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Based on observation, interview, and record review, the facility failed to
ensure education and personal protective equipment (PPE, personal protective equipment, used to prevent or minimize exposure to hazards and can include gloves and gowns) were provided to the family member (FM 1) of one of 46 sample patients (Patient 17), who was on contact plus isolation (a set of infection prevention measures which may be put in place when a patient is being treated for an infection and would include wearing a gown and gloves), and FM 1 was observed in Patient 17's room not wearing a gown and gloves, in accordance with the facility's policy and procedure (P&P).

This failure had the potential to spread infection to other patients.

Findings:

On October 14, 2024, at 11:30 a.m., an observation was made on the telemetry unit (Tele, unit where patients' heart rates and rhythms are continuously monitored remotely). A sign which indicated, "Contact Plus," was observed posted outside of Patient 17's door. FM 1 was observed sitting on a chair inside Patient 17's room and was not wearing a gown nor gloves. A concurrent interview was conducted with FM 1. FM 1 stated she was not told by the facility regarding what type of isolation Patient 17 was on or what PPE was necessary to be worn in the patient's room when visiting Patient 17.

On October 16, 2024, at 9 a.m., a concurrent interview and review of Patient 17's record were conducted with Quality Coordinator (QC) 2. A facility document titled, "History and Physical," dated September 26, 2024, was reviewed and indicated Patient 17 was admitted to the facility with bilateral (both) feet osteomyelitis (bone infection) and non-ST-elevation myocardial infarction (NSTEMI, a type of heart attack that occurs when one of the coronary arteries is partially blocked thus reducing the blood flow to the heart).

On October 16, 2024, at 9:45 a.m., a concurrent interview and review of Patient 17's record were conducted with Infection Preventionist (IP) 1. An untitled facility document, dated September 26, 2024, was reviewed and indicated Patient 17 had, "...History...C. Auris [Candida auris, a type of yeast infection that is difficult to treat and can cause serious infections in humans]..."

A facility document titled, "Infectious Dis. [Disease] Progress Note," dated October 9, 2024, was reviewed and indicated, "...Diagnosis, Assessment & [and] Plan...history of...Candida auris..."

IP 1 stated all staff members and family members must wear appropriate PPE which included gloves and gown when inside Patient 17's room and the family member should have been educated. IP 1 stated the P&P for isolation precautions was not followed.

During a review of the facility's P&P titled, "Guidelines for the Management of Patients Known or Suspected to be Infected with Candida Auris," dated June 20, 2024, the P&P indicated, "...C. auris...is a fungus that can cause illness in patinets with many medical problems...can be difficult to treat...Strict adherence to...Contact-Plus Precautions are important aspects in preventing and controlling the spread of C. auris...Use appropriate personal protective equipment (PPE), gloves and gowns, upon entry to room or patient area..."

Based on observation, interview, and record review, the facility failed to ensure the facility's policies and procedures (P&P) were implemented, for 10 of 46 sample patients (Patients 2, 8, 11, 24, 27, 34, 37, 38, 40, and 41), when:

1. For Patient 24, the wound dressing completed before the patient was admitted to the facility and which the patient came in with on admission to the facility was not removed nor changed, and the wound was not assessed;

2. For Patient 27, the supplies to be used in bladder irrigation (a procedure that flushes the bladder with sterile liquid) procedure, which should be done using aseptic (a set of practices which prevent the spread of microorganisms and protect patients and healthcare workers from infection) techniques, were placed on the floor of the patient's room;

3. For Patients 8, 37, 38, and 40, the patients were not turned nor repositioned, in accordance with the facility's P&P;

4. For Patients 37, 38, 40, and 41, skin assessment was not completed in accordance with the facility's P&P;

5. For Patient 11, the physician was not notified of abnormal heart rate, blood pressure, and oxygen saturation (amount of oxygen in the blood). In addition, for Patient 37, the blood sugar checks were not performed, in accordance with the physician's orders;

6. For Patient 11, the physician was not notified of the blood sugar results in accordance with the facility's P&P; and

7. For Patients 2 and 34, the patients' wounds were not treated in accordance with the facility's P&P.

These failures had the potential to cause a delay in patient care and harm for the patients.

Findings:

1. On October 14, 2024, at 10 a.m. a concurrent observation and interview were conducted with Infection Preventionist (IP) 1.

