HospitalInspections.org

Based on policy review, document review, and interview the Hospital failed to identify, acknowledge, and respond to grievances for 1 (Patient (P)4) of 18 patients reviewed. This deficient practice has the potential to place patients or representatives at risk for unresolved grievances and complaints and systemic issues that could lead to harm and other adverse outcomes.

Findings Include:


Review of the policy titled "Complaint and Grievance" reviewed 10/2022 " ...Purpose, A. To provide guidelines for staff regarding the difference between complaints and grievance and B. To identify the process for responding to patient grievances according to federal regulations ...a complaint is a concern communicated by patient or patient's representative that can be addressed or resolved promptly by staff members who are present or who are quickly available at the time of the complaint ... A complaint not resolved becomes a grievance ...Patient Advocate-the facility designated representative to assist in providing intake and investigation services to address patient /family care concerns, complaint, and grievances. 1. The Patient Advocate serves as a liaison between the patient and Above-named Hospital. The Patient Advocate is available to help resolve any issues related to the patient care and service. 2. The House Supervisor or Department Director may be contacted after hours and on weekends if the Patient Advocate is unavailable ... a patient grievance is a formal or informal written or verbal complaint that is made to the hospital by the patient, or the patient's representative regarding the patients care, abuse or neglect ...Addressing and resolving grievances: 1. Grievances are submitted to hospital personnel in writing, verbally, via email, over the telephone, or over Wesley website are forwarded to the appropriate personnel. 2. Above Named Hospital staff in receipt of grievance will communicate with the patient or their representative regarding the plan to investigate and follow-up the grievance...Information management of grievances. 1. Grievances are to be documented using the electronic Hospital Notification System, Hard copy HNS forms are available if needed ...


Patient 4


Review of P4's medical record showed she was admitted on 02/14/23 at 11:45 PM with a diagnosis of Acute Hypoxic Respiratory Failure (not enough oxygen in the blood) Secondary to Right Lung Effusion (buildup of fluid between the tissues that line the lungs and chest), Thyroid Mass (A lump in butterflied shaped gland at base of neck), Chronic Sacral Wound (bedsore near the lower back at the bottom of the spine).


Review of P4's "Patient Notes" dated 03/01/23 at 8:34 AM by Staff RN2, showed " ...PT [patient] alter to self and situation. Occasionally confused. Ambulated )1 (sic) assist to the chair ...PT slept until 0530. PT had mo (sic) compliant with care untill (sic) dalghter (sic) called and PT states she was being mistreated. PT refused heparin and denied sleeping all night. This RN [Registered Nurse] reoriented PT. Daughter called this RN accusing RN and PCT [Patient Care Technician] of mistreating PT. This RN inquired from daughter how maltreatment was carried out. Daughter failed to mention but insisted that her mother was being maltreated. This RN tried to correct daughter. State that neither RN or PCT maltreated PT. PCT assisted RN in cleaning and ambulating PT to the chair. Daughter started using curse words on RN. This RN ended the phone conversation."


Review of P4's "Patient notes" dated 03/01/23 8:04 PM by Staff RN " ...Pt [patient] is alert, partially oriented, but forgetful, and accusatory that staff is 'abusing' her by not getting her food temperature correct, that staff makes her turn and be position that she doesn't want to be in. Complains of being in pain and staff haven't tried to help her ..."


Review of P4's "Patient Notes" dated 03/03/23, by Staff RN5, Registered Nurse (RN), showed "Pt [patient] is making unfounded accusations about staff to her family over speaker phone and overheard by nursing staff ...Patient is very confused, particularly paranoid, makes paranoid unsolicited comments about motivations and actions of staff ...Recommended by charge nurse cares be performed by at least 2 staff ... F1 and second daughter (a known "trespasser') are very critical of all actions of staff ...P4, meanwhile, remains confused about why she is here and has to be reminded by her family and nursing. It is also notable that a "male voice" is heard intermittently though out shift today over patient's cell phone speaker phone, and he is, in this nurse opinion, egging patient on to make further accusations of mistreatment, trying to make patient repeat his words of "remember that they mistreated you?! (sic) Remember they abuse you?! (sic)"


Review of the hospital "Grievance Log" dated 01/10/23 to 07/13/23 showed there was no documentation of P4's grievance or complaint of abuse on 03/01/23 and 03/03/23 in accordance with hospital policy.
During an interview on 07/19/23 at 8:55 AM, Staff RN4, Surgical Intensive Care Unit (SICU) Manager, stated that there were times that family felt P4 was mistreated or neglected, F1 was not happy that we were not meeting the concerns of P4. I gave her my number and she never called back.


During an interview on 07/19/23 at 2:00 PM, Staff RN5, Medical Intensive Care Unit (MICU) Manager states "I remember that patient daughter wanted to sit in chair and not the patient, I don't remember being called about this incident. I was not there at the time it happened. Staff RN5, stated that a virtual camera was brought in and had 2 staff in P4's room to protect themselves When an incident is not resolved by charge nurse, they call the House Supervisor.


