site/condition with hematoma (collection of blood that pools outside the blood vessel). However, DCQI verified that the IV catheter was not removed. Instead, the IV catheter was discontinued the following day on 10/3/2024 at 4:19 a.m.

During an interview on 10/4/2024 at 10:12 a.m. with the DT, DT stated the bruise on Patient 8's arm was not communicated to the provider. DT said, "The IV site, if discovered with hematoma, even if flushable, should be removed. Also, take the picture (of the site) and notify the physician."
During a review of the facility's policy and procedure (P&P) titled, "IV Therapy-Central Venous Cath," November 2022, the P&P indicated the following: To provide guidelines to achieve the following goals during peripheral IV therapy: Provide standardization of care for continuous or intermittent IV therapy Administer IV Push medications. Reduce the risk of infection due to IV Therapy. Reduce the risk of clotting by establishing a standardized procedure for maintenance of peripheral saline lock therapy. Site Assessment - Inspect visually and palpate site for signs of infusion-related complications upon admission, every shift, with dressing change and PRN. If patient admitted with IV in place and insertion site not visible, remove dressing to inspect site. Notify physician for any of the following signs:
1. Infiltration - swelling, coolness, pain, fluid leaking, proximal or distal to the
insertion site, resistance met during infusion attempt.
2. Phlebitis - erythema, warmth, drainage, pain, streaking, palpable venous
cord
3. Inflammatory process - pain, discomfort to palpation

5.. During a review of Patient 4's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/9/2024, the "H&P" indicated, Patient 4 presented to the ED (Emergency Department) for shortness of breath (difficulty breathing) and also "experiencing dizziness upon climbing half a flight of stairs and becoming short of breath and having to stop." The H&P further indicated the plan was to admit Patient 4 to the telemetry unit (a floor in a hospital where patients undergo continuous heart monitor).

During a concurrent observation and interview on 10/1/2024 at 11:38 a.m. with the Director of ED (DED) in the Emergency Department, room 3, a translucent plastic bag with three bottles of medication without any label was left in the back of the gurney unattended. There was no patient or staff in room 3. The DED opened the plastic bag and retrieved the three medications. The medications were: Eliquis (apixaban, a prescription medication to prevent and treat blood clots), Lipitor (atorvastatin, a prescription medicine that contains a cholesterol-lowering property), and Amiodarone (a prescription drug used to treat certain types of abnormal heart rhythms). DED stated, "This should not be here unless the patient refuses to hand it over to staff, then we will ask them to have it sent home." The DED further stated, "The nurse is not here right now; we will find out where the patient is."

During an interview on 10/1/2024 at 12:15 p.m. with Pharmacist (PH) 1, PH 1 stated, "The medication should be left with the patient all the time. Medication brought from home should be checked into pharmacy if the patient refused to have a family member pick up the medication. It should be in a secure area until the family picks it up for patient safety."

During a review of the facility's policy and procedure (P&P) titled, "Medications Brought to the Hospital by Patient," dated January 2024, the P&P indicated the following: This policy applies to (name of the facility) and to all employees, Medical Staff members, contractors, patients, and visitors regardless of service location or category of patient. The purposes of this policy are (a) to provide for patient safety, continuity of care, and appropriate patient billing in circumstances when the patient brings his or her own medications to the Hospital; and (b) to provide safe and effective administration ...Handling of Medications Brought to the Hospital by the Patient: If a patient brings his or her own medications to the Hospital, the nurse shall request that a responsible family member or patient representative take the medications home. If the medications are unable to be removed from the Hospital, the admitting nurse shall be responsible for removing the medications from the patient's possession and taking the following steps:
1. The nurse will place all medications into a clear plastic "security bag" (see Attachment A) in the patient's presence.
2. The name of any medications placed into the bag shall be documented on the outside of the bag.
3. The RN will verify the medications with the charge nurse prior to delivery to pharmacy
4. The RN and Pharmacist will perform another check upon delivery to the Pharmacy.
5. Charge RN and patient will check the list of medications upon return to the patient prior to discharge.
6. The patient's name, unit, ID#, date and nurse's name are to be documented on the bag in the appropriate spaces. The patient and nurse shall initial the bag on the line titled "prepared by." If the patient is unable to initial, two nurses will initial the bag.

6. During a review of Patient 11's electronic medical record (EMR, digital version of the paper chart), the EMR indicated, Patient 11 presented in the ED (Emergency Department) on 9/7/2024 at 10:34 a.m. for evaluation of auditory hallucination (the perception of hearing sounds or voices that are not there). The EMR also indicated that "patient (Patient 11) states he has been hearing voices, feels depressed, thinks people want to hurt him (Patient 11), and has suicidal ideations (thoughts of killing oneself). The patient (Patient 11) has attempted to hurt himself in the past by cutting his wrists. Patient (Patient 11) is willing to go voluntarily to a psychiatric facility. Patient was transferred to a Behavioral Health Facility on 9/8/2024 at 6:05 a.m."