On October 14, 2024, at 11:15 a.m., an observation of Patient 24's dressing on the right foot was conducted with IP 1 and the Registered Nurse Telemetry (unit where patients' heart rates and rhythms are continuously monitored remotely) Manager (RNTM). The dressing was observed to be loose and falling off Patient 24's right foot and had dried yellowish color and a handwriten label which indicated, "October 8, 2024." The exposed portion of Patient 24's right foot was observed to be swollen, reddish, with dry skin, and had a blister that is fluid filled.

The RNTM stated the nurse assigned to the patient is responsible for assessing and dressing the patient's wound. The RNTM stated the nurse should have removed the dressing on Patient 24's right foot and should have assessed the wound.

On October 14, 2024, at 11:15 a.m., an observation and interview were conducted with RN 1. RN 1 stated daily wound care for Patient 24 should have been completed. RN 1 stated the dressing on Patient 24's foot is dated October 8, 2024, and it should have been changed.

On October 15, 2024, at 10:05 a.m., Patients 24's record was reviewed with Quality Coordinator (QC) 1. A facility document titled, "History and Physical," dated October 13, 2024, was reviewed and indicated Patient 24 was admitted to the facility on October 13, 2024, for possible osteomyelitis (inflammation in the bone) with MSSA (methicillin-susceptible staphylococcus aureus, a type of bacteria) bacteremia (bacteria in the blood).

On October 15, 2024, at 10:10 a.m., an interview was conducted with IP 1. IP 1stated Patient 24 was admitted to the facility on October 13, 2024. IP 1 further stated, based on the review of the picture taken of Patient 24's wound and the date on the dressing, wound care has not been performed on Patient 24's wound.

A review of the P&P titled, "[Name of Facility] Skin Integrity Management," dated October 2022, was conducted. The P&P indicated, "...All inpatients will be assessed in regard to integumentary [skin] integrity...All pre-hospital dressings are to be removed on admission for assessment..."

2. On October 14, 2024, at 9:30 a.m., a concurrent observation and interview were conducted with IP 1 in Patient 27's room. A blue chucks pad (a thin absorbent pad) was observed under Patient 27's urine bag. The blue chucks pad was observed to be folded in half and had a 100 milliliter (ml, unit of measurement) container of sterile Normal Saline fluid (a type of fluid), a triangular graduated container (tall narrow container with volume scale used for measuring liquids), a catheter irrigation container (a plastic container containing materials used to flush the bladder with sterile liquid to remove debris, mucus, and blood clots), and a 60 ml piston syringe on it. IP 1 stated the supplies and the blue chucks should not have been left on the floor as it was an infection control risk. IP 1 further stated the nurse should have disposed of the supplies properly.

On October 15, 2024, at 2 p.m., Patients 27's record was reviewed. A facility document titled, "History and Physical," dated October 10, 2024, indicated Patient 27 was admitted for ST elevation (an irregular electrical conduction in the heart) consistent with a ST- segment elevation myocardial infarction (heart attack), urinary retention (when one cannot empty one's bladder), and blood in his urine.

A review of an untitled facility document indicated, "...10/14/24 [October 14, 2024] 0945 [9:45 a.m.]...Urinary catheter [when urinary catheters are inserted into the bladder to allow urine to drain] type...temporary/indwelling...Insertion/applied date...10/10/24 [October 10, 2024]...Indication for urinary catheter...Gross hematuria [blood in urine]/irrigate (to flush the bladder with sterile liquid to remove debris, mucus, and blood clots.."

An untitled facility document indicated, "...Bladder irrigation...routine...10/10/24...frequency...PRN [as needed]...irrigation fluid: Normal Saline..."

A review of the P&P titled, "[Name of Facility] Standardized Procedure Urinary Catheter and Blader Management Protocol," dated June 2024, was conducted. The P&P indicated, "...Catheter tubing junction should be disinfected before disconnection...A large-volume sterile syringe and sterile irrigation solution should be used and then discarded. The person performing irrigation should use aseptic technique..."

3a. On October 15, 2024, at 1:05 p.m., a review of Patient 8's record was conducted with Scribe 1. An untitled facility document, dated September 28, 2024, at 12 a.m., was reviewed and indicated, " ...Skin Alteration...Stage 2 [injury due to pressure on a body area with open wound or blister; tail bone] coccyx [tailbone]...present upon admission...stage 3 [sic, injury due to pressure on a body area extending through skin into deeper tissue] right heel present upon admission..."