During an interview on 07/19/23 at 4:52 PM, Staff RN2, states " ...I remember P4 had base line confusion. I was going to give her the Chlorhexidine (CHG) bath and move her from bed to chair so she could eat her breakfast at 6:30 AM. I got a male aide to help. He left after we got her in the chair, and she was talking to a male on speaker phone saying she was being mistreated. At first, I thought she was joking but the male on the phone got angry and said if she says she is being mistreated she is being mistreated then he got another female on the phone, and she started cursing at me. Then she called my work phone and started to curse and scream at me about the way the patient was being treated. I let my manager know."

Based on record review, policy review, document review, observation, and interview, the hospital failed to ensure the Registered Nurse (RN) supervised and evaluated the care of each patient by failure to:

1. Assess each patient in accordance with the hospital's policy or in accordance with physician's orders for three (Patient (P) 1, P5, P10) of 10 patient records reviewed for RN assessments from a sample of 18 patients.

2. Notify the physician/physician assistant of the patient's elevated blood pressure and/or increase in pain for four (P1, P5, P6, P10) of four patient records reviewed for notification of the physician/physician assistant for elevated blood pressure and/or increase in pain from a sample of 18 patients.

3. Assess the effectiveness of pain medication administered in accordance with the hospital policy for two (P5, P6) of three patient records reviewed for pain assessments from a sample of 18 patients.

4. Implement the fall protocol policy for two (P2, P16) of three patient records reviewed for falls from a sample of 18 patients.

5. Ensure patients received showers/personal hygiene for three (P2, P3, P13) of 10 patient records reviewed for bathing from a sample of 18 patients.

6. Ensure patients were turned or repositioned every 2 hours as ordered by the physician for two (P3 and P4) of 18 sampled patients.

This deficient practice has the potential to place patients at risk for unmet care needs, skin breakdown and other harmful outcomes.


Findings include:


Review of the policy titled, "Patient Assessment and Reassessment - Emergency Department," effective December 2022, indicated ". . .All patients presenting to the Emergency Department will have a brief initial triage assessment performed in the treatment area. In addition to a visual and ABCD assessment, this includes obtaining the chief complaint and asking necessary questions to determine the severity of the patient's presentation. . . The Rapid Initial Assessment will be completed as soon as possible after patient arrival by the triage nurse or by a nurse in the treatment area if the patient is immediately bedded. E. Following the Rapid Initial Assessment, continued assessment of the patient will consist of detailed and complaint specific assessments. . . Detailed Assessment: This assessment will build on the data obtained during the Rapid Initial Assessment, to provide an in-depth look at the patient's overall presentation, considering psychosocial as well as physical data. A Detailed Assessment is required for all ESI [emergency severity index] Level 1, 2, and 3 patients . . . Pain Control: Pain assessments are to be done on all patients. Use one of the following scales to assess pain in the Emergency Department. . . Numerical: Any patient with the cognitive ability to understand and respond. . . Reassessments in the Treatment Area will be performed as follows: Level 1 and Level 2 Patients: Patient will be reassessed a minimum of every 15 minutes or more frequently if condition requires. Vital signs at these intervals will include blood pressure, pulse, respiration, and pulse oximetry. Frequency of vital signs can be decreased based on stability of patient condition and normalization of vital signs. This decision must be documented in the patient record before vital sign frequency is decreased. 2. Level 3 Patients: Patient will be reassessed a minimum of every hour or more frequently if condition requires. Vital signs at these intervals will include blood pressure, pulse, respiration, and pulse oximetry. Frequency of vital signs can be decreased based on stability of patient condition and normalization of vital signs. This decision must be documented in the patient record before vital sign frequency is decreased.


Review of the policy titled, "Patient Assessment and Reassessment - Emergency Department," effective December 2022, indicated ". . . Pain Control: Pain assessments are to be done on all patients. Use one of the following scales to assess pain in the Emergency Department. . . Numerical: Any patient with the cognitive ability to understand and respond. . . Pain will be assessed and documented to include: location. quality and intensity. It will be periodically reassessed and documented relative to the patient's pain status and after pain-relieving treatments and medication. . ." The policy did not indicate how soon after the administration of pain medication the pain medication effectiveness had to be assessed.

Review of the policy titled, "Fall Prevention" dated April 2004 and revised June 2022 documented, ..."A patient fall is a sudden, unintentional descent, with or without sustained injury, that results in the patient coming to rest on the floor, on or against some other surface, on another person, or on an object. This includes all unassisted and assisted falls regardless of the patients age or admission status ...Regardless of risk score or level of stratification, the following will be in place for all patients ...Gait Belts placed on patient for transferring or ambulating ...At a minimum, the Attending Physician, Nursing Leader, and patient's legal representative will be notified as soon as possible. All notifications will be documented in the EHR [electronic health record] ...For each patient fall, the nurse will document in the Post Fall Assessment Tool intervention within the EHR. ..."

Review of document titled "Prevent Infection During Your Stay Bathe daily with Chlorhexidine (CHG) Cloths" showed " ...During you stay we will bathe you every day with a special antiseptic (CHG) which removes germs and prevents infection better than soap and water ..."

