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Based on record review, staff interviews, and facility policy review, the facility failed to ensure that licensed nurses adhered to hospital policies for two patients (P) (P#1 and P#5) of five patients reviewed when facility staff failed to complete an assessment on P#1 until approximately 17 hours after admission to the nursing unit and when facility staff failed to assess blood pressure of P#2 for approximately two and one half hours during an infusion of Levophed (used to treat life-threatening low blood pressure).


Findings included:


Review of facility policy titled "Assessment of the Patient Job Aid 1," revised on 04/05/2023, indicated an assessment in acute care should be completed "Within 12 hours of arrival for admissions." The policy also indicated a re-assessment should be conducted in acute care, "At a minimum of every 12 hours." The policy revealed content for nursing-inpatient assessment should include, "Physical, psychological, social, environmental assessment ? including nutrition and hydration status as well as functional status."


Review of facility policy titled "Assessment of the Patient," dated 04/25/2024, indicated healthcare professionals should "Reassess the patient" at the following times:
- "After an invasive procedure
- After a non-invasive procedure
- When there is a significant change in condition or diagnosis
- Upon transfer to a different level of care or specialty unit.


Review of facility policy titled "Delivery of Patient and/or Family Education," dated 04/17/2023, indicated, "A. It is the responsibility of all healthcare team members to provide patient and family education that will foster patient self-management, promote patient safety, and achieve the desired state of wellness as defined in partnership with the patient/family and care providers. B. Patients and/or families will receive individualized education that incorporates specific learning needs, relevant healthcare information, and learning style preference." The policy also indicated, "4.3 "Document discharge instructions." "A completed copy of discharge instructions will be provided to the patient and/or family prior to discharge. Discharge instructions include but are not limited to the following: activity, diet, medications, follow up appointments, and when to call the doctor."


Review of facility policy titled "Care and Documentation of Critical Care Patients," dated 02/12/2024, indicated, "E. Assess and document vital signs (blood pressure, pulse, respirations, and oxygen saturation) every two hours or more frequently as warranted by clinical status."


1. Review of the "Hospital Medicine History and Physical" document for P#1 revealed the facility admitted the patient on 07/01/2023.


Review of the "Events" documentation for P#1 revealed the patient was transferred from the emergency department to an inpatient bed on 07/01/2023 at 3:42 p.m.


A "Charting Type" flowsheet revealed staff started an admission assessment for P#1 on 07/01/2023 at 5:27 p.m., however, only the neurological physical assessment was completed. The flowsheets revealed a complete physical assessment was not completed until 07/02/2023 at 9:00 a.m., approximately 17 hours after admission to the inpatient unit, when a nurse completed a shift assessment.


Review of the "Operative Note," dated 12/08/2023 (second hospital admission) for P#1 revealed that the patient had a left knee contracture and failed quadriceps tendon repair. The note revealed the patient had been walking with a flexed hip and knee due to a knee contracture and arthrofibrosis. Per the note, the patient had been using a knee caddy and a walker. The note revealed the provider explained that the risks of surgery including bleeding, and Patient #1 expressed understanding and desired intervention. The note revealed P#1 had an external fixator device applied to the femur and tibia bones of the left leg. The note revealed a "strut" was applied to the external device and "will be gradually corrected each day, breakfast, lunch, dinner, and before [the patient] goes to bed" until the patient achieved full extension of the knee. Per the note, the strut was locked, numbered, and a tape arrow was placed so the patient would know which way to turn the strut. According to the note, the physician went to the recovery room two times to teach the patient how to work the device. The note revealed the gradual correction of the knee contracture would be performed over the next few weeks and frame time would be 10 weeks. The note revealed silver sponges and Kerlix were wrapped around each pin that was attached to the bone and protruding through the skin. Per the note, the pin on the femur was stitched to minimize blood loss because the patient was on a blood thinner.


Review of the "OR [Operating Room] Nursing" note dated 12/06/2023 at 12:40 p.m., for P#1 revealed the nurse "Placed chucks on bed due to left leg oozy."


Review of the "OR Nursing" note dated 12/08/2023 at 2:06 p.m., for P#1 revealed the nurse notified the physician that the "patient left leg is oozing."


Review of the "OR Nursing" note dated 12/08/2023 at 2:40 p.m., for P#1 revealed the patient was transferred to another unit. The note revealed the patient was "keenly responsive" with stable vital signs and no apparent distress.


An "Events" report revealed P#1 was transferred from the Post Anesthesia Care Unit (PACU) to an outpatient extended stay bed on 12/08/2023 at 3:00 p.m. After being moved to a different level of care, there was no documented evidence a re-assessment of the patient was completed until 12/08/2023 at 8:00 p.m., approximately five hours after leaving the PACU after surgery.