An untitled facility document, dated September 28, 2024, at 11:24 p.m., was reviewed and indicated, " ...Multidisciplinary notes...SII [Stage 2] to coccyx and stage III [Stage 3] to R [right] heel; Pictures taken, Patient aware and updated on POC [plan of care], both present upon admission; MD [medical doctor] aware...Q2H [every two hours] turns..."

An untitled facility document, dated September 30, 2024, at 11:43 a.m., was reviewed and indicated, " ...Wound/Ostomy [a surgically created opening in the abdominal wall that allows waste to exit the body] Care RN [registered nurse] note: Consult received to evaluate Stage 2 coccyx & stage 3 R Heel...Assessment ...coccyx...Right heel - stage 3...Recommendation: Continue pressure injury prevention bundle with turning every two hours..."

An untitled facility document, dated October 10, 2024, at 12:33 p.m., was reviewed and indicated, " ...Wound/Ostomy Care RN note: Consult received to evaluate "L buttock and R heel unstageable...Assessment...Left buttock - stage 3 pressure injury (previous DTI [a deep tissue injury, a purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear])...Right heel - unstageable pressure injury [a full thickness injury due to pressure on a body area] (previous stage 3)...Recommendation: Continue pressure injury prevention with turning every 2 hours..."

A facility document titled, "Plan of Care," indicated, "Skin integrity alteration...comment: Q2 turns..."

A facility document titled, "Routine Daily Care," from September 28, 2024, through October 15, 2024, was reviewed. There was no documented evidence Patient 8 was turned or repositioned on the following dates and times:

- From September 29, 2024, 4 p.m., to 9 p.m. (5 hours);
- From October 3, 2024, 6 a.m., to 8 p.m. (14 hours);
- From October 7, 2024, 6 a.m., to 12:30 p.m. (6.5 hours);
- From October 11, 2024, 8 a.m., to 8 p.m. (12 hours);
- From October 12, 2024, 8 a.m., to 8 p.m. (12 hours);
- From October 13, 2024, 8 a.m., to 10 p.m. (14 hours); and
- From October 14, 2024, 10 p.m., to October 15, 2024, at 2 a.m. (4 hours)

Scribe 1 stated turning for Patient 8 was not documented every two hours in the medical record.

3b. A review of Patient 37's record was conducted on October 15, 2024, at 9:31 a.m., with the Patient Safety Director and Risk Management (PSDRM). A facility document titled, "History and Physical," dated January 27, 2024, was reviewed and indicated Patient 37 was admitted to the facility on January 27, 2024, with a diagnoses which included pleural effusion (fluid buildup in the lungs), sepsis (a life threatening condition), and pressure injury Stage 4 (a full-thickness tissue loss which exposes bone, muscle, tendon, ligament, cartilage, or the tissue surrounding these).

A facility document titled, "Orders," dated January 28, 2024, indicated, "...Activity: Bedrest/Turn Q 2hours..."

A facility document titled, "Admission/Shift Assessment - Skin Alteration," dated January 28, 2024, was reviewed and indicated, "...SKIN ALTERATION...Pressure Injury SacrumSacrum [area of the triangular bone at the base of the spine]...Pressure Injury Staging: 4..."

The facility document titled, "ROUTINE DAILY CARE," from February 4, 2024, through February 7, 2024, were reviewed and indicated there was no documented evidence Patient 37 was turned on the following dates and times:

- On February 13, 2024, from 4 p.m., to 10 p.m. (6 hours);
- On February 14, 2024, from 10 p.m., to 6 a.m. (8 hours); and
- On February 15, 2024, from 2 p.m., to 6 p.m. (4 hours).

An interview was conducted on October 15, 2024, at 1:57 p.m., with the PSDRM. The PSDRM stated the expectation is for staff to turn the patient every two hours and document the reason for not turning. The PSDRM stated these were not done.

3c. A review of Patient 38's record was conducted on October 15, 2024, at 3:15 p.m., with Scribe 1. A facility document titled,"History and Physical," dated August 9, 2024, was reviewed and indicated Patient 38 was admitted to the facility with a diagnoses which include Duchenne muscular dystrophy (DMD, a genetic disorder characterized by progressive muscle degeneration and weakness) and chronic hypoxic respiratory failure (inefficient breathing which lead to too little oxygen in the blood).