Review of document titled "Patient Talking Points: Chlorhexidine (CHG) Bathing" showed "Remember: Your enthusiasm and encouragement will be the greatest predictor of a patient's acceptance and their support for the protocol ...This is your protective bath while you are staying in this unit ...this type of bating is deeply cleaning and works better than soap and water to remove germs and protect you from infection ..."

Review of document titled "Pressure Injury Treatment #174" showed "Instructions: All checked orders are to be implemented unless crossed though by the ordering provider ...Nursing care...Turn at least every two hours; Do NOT turn on side with pressure injury: Post turning schedule or turn clock ..."


Patient 1

1. The RN failed to assess each patient in accordance with the hospital's policy.

Review of P1's "Rapid Initial Assessment" documented by the Registered Nurse (RN) on 01/21/23 at 12:03 AM indicated P1 arrived at the Emergency Department (ED) on 01/20/23 at 9:45 PM with the chief complaint of "GU" [genitourinary]. Documentation by the RN indicated P1 reported P1's nephrologist instructed P1 to come to the ED due to elevated lab values. Review indicated the RN triaged P1 at the Emergency Severity Index (ESI) level of three (urgent - nonlife threatening). P1's vital signs at the time of the "Rapid Initial Assessment" were blood pressure (BP) 167/108 (normal 120/80), pulse (P) 78 (normal 80-100), respirations (R) 20 (normal 12-16), temperature (T) 97.8 (degrees Fahrenheit), and pulse oximetry (O2) 98% (normal 95-100%).

Review of P1's documentation of vital signs while in the ED by the RN indicated initial vital signs were documented at 9:45 PM on 01/20/23. No BP, R, or T was documented every 15 minutes from 10:15 PM on 01/20/23 to 4:15 AM on 01/21/23 as required by the hospital policy. No vital signs were documented from 2:00 AM on 01/21/23 until 4:15 AM on 01/21/23 (policy required assessment of vital signs every hour for ESI level 3). There was no documentation in P1's EMR the frequency of P1's vital signs had been decreased based on P1's stability of condition and normalization of vital signs as required by hospital policy.

Review of P1's RN assessments indicated the RN's documentation of the assessment of P1 every hour indicated "No change." There was no documentation after the initial RN assessment by the triage nurse every hour that provided an in-depth look at the patient's overall presentation, considering psychosocial as well as physical data as required by hospital policy.

During an interview on 07/19/23 at 11:55 AM, Emergency Department Director (EDD) confirmed P1's vital signs were not assessed in accordance with the hospital's policy. EDD confirmed the RN hourly assessments did not include an in-depth look at P1's overall presentation, considering psychosocial as well as physical data, as required by hospital policy.

2. The RN failed to notify the physician/physician assistant of the patient's elevated blood pressure.

Review of P1's EMR indicated P1's BP on 01/21/23 was 178/115 at 1:30 AM, 195/130 at 1:45 AM, and 206/131 at 2:00 AM. There was no documentation that the RN notified the physician/physician assistant of the elevated BPs.

Review of P1's physician orders indicated an order was given on 01/21/23 at 4:22 AM to administer Labetalol HCL (used to treat high blood pressure) 10 mg (milligrams) IV (intravenously) stat. Review indicated there was no BP documented by the RN from 2:00 AM on 01/21/23 to the time the Labetalol order was received at 4:22 AM.

During an interview on 07/19/23 at 10:22 AM, EDD confirmed there was no documentation of the RN notifying the physician/physician assistant of P1's elevated BPs and no documentation of P1's BP from 2:00 AM on 01/21/23 to the time the Labetalol order was received at 4:22 AM.

Review of a physician's order documented on 01/21/23 at 4:43 AM indicated vital signs "SBP [systolic blood pressure] or MAP [mean arterial pressure] every five minutes until desired SBP or MAP obtained, then every 15 minutes." There was no documentation of the desired SBP or MAP to determine when the BP assessments could be decreased to every 15 minutes.

Review of P1's vital sign assessments by the RN on 01/21/23 after the physician order was received at 4:43 AM indicated P1's BP was documented every 15 minutes from 5:00 AM through 7:15 AM with no documentation of physician order to decrease the frequency from every five minutes.

During an interview on 07/19/23 at 10:22 AM, EDD stated the BP goal was 160/90. EDD confirmed the RN did not assess P1's BP every five minutes as ordered by the physician.


Patient 2

1. The RN failed to implement the fall protocol policy.

Review of P2's "Face Sheet" revealed P2 was admitted to the hospital on 03/23/23 with diagnoses that included non-Hodgkin's lymphoma with extensive metastatic disease.

Review of the daily nursing assessment dated 06/10/23 at 8:00 PM located in the EMR, revealed P2 was assessed as a high risk for falls. Interventions included use of a walker as an ambulatory aide, bed and chair alarm, bed in lowest position, gait belt for transfer, slow position changes, and staff rounding.

