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

1. A copy of the patient's rights information list (a list that outlines a patient's rights when admitted in the hospital. Example: right to access medical record information within a reasonable timeframe, etc.) was provided to the patients and/or the patients' responsible party (RP) for two of 14 sampled patients (Patients 18 and 30). This deficiency resulted in Patients 18 and 30, and their responsible party (RP) not informed of their rights as a patient. (Refer to A-117)

2. One of two patients (Patient 17) was properly assessed and evaluated for psychiatric condition (a broad range of problems that disturb a person's thoughts, feelings, behavior or mood), when Patient 17 was brought into the facility's Urgent Care Center (UC-a same day clinic focused on the delivery of same day medical care for minor injuries and illnesses) for psychiatric evaluation (used to determine a patient's mental state and guide recommendations for the best treatment) in accordance with the facility's policy and procedure regarding triaging (preliminary assessment of the patient to determine the urgency of the need for treatment) of patients. This deficiency resulted in Patient 17's inability to exercise the right to receive appropriate treatment in a higher level of care setting (a hospital capable of providing diagnostic and interventional care beyond the capacity of the hospital from which a patient originates). (Refer to A-129).

3. A consent for hemodialysis (HD - a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) was obtained from one of 14 sampled patients (Patient 18) and/or the patient's (Patient 18) responsible party (RP) prior to Patient 18's HD treatment. This deficiency resulted in Patient 18 not able to exercise the right to make informed decisions regarding his (Patients 18) care. (Refer to A-131)

4. A consent form for peripherally inserted central catheter line (PICC line -a long thin flexible line that goes all the way up to a vein near the heart and used as intravenous access) was provided and signed by one of 14 sampled patients (Patient 24) in a language that Patient 24 can understand. This deficiency resulted in Patient 24 not able to exercise the right to make informed decisions regarding his (Patients 24) care. (Refer to A-131)

5.The care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) was developed and updated to include the use of restraints (devices that limit a patient's movement) for five of five sampled patients (Patients 19, 25, 26, 30, and 13).This deficiency had the potential to result in harm to the patients' safety by not identifying the patients' needs and risks. (Refer to A-166)

6. The physician's telephone order for chemical restraints (a medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition) was co-signed and validated by the ordering physician for one of 4 sampled patients (Patient 19). This deficiency had the potential to result in an inappropriate, unnecessary, and prolonged use of chemical restraints. (Refer to A-168)

7. Three of four sampled patients' (Patients 19, 25, and 26) condition were assessed and have the assessment documented in the patients' (Patient 19, 25, and 26) medical records after chemical restraints (a medication when it is used as a restriction to manage the patient ' s behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition) were administered. This deficiency had the potential to result in inappropriate, unnecessary, and prolonged use of chemical restraints, and had the potential to violate the patients' (Patients 19, 25, and 26) rights. (Refer to A-175)

8. Three of four sampled patients (Patients 19, 25, and 26) were seen and evaluated face-to-face within one hour, after the initiation of a restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) to manage violent or self-destructive behavior, by a Registered Nurse (RN) who was trained in accordance with the regulatory requirements. This deficiency had the potential to result in an inaccurate in-person evaluation and assessment of the patients' physical and psychological status after restraints were applied. (Refer to A-178)

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 ensure that a copy of the patient's rights information list (a list that outlines a patient's rights when admitted in the hospital. Example: right to access medical record information within a reasonable timeframe, etc.) was provided to the patients and/or the patients' responsible party (RP) for two of 14 sampled patients (Patients 18 and 30).

This deficiency resulted in Patients 18 and 30, and the patients' responsible party (RP - a person designated as the guardian of the patient or a person liable for the support of the patient) not informed of their rights as a patient.

Findings:

1. During a concurrent interview and record review, on 4/19/2023, at 11:45 a.m., with the Director of Nursing (DON), Patient 18's medical record was reviewed. The History and Physical (H&P-a formal and complete assessment of the patient and the problem) indicated, Patient 18 was admitted to the facility on 4/07/2023 due to uncontrolled hypertension (defined as blood pressure (BP) above 140/90 and is considered severe if the BP is above 180/120). Patient 18's medical history included end stage renal disease (ESRD - loss of kidney function), legal blindness, and hearing impairment. The physical examination indicated Patient 18 was awake, alert, and "no other focal neurologic findings (problems in the brain function) are elicited."

A review of Patient 18's "Conditions of Admission (COA - a form which outlined the patient's obligation with respect to the hospital services received, provisions under which the patient provide informed consent for treatments, and the patient's rights)," form did not have Patient 18's or Patient 18's RP's signature.