An untitled facility document, dated August 11, 2024, was reviewed and indicated, "...WOUND CARE CONSULTS /NOTES...Assessment...Left hip- stage 2 pressure injury...left buttock - DTI pressure injury...Right Buttock - DTI pressure injury...Continue pressure injury prevention measures with turning every 2 hours..."

A concurrent interview and review of Patient 38's record was conducted on October 16, 2024, at 9:33 a.m., with Scribe 1. A facility document titled, "ROUTINE DAILY CARE - Activity: Turn," from August 10, 2024, through August 17, 2024, was reviewed.There was no documented evidence Patient 38 was turned on the following dates and times:

- On August 11, 2024, from 2 a.m., to 6 a.m. (4 hours); and
- On August 13, 2024, from 2 a.m., to 6 a.m. (4 hours).

Scribe 1 stated facility's policy was not followed when Patient 38 was not turned every two hours.

3d. A tour of the Intermediate Care Unit (a hospital unit that provides care for patients who are too sick for a general ward but not sick enough for intensive care) was conducted on October 14, 2024, at 1:13 p.m., with the Assistant Chief Nurse Officer (ACNO) and Quality Coordinator (QC) 2.

A concurrent observation and interview were conducted on October 14, 2024, at 1:45 p.m., in Patient 40's room with Intermediate Care Registered Nurse (IMCRN) 2. Patient 40 was observed to have a tracheostomy (a surgically created opening in the neck to provide an airway and remove secretions from the lung) connected to a ventilator (a breathing machine). Patient 40 was also observed to have a wound on the coccyx area. IMCRN2 stated Patient 40 is totally dependent with turning.

A review of Patient 40's medical record was conducted on October 16, 2024, at 10:18 a.m., with Scribe 1. A facility document titled, "History and Physical," dated September 26, 2024, indicated Patient 40 was admitted to the facility on September 26, 2024, with a diagnoses which included subacute bacterial endocarditis (an inflammation of the heart's inner lining and valve) and sepsis.

A facility document titled, "Nurse's Notes," dated September 26, 2024, indicated, "...WOUND CARE CONSULTS /NOTES...Assessment...Coccyx Stage 3...right buttock - pressure injury stage 3...left buttock - pressure injury stage 3...Continue pressure injury prevention measures with turning every 2 hours..."

A facility document titled, "ROUTINE DAILY CARE - Activity: Turn," from September 27, 2024, through October 4, 2024, were reviewed. There was no documented evidence Patient 40 was turned on the following shifts:

- On September 27, 2024, from 8 p.m., to 10 p.m. (4 hours);
- On September 28, 2024, from 6 p.m., to 10 p.m. (4 hours);
- On September 29, 2024, from 12 a.m., to 6 a.m. (6 hours);
- On September 30, 2024, from 12 a.m., to 6 a.m. (6 hours);
- On October 3, 2024, from 8 p.m., to 10 p.m. (4 hours); and
- On October 4, 2024, from 12 a.m., to 6 a.m. (6 hours).

Scribe 1 stated the facility's policy was not followed when Patient 40 was not turned every two hours.

A review of the facility's P & P titled, "Standards of Care, Practice Guidelines and Assessment for the Adult Patient (Excluding Maternal/Child)," dated September 2024, was conducted. The P & P indicated, "...The following routine care/practice guidelines are provided to the adult patient...If patient unable to reposition self...Patient turning needs will be individualized. Patient must be turned at least every 2 hours..."

4a. A review of Patient 37's record was conducted on October 15, 2024, at 9:31 a.m. with the PSDRM. A facility document titled, "History and Physical," dated January 27, 2024, indicated Patient 37 was admitted on January 27, 2024, with diagnoses which included pleural effusion (fluid in the lungs), sepsis, and pressure injury Stage 4.

A facility document titled, "Nurse's Notes," dated January 29, 2024, indicated, "...WOUND CARE CONSULTS /NOTES...Assessment...Coccyx/ bilateral buttock - unstageable pressure ulcer [the base of the wound is covered by a layer of dead tissue and the stage of the pressure injury is unclear]...Continue pressure injury prevention measures with turning every 2 hours..."