During a concurrent interview and record review on 10/3/2024 at 2:17 p.m. with the Clinical Informatics Manager (CIM), Patient 11's "Constant Observer Flowsheet (a document used by healthcare providers to record observations of a patient who is under constant observation)," dated 9/7/2024, was reviewed. The flowsheet indicated that patient (Patient 11) observation started at 10:45 a.m., patient (Patient 11) was continuously monitored until 7:00 p.m. CIM stated that Patient 11 had an order to be placed on constant observation because patient (Patient 11) was at risk for self-harm. CIM verified there was no entry in the flowsheet that patient (Patient 11) was observed from 9/7/2024 7:00 p.m. to 9/8/2024 6:05 a.m., which was the date and time of discharge. CIM stated, per Policy, staff who was assigned as constant observer must document patient observation every 15 minutes on the flowsheet.

During a review of the facility's policy and procedure (P&P) titled, "Suicide Risk Assessment and Intervention," dated November 2022, the P&P indicates the following:

-"(Name of the Facility) conducts an annual self-harm environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide, and (Name of the Facility) will take the necessary action to minimize the risk(s). This applies to all inpatient psychiatric units and outpatient psychiatric programs."

-"The nursing staff will use the Constant Observation Flowsheet to document observation."

7.a. During a review of Patient 22's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/17/2024, the H&P indicated Patient 22 was admitted for low oxygen levels and had a history of End Stage Renal Disease (ESRD, poor kidney function), on dialysis (procedure that cleans the blood by removing extra fluids and waste), and a Stage III Pressure Injury (Full-thickness loss of skin, with dead and black tissue that may be visible). on the sacrum (lower back bone, part of the pelvis).

During a review of Patient 22's "Wound Care Note," dated 9/26/2024, the note indicated Patient 22 had several wounds:

- Stage III PI (Pressure Injury) on the sacrum and right upper buttock (rear);

- Bruises (leaking blood vessels causing purple/blue skin discoloration) and skin tears on the right and left arms; and,

-Multiple blood blisters (skin bubble filled with blood), bruises, and scabs (dry, crusted blood over a wound) on both legs.

During a concurrent interview and record review on 10/3/2024 at 11:55 a.m. with the Wound Care Nurse 1 (WCN 1), WCN 1 verified Patient 22's "Wound and Impaired Skin Assessment Form," dated 9/17/2024, indicated the following:

- Patient 22's right buttock wound, and sacrum (lower back bone, part of the pelvis) wound photos did not include wound measurements; and,

-Patient 22's left thigh, right thigh, left arm, and lower extremities (both legs) did not include wound measurements and the nurse's name/signature of who took the photos.

During the same interview and record review on 10/3/2024 at 11:55 a.m., WCN 1 verified Patient 22's "Wound and Impaired Skin Assessment Form," dated 9/18/2024, indicated Patient 22's left leg and sacrum wound photos were missing wound measurements.

During the same interview and record review on 10/3/2024 at 11:55 a.m., WCN 1 verified Patient 22's "Wound and Impaired Skin Assessment Form," dated 9/25/2024, indicated Patient 22's left hand, left knee, left lower leg, right and left legs, right buttock, and sacrum wound photos were missing wound measurements.

During an interview on 10/3/2024 at 11:55 a.m. with WCN1, WCN 1 stated wound photograph documentation should include a site, measurements, the nurse's name and signature, and the date and time (when the wound photo was taken). WCN 1 stated wound measurement should be included with the wound photo to monitor for improvement or deterioration of the wound.

During a review of the facility's policy and procedure (P&P) titled, "Tissue and Pressure Ulcer Prevention and Management Policy," dated 11/2023, the P&P indicated, "Documentation to accompany photograph includes: Wound dimensions and Wound descriptors as noted in the wound assessment."

7.b. During a review of Patient 31's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 9/12/2024, the H&P indicated Patient 31 was admitted to the facility for alcohol intoxication (a condition associated with drinking too much alcohol in a short amount of time) with sepsis (a life-threatening medical emergency that occurs when the body's immune system has an extreme response to an infection or injury), rhabdomyolysis (a serious medical condition that occurs when muscle tissue breaks down and releases harmful substances into the blood), cirrhosis (a chronic liver disease that occurs when the liver is damaged over time and scar tissue replaces healthy liver tissue) of liver and on mechanically assisted ventilation (a medical procedure that uses a machine to help a patient breathe or breathe for them).

During a concurrent interview and record review on 10/3/2024 at 11:51 a.m. with Wound Care Nurse 1 (WCN 1), Patient 31's "Wound and Impaired Skin Assessment," dated 9/18/2024, was reviewed. The assessment included the following wound photo of Patient 31:

-right lower extremity wound, the wound photo did not include wound measurement; and,
right upper extremity wound, the wound photo did not include wound measurement.