Review of the nurse's note dated 06/11/23 at 5:30 AM revealed, "Patient bumped his head on the counter when trying to stand up. DR [Doctor] notified and a CT [computed tomography] scan without contrast ordered. CT head done. Currently awaiting the results of the CT Head ..."

Review of the Electronic Medical Record (EMR) on 07/19/23 from 9:00 AM to 10:00 AM with the Manager of Quality and Regulatory Compliance (MQRC), failed to reveal documentation the legal representative was notified of the fall on 06/11/23, a Post-Fall Assessment Tool was completed, and that a gait belt was used during the transfer of P2 on 06/11/23.

During an interview on 07/19/23 at 10:25 AM, Registered Nurse (RN) 8 stated that on 06/11/23 at 5:30 AM, Patient Care Technician (PCT) 4 reported that P2 slipped down when being transferred to a wheelchair and bumped his head on the counter in the room. RN8 stated he assessed P2's head and there was swelling on the right occipital side of P2's head. The charge nurse, house supervisor and hospitalist were notified of the incident. The hospitalist ordered to obtain a CT scan of the head. RN8 stated she did not notify P2's legal representative or complete a "Post Fall Assessment Tool" per the hospital Fall Prevention policy because she did not consider the incident a fall since P2 did not land on the floor. RN8 stated she did not recall if PCT4 used a gait belt during transfer of P2 on 06/11/23.

During an interview on 07/19/23 at 10:55 AM PCT4 stated she transferred P2 on 06/11/23 at 5:30 AM because P2 was being moved to the new room. During the transfer, the bed alarm went off and the intravenous (IV) tubing got caught in the side rail. P2 reached to turn the alarm off, and she reached to untangled the IV tubing. P2's legs gave out and he slipped down and to the side hitting his head hard on the counter. PCT4 stated she was able to stop P2 from landing on the floor by leaning him to the side and back onto the bed. PCT4 stated she knew P2 was at risk for falls but did not use a gait belt to transfer P2 to the wheelchair on 06/11/23 because she did not know it was needed.


2. The RN failed to ensure patients received showers/personal hygiene.

Review of the "Routine Daily Care" documentation dated 04/12/23 through 07/09/23, revealed P2's activity included ambulating in the room, using the bathroom, getting up to a bedside chair, and received a bed bath or CHG wipes for bathing.

Review of the "Routine Daily Care" documentation dated 07/10/23 revealed the Occupational Therapist provided a shower to P2. The "Routine Daily Care" documentation failed to reveal a shower was part of P2's individualized plan of care or was given except on 07/10/23.

Observation on 07/19/23 at 11:15 AM revealed P2 had a private room that included a bathroom and a shower.

During an interview on 07/19/23 at 11:15 AM, P2 stated he has been at the hospital for several months and during the stay, staff offered to provide a shower only once about a week ago. P2 stated that staff provide treated wipes every day to use for a bath. P2 stated he wanted to be able to take a shower but doesn't want to have to ask staff.

During an interview on 07/19/23 at 11:30 AM, RN11 stated patients are provided a CHG bath or shower during their stay at the hospital. RN11 stated the hospital did not have a specific policy that directs PCT staff when to give a shower versus a CHG bath. RN11 stated P2's individualized plan of care should include when to provide a shower.

During an interview on 07/19/23 at 11:40 AM, MQRC stated patients should not have to request a shower every day. The PCT should offer a shower based on the patient's individualized plan of care.


Patient 3

1. The RN failed to ensure patients received showers/personal hygiene.

Review of Patient 3's (P3) discharged medical record shows P3 61-year-old was admitted on 02/26/23 and discharged on 03/03/23 with dismissal diagnoses Subacute (over 24 hours to 5 days) ischemic stroke (sudden loss of blood circulation area in brain), severe toxic metabolic encephalopathy (varying state of confusion and consciousness), acute hypoxemic respiratory failure (not enough oxygen in the blood) due to aspiration pneumonia (food or liquid is breathed into airways or lungs instead being swallowed), Hemoptysis (coughing up blood) due to traumatic Dobhoff tube insertion (feeding tube), dysphagia (swallowing difficulties), thrombocytopenia (low level of platelets), obesity class 1 (low risk), Schizophrenia (symptoms including delusions, hallucinations, disorganized speech, trouble with thinking and lack of motivation).

Review of P3's "Routine Hygiene Care" indicated on 02/27/23 "showered" There was no documentation of "daily bath" for the dates of 02/25/23, 02/26/23, 02/28/23, 03/01/23, 03/02/23 and 03/03/23 as required by hospital policy during P3's 15-day inpatient stay.

2. The RN failed to ensure patients were turned or repositioned every 2 hours as ordered.

Review of P3 Provider order "Turn-*Turn Patient" dated 02/20/23 at 11:26 AM showed " ...Turn at least every 2 hours; Do NOT turn on a side with pressure injury; Post turning schedule or turn clock."

Review of P3's turning documentation failed to show P3 was turned on 02/21/23 during the 7:00 PM-7:00 AM shift; on 02/24/23 only one turn was documented at 9:00 PM, on 02/25/23 one turn at 5:00 AM, and no turning was documented on 02/26/23 during the 7:00 AM-7:00 PM shift as ordered by provider every two hours.