A concurrent interview and review of Patient 37's record were conducted on October 15, 2024, at 2:10 p.m., with the PSDRM. A facility document titled, "Admission/Shift Assessment - Skin Alteration," dated January 28, 2024, through February 2, 2024, was reviewed. There was no documented evidence the skin assessment on Patient 37 was completed on February 28 and 29, 2024, during the night shift (7 p.m. to 7 a.m.). The PSDRM stated the expectation is for the skin assessment to be completed and documented once a shift and these were not done.

4b. A review of Patient 38's record was conducted on October 15, 2024, at 3:15 p.m., with Scribe 1. A facility document titled, "History and Physical," dated August 9, 2024, indicated Patient 38 was admitted to the facility o August 9, 2024, with diagnoses which included DMD and chronic hypoxic respiratory failure.

A facility document titled, "Nurse's Notes," dated August 11, 2024, indicated, "...WOUND CARE CONSULTS /NOTES...Assessment...Left hip- stage 2 pressure injury...left buttock - DTI pressure injury...Right Buttock - DTI pressure injury...Continue pressure injury prevention measures with turning every 2 hours..."

A concurrent interview and review of Patient 38's record was conducted on October 16, 2024, at 9:33 a.m., with Scribe 1. A facility document titled, "Admission/Shift Assessment - Skin Alteration," dated August 10, 2024, through August 17, 2024, was reviewed. There was no documented evidence Patient 38's skin assessments were done from September 13 to 17, 2024, day shift (7 a.m. to 7 p.m.).

Scribe 1 stated the facility's policy was not followed when Patient 38's skin assessment was not completed every shift.

4c. A review of Patient 40's record was conducted on October 16, 2024, at 10:18 a.m., with Scribe 1. A facility document titled, "History and Physical," dated September 26, 2024, was reviewed and indicated Patient 40 was admitted to the facility on September 24, 2024, with diagnoses which included subacute bacterial endocarditis and sepsis.

A facility document titled, "Nurse's Notes," dated September 26, 2024, indicated, "...WOUND CARE CONSULTS /NOTES...Assessment...Coccyx Stage 3...right buttock - pressure injury stage 3...left buttock - pressure injury stage 3...Continue pressure injury prevention measures with turning every 2 hours..."

A concurrent interview and review of Patient 40's record was conducted on October 16, 2024, at 11:08 a.m., with Scribe 1. A facility document titled, "Admission/Shift Assessment - Skin Alteration," dated September 27, 2024, through October 4, 2024, was reviewed. There was no documented evidence Patient 40's skin assessment was completed on September 27, 2024, day shift (7 a.m. to 7 p.m.) and night shift (7 p.m. to 7 a.m.). Scribe 1 stated the nurses did not follow the facility's policy when Patient 40's skin assessment was not completed every shift.

4d. A tour of the Medical Intensive Care Unit (MICU, a unit for critically ill patients) was conducted on October 14, 2024, at 11:05 a.m., with the ACNO and Scribe 1.

An observation was conducted on October 14, 2024, at 11:15 a.m., at Patient 41's room. Patient 41 was observed lying in bed with eyes closed, was not moving, and had a tracheostomy on his neck connected to a ventilator.

A review of Patient 41's record was conducted on October 15, 2024, at 3:15 p.m., with Scribe 1. A facility document titled, "History and Physical," dated August 25, 2024, indicated Patient 41 was admitted to the facility on August 25, 2024, with diagnoses which included shock secondary to pericarditis (a swelling and irritation of the thin saclike membrane surrounding the heart), uremia (a condition involving abnormally high levels of waste products in the blood), and possible sepsis.

A facility document titled, "Nurse's Notes," dated August 26, 2024, indicated,"...WOUND CARE CONSULTS /NOTES...Assessment...Coccyx with scattered partial thickness open areas...does not appear to be pressure injuries, they appear to have been caused by moisture... left heel unstageable pressure injury..."

A facility document titled, "Admission/Shift Assessment - Skin Alteration," dated October 4, 2024, through October 12, 2024, was reveiwed. There was no documented evidence skin assessment was done on Patient 41 on the following dates and shifts:

- On October 7, 2024, night shift (7 p.m. to 7 a.m.);
- On October 8, 2024, night shift;
- On October 9, 2024, night shift; and
- On October 11, 2024, day shift (7 a.m. to 7 p.m.).