A review of patient 18's record titled, "Unable to Sign Reattempt Documentation Form," indicated one attempt was made on 4/06/2023, for Patient 18 to sign the COA with a comment, "unable to sign, pt [Patient 18] was too weak, refused, daughter interpreted."

A review of Patient 18's demographic information indicated Patient 18's RP was the patient's (Patient 18) spouse.

During an interview on 4/19/2023, at 11:45 a.m., with the facility's Director of Nursing (DON), the DON stated when a patient was not able to sign the COA, the patient's RP should be contacted to get the signature. There should be three attempts to have the COA signed by the patient or the patient's RP and it (attempts made to sign the COA) should be documented in the COA form.

A review of Patient 18's record indicated there was only one attempt made to obtain Patient 18's signature for the COA and there was no documentation Patient 18's RP was informed of the COA. Likewise, there was no documentation that Patient 18's RP was contacted.

During an interview on 4/19/2023, at 12:12 p.m., with the Admission Coordinator (AC), the AC stated the following:

- admitting staff has the responsibility to provide the COA information and have the COA signed by the patient or the patient's RP upon arrival to the admitting department.

-when a patient refuses to sign or is unable to sign the COA due to medical condition, it (the refusal) should be documented in the COA form. The patient's RP would then be given the COA information and would be asked to sign the COA if the patient was refusing or not able to sign the COA.

-the admitting staff would attempt three times for the COA to be signed by the patient or the patient's RP, and the outcome of the attempt would be documented in the COA form including the reason for not signing the COA.

-The AC stated she (AC) was the one who gave the COA information to Patient 18. The AC stated she (AC) remembered Patient 18 was too weak to sign and she (AC) explained the COA to the patient's (Patient 18) daughter. The AC stated she (AC) did not remember if Patient 18's daughter was the patient's (Patient 18) RP. The AC stated Patient 18's RP would be indicated in the patient's (Patient 18) demographic information form.

The AC stated the process should have been followed in providing the COA information to Patient 18 and the patient's (Patient 18) RP including obtaining the signature for the COA.

A review of the facility's policy and procedure (P&P) titled, "Admission Process," dated September 2023, indicated, " ...Review the Condition of Admission Form, and all other consent forms with the patient. (See the specific Policy and Procedure for each form for further details) ..."

During an interview on 4/20/2023, at 1:35 p.m., with the DON, the DON stated there was no specific P&P made for COA, the facility's current practice for providing the COA was based on the facility process and guideline that should be followed.

2. During a concurrent interview and record review on 4/21/2023, at 9:25 a.m., with the Director of Nursing (DON), Patient 30's medical record was reviewed. The "History and Physical (H&P -a formal and complete assessment of the patient and the problem)," indicated Patient 30 was admitted to the facility for evaluation of generalized weakness and psychiatric decompensation (worsening symptoms of mental illness).

A review of Patient 30's Conditions of Admission (COA - a form which outlined the patient's obligation with respect to the hospital services received, provisions under which the patient provide informed consent for treatments, and the patient's rights) form, indicated the COA did not have Patient 30's or the patient (Patient 30) RP's signature. The COA also indicated the patient (Patient 30) was unable to sign due to medical condition.

A review of Patient 30's form titled, "Unable to Sign Reattempt Documentation Form," indicated one attempt was made on 4/16/2023, for Patient 30 to sign the COA.

A review of Patient 30's demographic information indicated the contact number of Patient 30's RP.

During an interview on 4/21/2023, at 9:25 a.m., with the DON, the DON stated when a patient was not able to sign the COA, the patient's RP should be contacted to get the signature. There should be three attempts to have the COA signed by the patient or the patient's RP and it (referring to the attempts to have the COA signed) should be documented.

A review of Patient 30's record indicated there was only one attempt made to obtain Patient 30's signature for the COA and there was no documentation Patient 30's RP was informed of the COA.

During an interview on 4/19/2023, at 12:12 p.m., with the Admission Coordinator (AC), the AC stated the admitting staff has the responsibility to provide the COA information and have the COA signed by the patient or the patient's RP upon arrival to the admitting department.

In addition, the AC stated when a patient refuses to sign or is unable to sign the COA due to medical condition, it (referring to the refusal or inability to sign the COA) should be documented. The patient ' s RP would then be given the COA information and would be asked to sign the COA if the patient was refusing or not able to sign the COA.

The AC stated the admitting staff would attempt three times for the COA to be signed by the patient or the patient's RP, and the outcome of the attempt would be documented including the reason for not signing the COA.

A review of the facility's policy and procedure (P&P) titled, "Admission Process," dated September 2023, indicated, " ...Review the Condition of Admission Form, and all other consent forms with the patient. (See the specific Policy and Procedure for each form for further details) ..."