During an interview on 07/18/23 at 9:25 AM, RN4, Surgical Intensive Care Unit (SICU) Manager, states, "Turn patients every two hours is the standard and if they have pressure ulcer more often. Patient are bathed every night shift and linens are changed when they get a bath or have soiled linens."

During an interview on 07/19/23 at 2:14 PM, RN6, states, " ...If a patient cannot turn themselves then we turn them everyone to two hours, and chart in notes that we turned patient..."

During an interview on 07/20/23 at 3:10 PM, Contract Employee Company A (CE1), states, " ...A nurse [Company A] went to pick up P3 in wheelchair van when she got there P3 was in a chair wrapped in blanket in a gown and her hair was matted ... P3 is very prone to skin break down and pressure ulcers so she has to be turned frequently ..."


Patient 4

1. The RN failed to ensure patients were turned or repositioned every 2 hours as ordered.

Review of P4's medical record showed she was admitted on 02/14/23 at 11:45 PM with a diagnosis of Acute Hypoxic Respiratory Failure (don't have enough oxygen in your blood) Secondary to Right Lung Effusion (Buildup of fluid between the tissues that line the lungs and chest), Thyroid Mass (A lump in butterflied shaped gland at base of neck), Chronic Sacral Wound (bedsore near the lower back at the bottom of the spine).

Review of P4's Provider orders on 02/15/23 at 1:12 AM indicated " ...turn at least every two hours, Do NOT turn on side with pressure injury, Post turning schedule or turn clock."

Review of P4's turning documentation failed to show P4 was turned on 02/16/23 during the 7:00 PM-7:00 AM shift, on 02/17/23 during the 7:00 PM-7:00 AM shift, on 02/20/23 during the 7:00 PM-7:00 AM shift, or on 02/22/23 during 7:00 PM-7:00 AM shift as ordered by provider every two hours.

During an interview on 07/20/23 at 8:35 AM, RN10, 10th tower manager, states, " ...If patient identified as a skin break down risk, they would be turned as scheduled as implemented on chart every two hours there is also a place in EMR to chart intervention and document when turned each time."


Patient 5

1. The RN failed to assess each patient in accordance with the hospital's policy.

Review of P5's EMR indicated P5 presented to the ED ambulatory on 07/17/23 at 10:12 PM. P5 was triaged by the RN on 07/17/23 at 11:24 PM with an ESI level of two (Emergency: could be life-threatening) and chief complaint of "GI [gastrointestinal]/Abdominal Pain."

Review of P5's documentation of vital signs by the RN indicated no vital signs were documented after the vital signs assessed during the "Rapid Initial Assessment" on 07/17/23 at 11:24 PM until 07/18/23 at 7:12 AM. There was no documentation of an assessment of vital signs every 15 minutes as required by hospital policy for patients in the ED with an ESI level two.

Review of P5's EMR indicated P5 was not assessed by the RN every 15 minutes as required by hospital policy.

During an interview on 07/20/23 at 9:29 AM, ED Manager (EDM) 2 confirmed P5's vital signs were not assessed in accordance with hospital policy.

During an interview on 07/20/23 at 9:32 AM, EDM2 confirmed P5 was not assessed by the RN every 15 minutes as required by hospital policy.

2. The RN failed to notify the physician/physician assistant of the patient's increase in pain

Review of P5's "Rapid Initial Assessment" documented by the RN on 07/17/23 at 11:24 PM indicated P5 arrived at the ED on 07/17/23 at 10:12 PM ambulatory. Review indicated P5 stated ". . . since yesterday she has been having some bloody diarrhea. Pt [patient] states that she has probably had 5 episodes of this. Pt states she has also been having some abdominal pain. Pt describes the pain as stabbing on the right side. Pt also states she is having a stabbing pain to her right back as well. . . Pain 8/10." There was no documentation in P5's EMR that the RN reported P5's pain to the physician assistant.

Review of P5's physician assistant orders indicated an order to administer Dilaudid (narcotic pain medication indicated for relief of moderate-to-severe pain) 0.5 mg IV stat on 07/18/23 at 2:30 AM (three hours six minutes after P5 reported a pain level of eight on a scale of one to ten, with ten being the most pain). Dilaudid 0.5 mg was administered by the RN on 07/18/23 at 2:48 AM.

During an interview on 07/20/23 at 9:35 AM, EDM2 confirmed there was no documentation that the RN reported P5's pain of eight to the physician assistant after the "Rapid Initial Assessment" was performed on 07/17/23 at 11:24 PM.

3. The RN failed to assess the effectiveness of pain medication administered in accordance with the hospital policy.

Review of P5's physician assistant orders indicated an order to administer Dilaudid 0.5 mg IV STAT [immediately] on 07/18/23 at 2:30 AM. Review indicated Dilaudid 0.5 mg was administered by the RN on 07/18/23 at 2:48 AM. Review indicated there was no documentation of an assessment by the RN to determine if the Dilaudid was effective for relieving P5's pain.