Scribe 1 stated the facility's policy was not followed when Patient 41's skin assessment was not completed every shift.

An interview was conducted on October 17, 2024, at 10:01 a.m., with ACNO 2. ACNO 2 stated her expectation is for nurses to perform a skin assessment once a shift.

A review of the facility's P&P titled, "Skin Integrity Management," dated October 2022, was conducted. The P&P indicated, "...Policy...All inpatients will be assessed in regard to integumentary integrity...This will be documented on admission, minimum once per shift..."

5a. A concurrent interview and review of Patient 37's record were conducted on October 17, 2024, at 9:35 a.m., with the Chief Nursing Officer (CNO) and the Intermediate Care Unit Manager (IMCUM). A facility document titled, "Discharge Report," dated January 27, 2024, was reviewed and indicated, "...Order Date: January 27, 2024 ...NUR [Nurse] PHYS [Physician] Notify ...Order Details...O2 [Oxygen], Sat [saturation, level of oxygen in the blood] under (%) [percent] 92 [normal is between 95% and 100%] ...HR [heart rate, normal is 60 to 100] over (beats/min [minute]): 110 ...HR under: 60 ...Syst [Systolic] BP [blood pressure, normal is 120] over (mm/Hg) [millimeter mercury, unit of measurement]: 170 ...Sys BP under (mm/Hg): 90 ...Diastolic BP over (mm/Hg, normal is 60 to 90): 100..."

A facility document titled, "Clinical Monitor Interface," dated January 28, 2024, through February 25, 2024, was reviewed.There was no documented evidence the physician was notified of the following values on the following dates, in accordance with the physician's order:

- On January 28, 2024, at 1:15 a.m., when Patient 37's blood pressure was 86/56;
- On January 28, 2024, at 1:46 a.m., when Patient 37's pulse rate (same as the heart rate) was 127 and the SPO2% (O2 saturation) was 91;
- On January 28, 2024, at 2 a.m., when Patient 37's pulse rate was 127;
- On January 28, 2024, at 2:30 a.m., when Patient 37's pulse rate was 132;
- On January 28, 2024, at 3 a.m., when Patient 37's pulse rate was 132;
- On January 28, 2024, at 3:31 a.m., when Patient 37's pulse rate was 132;
- On January 28, 2024, at 4 a.m., when Patient 37's pulse rate was 131;
- On January 28, 2024, at 5:30 a.m., when Patient 37's pulse rate was 133;
- On January 28, 2024, at 6 a.m., when Patient 37's pulse rate was 132;
- On January 28, 2024, at 8 a.m., when Patient 37's pulse rate was 136 and SPO2 %: was 90;
- On February 2, 2024, at 6:22 p.m., when Patient 37's blood pressure was 89/57;
- On February 3, 2024, at 5:01 p.m., when Patient 37's SPO2 %: was 91;
- On February 3, 2024, at 6 p.m., Patient 37's pulse rate was 124, respiratory rate was 33, and SPO2% was 88;
- On February 3, 2024, at 8:37 p.m., when Patient 37's pulse rate was 134;
- On February 4, 2024, at 7 a.m., when Patient 37's pulse rate was 132;
- On February 4, 2024, at 8 a.m., when Patient 37's pulse rate was 134;
- On February 4, 2024, at 9 a.m., when Patient 37's pulse rate was 131;
- On February 4, 2024, at 10 a.m., when Patient 37's pulse rate was 120;
- On February 6, 2024, at 9:08 a.m., when Patient 37's SPO2% was 91;
- On February 6, 2024, at 11 p.m., when Patient 37's blood pressure was 78/51;
- On February 8, 2024, at 7 p.m., when Patient 37's pulse rate was 136;
- On February 9, 2024, at 12 a.m., when Patient 37's blood pressure was78/51;
- On February 9, 2024, at 5 a.m., when Patient 37's pulse rate was 121;
- On February 10, 2024, at 3 a.m., when Patient 37's pulse rate was 116 and SPO2 % was 88;
- On February 11, 2024, at 10 a.m., when Patient 37's SPO2% was 91;
- On February 11, 2024, at 12 p.m., when Patient 37's blood pressure was 74/54;
- On February 13, 2024, at 11 p.m., when Patient 37's blood pressure was 76/50;
- On February 24, 2024, at 10 p.m., when Patient 37's pulse rate was 130 and SPO2% was 91; and
- On February 25, 2024, at 2:42 a.m., when Patient 37's pulse rate was 160.