During an interview on 4/20/2023, at 1:35 p.m., with the DON, the DON stated there was no specific P&P made for COA, the facility's current practice for providing the COA was based on the facility process and guideline that should be followed.

Based on interview and record review, the facility failed to ensure that one of two patients (Patient 17) was properly assessed and evaluated for psychiatric condition (a broad range of problems that disturb a person's thoughts, feelings, behavior or mood), when Patient 17 was brought into the facility's Urgent Care Center (UC-a same day clinic focused on the delivery of same day medical care for minor injuries and illnesses) for psychiatric evaluation (used to determine a patient's mental state and guide recommendations for the best treatment) in accordance with the facility's policy and procedure regarding triaging (preliminary assessment of the patient to determine the urgency of the need for treatment) of patients.

This deficiency resulted in Patient 17's inability to exercise the right to receive appropriate treatment in a higher level of care setting (a hospital capable of providing diagnostic and interventional care beyond the capacity of the hospital from which a patient originates).

Findings:

On 4/17/2023, an investigation was conducted in the facility for a complaint received regarding Patient 17 who was denied psychiatric evaluation by the facility when Patient 17 was brought into the facility's Urgent Care Center (UC) on 4/17/2023.

During an interview on 4/17/2023, at 2:08 p.m., with the Director of Quality and Risk Management (DQRM), the DQRM stated there was no record of Patient 17 being evaluated or admitted in the facility. The DQRM stated all the patients that came in the UC would be registered and would be recorded in the facility's system.

During an interview on 4/17/2023, at 2:53 p.m., with the Admission Coordinator (AC), the AC stated the following:

-she (AC) was the one who receives the patient intakes (process through which healthcare organizations key pieces of information [example: social and clinical data, demographics, etc.] from new patients prior to admission) for admission and the patient referrals needing psychiatric evaluation.

-when a patient was referred for psychiatric evaluation, the patient would be evaluated via telehealth (live video conference between the health care provider and the patient) or through the UC.

-on 4/17/2023, Patient 17 was brought in the UC via ambulance stretcher accompanied by the police and the Emergency Medical Technician (EMT - medical profession that provides emergency medical services). The AC stated she (AC) was called to come to UC because Patient 17 was not in the system for patient referral or admission. The AC stated, she (AC) did not receive any report from the Skilled Nursing Facility (SNF-provides 24 hour medical care onsite and activities of daily living) where Patient 17 came from regarding Patient 17 being sent to the facility for psychiatric evaluation.

-she (AC) called the House Supervisor Registered Nurse 1 (HS RN 1) to assess Patient 17. The AC stated after HS RN 1 assessed the patient (Patient 17), they (AC and the HS RN 1) both went to the Urgent Care Physician (Physician 1) and informed Physician 1 about Patient 17's condition.

-Physician 1 told her (AC) and HS RN 1 that Patient 17 was not stable to be seen in the UC and to reroute the patient (Patient 17) to an Emergency Department (ED). The AC stated she (AC) told the police and the EMT of Physician 1's order to reroute Patient 17 in an ED. The police told her (AC) that Patient 17 was refused by the ED and that was why Patient 17 was brought in the facility's UC.

-the police and the EMT left with Patient 17 and the police told the AC they will return the patient (Patient 17) back to the SNF instead.

During an interview on 4/18/2023, at 8:02 a.m., with HS RN 1, HS RN 1 stated he (HS RN 1) was the nursing supervisor for the facility which included the UC. HS RN 1 stated patients seen in the UC could be from walk-in (patients who arrive in the UC without appointments) needing medical or psychiatric treatment (therapeutic treatment of mental health conditions), or patients referred by other facilities for psychiatric evaluation.

In addition, HS RN 1 stated the process in the UC was when a patient arrived, the patient should be registered in the system, then the RN would triage (preliminary assessment of the patient to determine the urgency of the need for treatment) the patient and the physician would evaluate the patient. After the physician evaluated the patient, the physician would decide the patient ' s disposition (discharge home, admission to the facility, or transfer to higher level of care).

Likewise, HS RN 1 stated he (HS RN 1) could not remember his (HS RN 1) encounter with Patient 17. HS RN 1 stated the process in accordance with the facility ' s policy and procedure (P&P) should have been followed when Patient 17 was brought in the UC.

During an interview on 4/18/2023, at 8:39 a.m., with the Medical Director of Urgent Care (MDUC), the MDUC stated all the patients brought in the UC must be seen by the RN for triage and must be evaluated by the physician before making a decision on the patient's disposition.

The MDUC stated he (MDUC) was not the physician in the UC when Patient 17 arrived at the facility on 4/17/2023. The MDUC stated he (MDUC) spoke with Physician 1 who was the assigned MD and Physician 1 told him (MDUC) Patient 17 was not evaluated by Physician 1, and Physician 1 made the decision to send Patient 17 to ED based on the report of the Admission Coordinator (AC) to Physician 1.