During an interview on 07/20/23 at 9:35 AM, EDM2 confirmed there was no reassessment done by the RN to determine the effectiveness of the Dilaudid that was administered to P5.


Patient 6

1. The RN failed to notify the physician/physician assistant of the patient's increase in pain.

Review of P6's EMR indicated P6 presented to the ED by ambulance on 07/18/23 at 12:30 AM. Review of P6's "Rapid Initial Assessment" documented by the RN indicated the assessment was performed on 07/18/23 at 12:39 AM with the chief complaint of GI (gastrointestinal)/abdominal pain. The RN documented P6's reported pain intensity as 10. There was no documentation in P6's EMR that the RN reported P6's pain to the physician.

Review of P6's physician orders indicated an order was received on 07/18/23 at 1:38 AM to give Dilaudid 1 mg IV for pain 9 out of 10 (59 minutes after P6 reported pain of 10). Dilaudid was administered on 07/18/23 at 2:04 AM.

During an interview on 07/19/23 at 2:50 PM, EDD stated the ED doesn't have a standard for how soon after a patient complains of pain that pain medication should be administered. EDD stated "I don't think that was a delay in treatment."

2. The RN failed to assess the effectiveness of pain medication administered in accordance with the hospital policy

Review of P6's physician orders indicated an order was received on 07/18/23 at 1:38 AM to give Dilaudid 1 mg IV for pain 9 out of 10. Dilaudid was administered on 07/18/23 at 2:04 AM. There was no documentation in P6's EMR that P6 was reassessed to determine the effectiveness of the pain medication that was administered.

During an interview on 07/19/23 at 2:56 PM, EDD stated a patient should be reassessed for effectiveness of the medication 30 minutes after IV pain medication was administered. EDD confirmed the time interval for the reassessment was not specified in the hospital policy.


Patient 10

1. The RN failed to assess each patient in accordance with the hospital's policy.

Review of P10's "Face Sheet" revealed P10 arrived at the Emergency Department (ED) on 07/15/23 at 12:54 AM.

Review of the "Initial Rapid Assessment" dated 07/15/23 at 1:15 AM, revealed, " ...PT [patient] presents to the ER [emergency room] with chief complaint of right sided facial swelling since Monday. PT states the swelling has worsened every day even after going to outside facility ER multiple times. PT states that she thinks she was bitten by a spider on Monday that started the swelling. PT states she is severely concerned about her breathing as the swelling has moved down to the anterior aspect of her neck. PT denies further complaint ...PT presents alert, oriented, and with clear speech. Responds to questions appropriately. Resp even unlabored ...Right side of face with noted red raised rash/cellulitis. Right eye nearly swollen shut ...Pain scale blank ...Priority 3 ..."

Review of the "Pain Assessment/Reassessment" dated 07/15/23 at 3:08 AM revealed a verbal pain scale with an intensity of eight out of 10 (score of eight indicates severe pain).

Review of the "Pain Assessment/Reassessment" dated 07/15/23 at 1:14 PM revealed a pain level of six out of 10 and Norco 5/325 (narcotic pain medication) one tablet was administered with effectiveness.

Review of the EMR with Emergency Department Manager (EDM)1 on 07/20/23 at 9:00 AM failed to reveal documentation that a pain reassessment was conducted from 07/15/23 at 3:08 AM until 07/15/23 at 1:14 PM.

During an interview on 07/19/23 at 1:40 PM, RN13 stated that she came on duty on 07/15/23 at 7:00 AM and was assigned to P10. RN13 stated that she assessed P10's pain on first rounds and P10 reported right ear and jaw pain and itching of the right side of the face but did not want any pain medication. RN13 stated that she did not document the pain assessment conducted at 7:00 AM in the EMR. RN13 stated Benadryl was administered, and an ice pack and Vaseline were given to P10. A pain reassessment was conducted at 1:14 PM and P10 reported a pain level of six out of 10 and Norco was administered with good effect.

During an interview on 07/19/23 at 2:25 PM, RN12 stated that she was assigned to provide care to P10 on 07/15/23 night shift. RN12 stated that she checked P10 initially when she came on duty and made her comfortable. RN12 stated that she asked P10 about her pain at approximately 7:00 AM before shift report and P10 reported the pain was starting to get bad again but manageable. RN12 stated a patient's pain re-assessment would be documented in the EMR. RN12 stated, "I might not have documented hers [P10]. I don't remember." RN12 stated P10 was triaged at a Level 3 which requires an assessment be conducted every hour depending on the patient's chief complaint. This is documented in the medical record as improved, no change, or deteriorated and if there is a deterioration, what has deteriorated is included in the medical record. RN12 stated that she focused on P10's respiratory complaints and did not ask about pain. RN12 stated that she was not aware of the 07/15/23 at 3:08 AM pain assessment that indicated P10's pain level was eight out of 10. RN12 stated the pain assessment might have been done when she was with another patient, or on break. RN12 stated that when she comes on duty, she reads the initial assessment conducted by the triage nurse and goes by that to follow through with the patient. RN12 stated, "I did not focus on pain assessments."