The IMCUM stated on the majority of patient values she was unable to determine if nurses notified the physician as ordered.

On October 17, 2024, at 9:35 a.m., the CNO was interviewed. The CNO stated after reviewing the record, he is unable to determine if the nurses followed the physician's order or policy.

The facility's P&P titled, "Physician Notification Process," dated February 2023, was reviewed and indicated, "...Applies to ...All staff and physicians...Policy Statement...Examples of circumstances to notify physician(s) include but are not limited to...Per physician instructions or preset parameters..."

5b. On October 14, 2024, at 2:15 p.m., a concurrent interview and review of Patient 11's record was conducted with IP 1. A facility document titled, "History and Physical," dated June 14, 2024, was reviewed and indicated Patient 11 was admitted to the facility on June 14, 2024, with diagnoses which included sepsis, pyelonephritis (infection causing inflammation of the kidneys), peripheral artery disease (condition in which narrowed blood vessels reduce blood flow to limbs), and hypertension (high blood pressure). The document indicated Patient 11 had a history of diabetes mellitus (condition with abnormal blood sugar level).

On October 15, 2024, at 1:05 p.m., a review of Patient 11's record was conducted with Quality Coordinator (QC) 2. An untitled facility document dated September 7, 2024, at 6:11 a.m., was reviewed and indicated, "...ACCUCHECK-BLOOD GLUCOSE (point of care testing for blood sugar) MONITORING...Frequency: Every hour..."

An untitled facility document dated, October 6, 2024, at 1:48 p.m., was reviewed and indicated, "...Blood Glucose Monitoring...Frequency: Every 2 hours..."

On October 16, 2024, at 10:40 a.m., a concurrent interview and review of Patient 11's record were conducted with the IMCUM. There is no documented evidence accucheck was performed on Patient 11 every hour on September 7, 2024, through October 6, 2024, as ordered by the physician.

The IMCUM stated the order for blood glucose monitoring was not completed as ordered from September 7, 2024, to October 6, 2024. The IMCUM stated the order should have been changed from hourly blood sugar monitoring to every two hours but this was not done.

6. On October 15, 2024, at 10:50 a.m., a concurrent interview and review of Patient 11's record were conducted with the IMCUM. A facility document titled, "Laboratory Test History," indicated the physician was not notified when Patient 11's blood sugar (BS) level was less than 50 milligram/deciliter (mg/dl, unit of measurement, normal is between 80 to 130 mg/dL) or more than 450 mg/dl, in accordance with the facility's P&P on the following dates and times:

- On September 14, 2024, at 6:46 a.m., when Patient 11's BS was 521;
- On September 17, 2024, at 12:47 a.m., when Patient 11's BS was 46;
- On September 18, 2024, at 7:27 a.m., when Patient 11's BS was 452;
- On September 18, 2024, at 8:19 a.m., when Patient 11's BS was 460;
- On September 18, 2024, at 10:19 a.m., when Patient 11's BS was 533;
- On October 4, 2024 at, 11:58 a.m., when Patient 11's BS was 525;
- On October 6, 2024 at, 11:43 a.m., when Patient 11's BS was greater than 600;
- On October 6, 2024 at, 12:24 p.m., when Patient 11's BS was greater than 600 and the laboratory draw BS= 849;
- On October 6, 2024 at, 2:18 p.m., when Patient 11's BS was 499;
- On October 7, 2024 at, 12:16 p.m., when Patient 11's BS was 596; and
- On October 9, 2024 at, 2:03 p.m., when Patient 11's BS was 474.

The IMCUM stated the facility's P&P for critical results was not followed and the physician should have been notified for BS of less than 50 or greater than 450 mg/dl for Patient 11.

During a review of the facility's P&P titled, "Critical Results Management," dated February, 2023, the P&P indicated, "...For inpatient critical results...Licensed caregiver will attempt to notify ordering/covering Provider within 15 minutes of receiving critical result per unit standard...Notification of critical test must be documented in the Medical Record...APPENDIX B CRITICAL LAB RESULTS...Glucose, Adult...Less Than 50 mg/dL...Greater Than 450 mg/dL..."