During the same interview on 10/2/2024 at 11:51 a.m., WCN 1 stated Patient 31's wound photos taken on 9/18/2024 did not have wound measurements. WCN 1 stated the wound photos should have wound measurements to indicate if the wound was getting better or worse.

During a review of the facility's policy and procedure (P&P) titled, "Tissue and Pressure Ulcer Prevention and Management Policy," dated 11/2023, the P&P indicated, "Documentation to accompany photog

Based on interview and record review, the facility failed to ensure for two of 31 sampled patients (Patients 26 and 29) the following:

1. Patient 26's Hydralazine (medication used to lower blood pressure [BP, amount of force blood uses to move through the body]) was given as ordered by the physician.

This deficient practice had the potential to cause adverse health outcomes which could negatively affect Patient 26's health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death of the patient.

2. Patient 29 received the first dose of cefepime (antibiotic, use for treatment of an infection) in a timely manner, in accordance with the facility's Policy and Procedure regarding medication administration.

This deficient practice resulted in a delay in treatment and had the potential for the antibiotic to be ineffective in the treatment of Patient 29's infection.

Findings:

1. During a review of Patient 26's "Discharge Summary (a narrative document for communicating clinical information about what happened to the patient in the hospital)," dated 10/2/2024, the discharge summary indicated, Patient 26 was admitted to the facility on 9/23/2024 for back pain. Patient 26 had a medical history of high blood pressure (BP, amount of force blood uses to move through the body).

During a review of Patient 26's "Order Information," dated 9/23/2024, the order indicated for Patient 26 to be given Hydralazine (medication used for lowering BP) 10 milligram (mg, unit of measure) intravenously (IV, through the vein), every six 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).

During a concurrent interview and record review on 10/4/2024 at 10:40 a.m. with Clinical Manager of Med-Surg (CMMS), the CMMS verified Patient 26's "Vital Sign Flowsheet" dated 9/23/2024 at 9:10 p.m., Patient 26's BP was 177/62.

During the same interview and record review, on 10/4/2024 at 10:40 a.m., the CMMS verified Patient 26's "Medication Administration Record (MAR)," indicated the PRN Hydralazine 10 mg IV was given to Patient 26 on 9/23/2024 at 10:53 p.m. (1 hour and 43 minutes since Patient 26's BP of 177/62 was taken). CMMS stated Patient 26 should have been given the PRN Hydralazine when the patient's BP was 177/62 at 9:10 p.m.

During a review of the facility's "Policy and Procedure (P&P)" titled, "Medication Administration of," dated 8/2022, the P&P indicated, "All medications...will be administered in a safe manner following "The Five Rights" ...Prior to obtaining medications for administration, validate orders entered into the patient's electronic medical record (EMR) by comparing against written or electronic orders, and documenting accordingly... The licensed personnel will assure that the drug is delivered at the appropriate time."

2. During a review of Patient 29's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 10/1/2024, the H&P indicated Patient 29 was admitted to the facility for fever (a body temperature that is higher than normal) associated with vomiting and productive cough.

During a concurrent interview and record review on 10/3/2024 at 3:30 p.m., with Clinical Manager of Medical Surgical (CMMS), CMMS stated Patient 29's "Medication Administration Record (MAR)," dated 10/2/2024, included a physician's order for Patient 29 to receive cefepime (antibiotic), 1 gram in 50 milliliters (mL, a unit of measurement), intravenous (IV - within the veins), to start on 10/2/2024 at 6 p.m.

During the same interview and record review on 10/3/2024 at 3:30 p.m., CMMS stated Patient 29's MAR indicated Patient 22's first dose of cefepime was given on 10/2/2024 at 9:50 p.m. (3 hours and 50 minutes after it was ordered to be given at 6 p.m.). CMMS stated antibiotics should be given within one hour of scheduled time. CMMS further stated Patient 29's first dose of cefepime was given late because it was not available. CMMS stated two high priority requests were made to pharmacy regarding Patient 29's cefepime. The CMMS stated the antibiotic not given on time could delay treatment of the patient's infection.

During an interview on 10/4/2024 at 12:16 p.m. with the Director of Pharmacy (DP), the DP confirmed two high priority medication request was received for Patient 29's IV cefepime, 1 gram in 50 mL, due to missing medication on 10/2/2024 at 6:05 p.m. and 7:55 p.m. The DP stated there was no note entered by the pharmacy staff indicating the reason for the late refill and processing of Patient 29's cefepime.

During the same interview on 10/4/2024 at 12:16 p.m., The PD stated Patient 29's cefepime was delivered to the unit on 10/2/2024 at 8:27 p.m., and cefepime was scheduled to be given on 10/2/2024 at 6 p.m. The DP stated after a high priority medication was requested, the medication should be refilled, processed and ready for pick up or delivery to the unit within an hour.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration of," dated 08/2022, the P&P indicated, "antibiotic first doses should be given within 30 minutes of the order."