During an interview on 07/20/23 at 7:45 AM RN7 stated that she was working on 07/15/23 in the ED but was not specifically assigned to care for the P10. RN7 stated that she was covering for the assigned nurse and conducted the pain assessment on 07/15/23 at 3:08 AM but did not conduct any additional assessments.

During an interview on 07/20/23 at 8:00 AM, Interim Vice President of Quality (IVPQ) confirmed the hospital "Patient Assessment and Reassessment- Emergency Department" policy did not state when and how often pain assessments are to be conducted. MQRC stated the hospital did not have another pain assessment policy for ED patients.

2. The RN failed to notify the physician/physician assistant of the patient's increase in pain.

Review of Patient 10's "Pain Assessment/Reassessment" dated 07/15/23 at 3:08 AM revealed a verbal pain scale with an intensity of eight out of 10 (score of eight indicates severe pain).

Review of Patient 10's "Pain Assessment/Reassessment" dated 07/15/23 at 1:14 PM revealed a pain level of six out of 10 and Norco 5/325 one tablet was administered with effectiveness.

Review of the EMR with Emergency Department Manager (EDM)1 on 07/20/23 at 9:00 AM failed to reveal documentation the physician was notified of P10's pain reassessment conducted on 07/15/23 at 3:08 AM.


Patient 13

1. The RN failed to ensure patients received showers/personal hygiene.

Review of Patient 13's (P13) inpatient medical record shows P13 was admitted on 07/18/23 at 8:07 AM for Severe leg cramping with inability to walk.

Review of P13's documentation of "Routine Hygiene Care" indicated no documentation of "daily bath" as required by hospital policy during P13's three-day inpatient stay.

During an interview on 07/20/23 at 10:40 AM, P13, states, " ...My husband told me I needed to shower, so I just got one today since I can shower myself and they changed sheets while I was in shower. I have not asked for a shower since I have been here, nor did they change my sheets."

During an observation on 07/20/23 at 10:40 AM, P3 had wet hair and fully dressed bed walking out of bathroom with husband assistance.

During an interview on 07/20/23 at 8:40 AM, 7th Tower Manager, RN11, states " ...We bathe every other day or as requested, CHG bathe every day if have a foley or central line..."

Patient 16

1. The RN failed to implement the fall protocol policy.

Review of P16's "Face Sheet" revealed P16 was admitted to the hospital on 02/19/23 and discharged on 03/03/23. Diagnoses included cerebral infarct [stroke] and hemiparesis [paralysis on one side].

Review of the nursing assessment dated 03/01/23 revealed P16 was assessed as a high fall risk. Interventions included supervision and assistance for transfer, bed and chair alarm, and use of a gait belt for transfers.

Review of the nurse's note dated 03/02/23 at 3:45 PM revealed, " ...PT [patient] slipped out of chair. Chair alarm going off. RN entered the room and PT was sitting in front of the chair. VS [vital signs] obtained and no visible signs of injury. Neuro's [neurological assessment] okay, no change. MD notified ..."

Review of the "Fall Checklist and Post Fall Debriefing Tool" dated 03/02/23 provided by MQRC revealed, the check off box in front of "contact patient's emergency contact" was not initialed by the nurse as being done.

Review of the EMR and the "Fall Checklist and Post Fall Debriefing Tool" on 07/19/23 at 3:00 PM with MQRC failed to reveal documentation the legal representative was notified of P16's fall on 03/02/23 per hospital policy.

During an interview on 07/19/23 at 3:00 PM MQRC stated the nurse is responsible as part of the post fall assessment and debriefing to notify the physician and the legal representative when a patient has a fall.

Based on policy review, observations, and interviews, the hospital failed to ensure a sufficient number of pillows were available for the emergency department (ED) beds in accordance with hospital policy. This deficient practice had the potential to affect all patients receiving services in the hospital's ED.

Findings Include:

Review of the policy titled "Emergency Room Cleaning," revised March 2022, indicated ". . . Standard Room Set Up for ER [emergency room] Exam Rooms. . . Stretcher linens: Place a fitted sheet over the mattress, cover the pillow with a pillowcase, and place the pillow at the top of the stretcher. When the stretcher is made, the linen should appear tight and neat. . ."

Observation on 07/20/23 at 9:50 AM in the ED revealed the stretchers in unoccupied Room 28, Room 29, Room 30, Room 31, and Room 32, and two unoccupied stretchers in the hall of the ED had no pillow at the top of the stretcher. Observation revealed an unidentified patient in Room 34 had no pillow on the stretcher. Observation in the ED clean linen room indicated there was one pillow on top of the linen storage cart.

During an interview on 07/20/23 at 9:55 AM, ED Manager (EDM2) stated it was difficult to keep pillows on stretchers in the ED, because the emergency medical service and staff from the inpatient units leave with patients and take the pillow with the patient.

Observation on 07/20/23 at 10:20 AM in the hospital's environmental storage area revealed there were four unopened boxes of pillows that contained 20 pillows in each box.