7a. On October 14, 2024, at 9:35 a.m., an interview was conducted with the ED (Emergency Department) Director (EDD). The EDD stated if a patient comes into the ED after a motor vehicle accident (MVA) the process is to follow ABCs (Airway, Breathing, Circulation) or whatever needs to be stabilized and treated first. The EDD stated it also depends on what problem the patient presents to the ED with. The EDD stated if the patient's airway is stabilized, tests and scans are done, and when the patient is stable, the ED staff would move on to the patients' wounds. The EDD further stated patients would not be discharged with wounds that were not cleaned.

On October 14, 2024, at 2:40 p.m., a review of Patient 2's record was conducted with the CV Quality Manager (CVQM).

A facility document titled, "Emergency Provider Report," dated August 22, 2024, at 11:23 p.m.. indicated Patient 2 came to the ED on August 22, 2024, as a trauma patient after a motorcycle accident. The document indicated Patient 2 had a three by four centimeters (a unit of measurement) gaping laceration to the right lower abdomen near the hip and multiple abrasions to the legs and right flank. The document further indicated, " ...(Patient 2) complaining of right calf pain with large abrasion to the calf. Trauma team involved in his care...ordered an Xray [an imaging procedure] of [Patient 2's] right lower leg...prophylactic [administered to prevent infection] antibiotics...tetanus vaccine...Patient found to have a right 7th [seventh] rib fracture [a break in the bone] and a very small pneumothorax [occurs when air leaks into the space between the lung and the chest wall)...patient admitted by the trauma team..."

A facility document titled, "Emergency Department Trauma Flowsheet," dated August 22, 2024, was reviewed and indicated Patient 2 had abrasions to left and right lower legs and the right hand. The document indicated, on August 22, 2024, at 11:45 p.m., " ...patient [Patient 2] complained of right hip, right thumb, right calf, and generalized chest wall pain at this time..." The document did not indicate Patient 2's abrasions were cleaned.

A facility document titled, "Discharge Summary," dated August 23, 2024, indicated, " ...patient to follow up with his PCP [primary care physician] in 5-7 [five to seven] days." The document did not indicate instructions on how to clean the patient's wounds after the patient is discharged.

On October 15, 2024, at 1:05 p.m., a concurrent interview and review of Patient 2's record was conducted with Scribe 1. Scribe 1 stated staff should clean and dress any wounds prior to discharge. Scribe 1 stated they could not find any documentation Patient 2's wounds were cleaned prior to discharge.

On October 15, 2024, at 1:45 p.m., an interview was conducted with the EDD. The EDD stated wound cleaning should be documented in the nursing notes or trauma charting notes, or the MD may document it in their notes if the MD cleaned the wound. The EDD stated the patient's wounds should be cleaned prior to the patient being discharged from the facility. The EDD stated there is no documentation indicating Patient 2's wounds were cleaned prior to Patient 2's discharge. The EDD further stated deeper wounds usually get washed out, but more superficial wounds may not always be cleaned out prior to discharge. The EDD stated patients would be instructed to shower and clean wounds after discharge.

7b. On October 16, 2024, at 9 a.m., a review of Patient 34's record was conducted with the PSDRM. A facility document titled, "Emergency Provider Report," dated October 10, 2024, was reviewed and indicated Patient 34 came to the ED on October 10, 2024, as a trauma patient after a MVA.

A facility document titled, "Trauma - History & Physical," dated October 10, 2024, was reviewed and indicated, "...Skin: dry, superficial abrasions to right medial knee and right hand..."

A facility document titled, "[Name of Facility] Coding Summary," was reviewed and indicated, " ...Adm [Admit] Date: 10/10/24 [October 10, 20204] ...Diagnoses...Abrasion, right knee...abrasion of right hand..."

A facility document titled, "Emergency Department Trauma Flowsheet," dated October 10, 2024, indicated Patient 34 had abrasions to the right knee and right hand.

During a concurrent interview, the PSDRM stated the trauma charting indicates Patient 34 had abrasions to the right hand and right knee. The PSDRM stated there is no documentation the patient's hand or knee were cleaned prior to discharge.

A review of the facility P&P titled, "[Name of Facility] Skin Integrity Management," dated October 2022, was conducted. The P&P indicated, "...Scope: All nursing staff at [Name of facility]...Purpose: to provide a standard for assessment, documentation, prevention and treatment of skin integrity...The nurse should notify the practitioner of any new or existing wound and o