A "Charting Type" flowsheet indicated there was no documented evidence that neurological, peripheral vascular, neurovascular, or surgical wound site assessments were completed until 12/08/2023 at 8:00 PM, when a shift assessment was completed; according to the assessment, P#1 had bleeding to the left surgical wound site.


Review of the "Provider Notification" flowsheet for P#1 revealed that on 12/08/2023 at 8:02 p.m., staff sent the provider a message that the patient had "large, copious amounts of blood" from the fixator insertion sites.


A "Physician Discharge Summary" dated 12/13/2023 at 1:51 p.m., revealed that P#1 was discharged in good condition. The summary revealed that the external fixator on the left lower extremity was in place with no active drainage, and the pin sites were clean, dry, and intact. Per the summary, the patient's disposition was to home with activity as tolerated, a regular diet, nutritional supplements, and instructions to keep the wound clean and dry and enforce the dressing as needed. Per the summary, the patient was to follow up with the physician in two weeks.


A "Nursing Note" dated 12/13/2023 at 4:05 p.m., revealed RN #7 documented that P#1's spouse informed the nurse that an "existing blister" on the patient's heel had ruptured. The note revealed a padded dressing was applied and the area was wrapped with Kerlix.


A "Nursing Note" dated 12/13/2023 at 5:44 p.m., revealed that the discharge instructions had been reviewed with P#1, and all questions had been answered. The note revealed the patient verbalized understanding and follow up instructions had been reviewed with the patient.


"Written Discharge Information" revealed the P#1 was hospitalized from 12/08/2023 to 12/13/2023. The Written Discharge Information did not contain any individualized information for the patient related to the surgical procedure or care for the surgical site, external fixator device, or the wound to the heel.


During an interview on 09/20/2024 at 3:26 p.m., the Executive Director of Regulatory (EDR) stated that P#1 did not have an admission physical assessment on 07/01/2023 when they were admitted, and night shift did not document a physical assessment of the patient. The EDR stated that the only physical assessment documented for P#1 on 07/01/2023 was a neurologic assessment. The EDR stated the patient's first fully documented physical assessment was on 07/02/2023 at 9:00 a.m.

During an interview on 09/20/2024 at 3:44 p.m., the EDR stated that the nurse that accepted P#1 for admission from the PACU did not document a re-assessment of the patient after the patient's invasive procedure and transfer to a new level of care. The EDR stated that due to the nurse's lack of documentation, it was unknown whether the patient's surgical site had been bleeding since arrival to the floor or if it was new when the night shift nurse assessed the patient and notified the provider.


During an interview on 09/20/2024 at 3:53 p.m., the EDR stated that the discharge instructions were not individualized for P#1's needs. The EDR stated there was a note from the nurse that the patient was verbally given discharge instructions, but the take-home discharge instructions did not address the needs or reason for being in the hospital.


During an interview on 09/20/2024 at 11:00 p.m., Registered Nurse (RN) #7 stated no assessment was completed when P#1 arrived on 12/08/2023 at 3:00 PM. RN #7 stated the nurse that admitted the patient was a float nurse from another unit and RN #7 did not know why the nurse did not complete an assessment.


2. Physician order for P#2 for intravenous (IV) norepinephrine (Levophed) (used to treat life-threatening low blood pressure). 4 milligrams (mg)/250 milliliters (mL) (standard premix) was placed on 05/31/2024 at 12:03 a.m. to start on 05/31/2024 at 1:00 a.m., with an end date of 06/06/2024 at 1:24 p.m.


A Levophed "Highlights of Prescribing Information" document revised 11/2020 revealed the medication was indicated "for restoration of blood pressure in adult patients with acute hypotensive states." The prescribing information section "2.2 Dosage" indicated "Monitor blood pressure every two minutes until the desired hemodynamic effect is achieved, and then monitor blood pressure every five minutes for the duration of the infusion."


A "Vital Signs" flowsheet revealed staff documented that P#2's blood pressure on 06/02/2024 at 10:30 a.m., was 88/56 millimeters of mercury (mmHg). Per P#2's "Medication Administration" record, the patient received Levophed on 06/02/2024. However, per the Vital Signs flowsheet, there was no documented evidence staff monitored P#2's blood pressure again until 06/02/2024 at 1:00 PM, which was approximately 2.5 hours between blood pressure checks while Levophed was infusing.


During an interview on 09/20/2024 at 12:23 p.m., Registered Nurse (RN) #6 stated blood pressures should be re-assessed every 15 minutes during IV vasopressor administration and every five minutes when titrating the medication.


During an interview on 09/20/2024 at 4:15 p.m., the Executive Director of Regulatory (EDR) stated that blood pressures for P#2 were not documented on 06/02/2024 from 10:30 AM to 1:00 p.m., and there was no documentation to indicate that P#2 was in a different department or in a procedure during that time.