During an interview on 07/20/23 at 10:20 AM, Director of Environmental Services (DEVS) stated pillows were stored in the environmental storage area until the pillows were disinfected, and the pillows were then dispersed to the units as needed. DEVS stated most of the time the unit would call for pillows or complete a work order to obtain pillows. DEVS stated the process was the housekeeper was supposed to have two pillows on the bed when the housekeeper was finished cleaning a room. DEVS stated there should be pillows on top of the linen cart in the clean linen room, and if there were none, the housekeeper should call the environmental service department to send some to the unit.

During an interview on 07/20/23 at 10:30 AM, Supervisor of Bed Board (SBB) stated she usually writes down on a log when SBB gets a call from a unit. SBB stated the call she received from the ED about 15 minutes prior to the surveyor's arrival was the first call SBB received from the ED to get pillows.

Based on record review, policy review, and interview, the hospital failed to ensure infection control policies were implemented to prevent transmission of infection for 1 of 3 sampled patients (Patient (P) 2) identified with bed bugs. This deficient practice had the potential to affect all patients receiving services in the hospital and all employees.

Findings Include:

Review of the policy titled, "Management of Bed Bugs, Lice and Scabies" dated December 2022 documented, " ...Bed Bugs: Place patient in Contact Isolation. Notify EVS [environmental services] that the patient is suspected or confirmed to have bed bugs. Shower or bathe patient and give patient a clean hospital gown to wear. Double bag all patient clothing and belongings in clear plastic trash bags and send home with family member. lf bagged belongings must remain with the patient, instruct patient and family members that the bags will not be opened while in the facility. Patient and family members will be instructed to launder clothing with hot water and detergent and heat dry. Bed bugs also succumb to cold temperatures below 32' F [Fahrenheit], but the chilling period must be maintained for at least two weeks. Transfer patient to clean room. Do not move any un-bagged clothing or linens to the new room. Contact Isolation can be discontinued once the patient is clean, in a new room, and all belongings have been either double bagged and/or sent home. After patient has left the room, close the door and call EVS. EVS will inspect the room and may contact a Pest Control Company to further evaluate and treat the room. lf a bed bug or suspected bed bug is observed and can be caught, collect the bug in a specimen cup and send the bug to Microbiology for identification. Privacy curtain and linen will be removed and bagged per EVS protocols. EVS will notify the Charge Nurse when the room is ready to be occupied ..."

Review of P2's "Face Sheet" revealed P2 was admitted to the hospital on 03/23/23 with diagnoses that included non-Hodgkin's lymphoma with extensive metastatic disease.

Review of the "Department of Pathology Inquiry Report" dated 06/11/23 located in the hospital "Ecolab Pest Sighting and Evidence Log" provided by the interim Vice President of Quality (IVPQ) on 07/18/23 at 11:00 AM revealed on 06/11/23 at 6:12 AM bed bugs were found in P2's room, Environmental Services (EVS) was notified, and the room was treated on 06/12/23 at 8:40 AM.

Review of the physician "Trauma Consultation" dated 06/11/23 showed, " ...Had [P2] fall this morning. He said that bed bugs were found in his bed and the bedding needed to be changed ...He was assisted out of bed, but he said his legs gave out and he hit his head ...CT scan of head ordered ..."

Review of P2's medical record on 07/19/23 at 3:00 PM with the Manager of Quality and Regulatory Compliance (MQRC) failed to reveal documentation P2 was provided a shower or was bathed prior to being sent for the CT scan on 06/11/23.

During an interview on 07/19/23 at 10:25 AM Registered Nurse (RN) 8 stated P2 was being transferred at 5:30 AM because Patient Care Technician (PCT) 4 found bed bugs in the patient's bed. During the transfer, P2's legs gave out and P2 slipped downward and bumped his head on the counter in the room. RN8 stated all belongings were bagged, a hairnet applied and P2 was placed on contact precautions. RN8 stated she did not, and she did not direct PCT4 to give the patient a bath or shower before he was sent for the CT scan.

During an interview on 07/19/23 at 10:55 AM, PCT 4 stated that she was assigned to care for P2 on 06/11/23 on the night shift. P2 called to tell the nurse she found a bed bug in bed. PCT4 stated she put one bug in a jar to send to Ecolab. PCT4 stated that she found a few more bed bugs underneath the bed sheet and in the zipper part of the mattress. P2 was moved to the couch and the nurse, and I took all the linen off and it was loaded with bed bugs. PCT4 checked the patient's hair for bed bugs and gave P2 a new gown and a hairnet and P2 was sent for the CT scan. PCT4 stated the nurse [RN8] did not direct her to bathe/shower P2 before transfer. PCT4 stated she never took care of a patient with bed bugs and did not know a bathe or shower should be given before moving the patient to another area.

During an interview on 07/19/23 at 12:00 PM, Infection Preventionist (IP) 1 stated if bed bugs are suspected, either a shower is given, or Chlorhexidine (CHG) wipes are used head to toe." IP1 stated after staff check the patient's entire body for bugs, including the head a clean gown is put on before transferring the patient to a new room. All patient belongings are bagged, and the room is treated by EVS.