The MDUC stated Physician 1 should not rely on others ' report regarding any patient's condition. The MDUC stated Physician 1 should have evaluated Patient 17 himself and whatever the patient ' s situation was, Physician 1 should have seen Patient 17 first before deciding the patient's (Patient 17) treatment plan.

A review of the facility's policy and procedure (P&P) titled, "Patient's Rights," dated March 2019, indicated, " ...The patient has a basic right to treatment. Provision of treatment is the physician's and Hospital's fundamental responsibility to the patient ..."

A review of the facility's policy and procedure (P&P) titled, "Assessment and Triage of Urgent Care Center Patients," revised on March 2021, indicated, " ...All Urgent Care patients will be triaged by a Registered Nurse ...assessed according to acceptable nursing standards that provision shall be made for the treatment of Urgent Care Center patients based on initial assessment ...The physician will perform Medical Screening regardless of diagnosis, financial status, insurance status, race, color, national origin, sexual orientation, developmental disability or similar factors upon arrival of patient ..."

Based on observation, interview, and record review, the facility failed to ensure the following for two of 14 sampled patients (Patients 18 and 24):

1. A consent for hemodialysis (HD - a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) was obtained from Patient 18 and/or the patient's (Patient 18) responsible party (RP -a person designated as the guardian of the patient or a person liable for the support of the patient) prior to Patient 18's HD treatment.

2. A consent form for peripherally inserted central catheter line (PICC line - a long thin flexible line that goes all the way up to a vein near the heart and used as intravenous access) was provided and signed by Patient 24 in a language that Patient 24 can understand.

These deficiencies resulted in Patient 18 and Patient 24 not able to exercise the right to make informed decisions regarding their (Patients 18 and 24) care.

Findings:

1. During a concurrent interview and record review, on 4/19/2023, at 8:40 a.m., with the Director of Nursing (DON), Patient 18's medical record was reviewed. Patient 18 ' s "History and Physical (H&P -a formal and complete assessment of the patient and the problem)," indicated Patient 18 was admitted to the facility on 4/07/2023 due to uncontrolled hypertension (defined as blood pressure [BP] above 140/90 and is considered severe if the BP is above 180/120). Patient 18's medical history included end stage renal disease (ESRD - loss of kidney function) and needed HD. The physical examination indicated Patient 18 was awake, alert, and "no other focal neurologic findings (problems in the brain function) are elicited."

A review of Patient 18's "Conditions of Admission (COA - a form which outlined the patient's obligation with respect to the hospital services received, provisions under which the patient provide informed consent for treatments, and the patient's rights)" form, did not have Patient 18's or the patient's (Patient 18) Responsible Party's (RP) signature.

A review of patient 18's "Unable to Sign Reattempt Documentation Form," indicated one attempt was made on 4/06/2023, for Patient 18 to sign the COA with a comment, "unable to sign, pt (Patient 18) was too weak, refused, daughter interpreted."

A review of Patient 18's demographic information indicated Patient 18 ' s Responsible Party (RP) was the patient's (patient 18) spouse.

A review of Patient 18's physician's order, dated 4/08/2023, indicated Patient 18 to have HD every Tuesday, Thursday, and Saturday.

A review of Patient 18's "Hemodialysis Flowsheet" indicated Patient 18 received HD on April 8, 11, 13, 15, and 18, 2023.

There was no documented evidence Patient 18 or the patient's (Patient 18) RP's consent for HD was obtained prior to Patient 18's HD treatments. This finding was confirmed by the DON on 4/19/2023.

During an interview on 4/19/2023, at 8:40 a.m., with the DON, the DON stated a consent should be obtained prior to a patient receiving HD. The DON stated the consent could be from signing the COA or having the patient or patient's RP sign a consent for therapeutic procedures. The DON further said Patient 18's COA was not signed by the patient (Patient 18) or the patient's (Patient 18) RP and there was no therapeutic procedure consent signed by Patient 18 or the patient's RP prior to Patient 18's HD treatments.

During an interview on 4/19/2023, at 10:38 a.m., with the Manager of Dialysis Services (MDS), the MDS stated they (the dialysis staff) were contracted by the facility to provide HD to the patients at bedside. The MDS said prior to a patient's HD treatment, the HD Registered Nurse (HD RN) should verify the HD orders and the patient's consent for the HD treatment. The MDS stated consent for HD treatment was included on the COA. The MDS stated HD RN should verify if the COA was signed by the patient or patient's RP. The MDS stated if the COA was not signed, the HD RN should obtain a consent for HD treatment from the patient or the patient's RP.

A review of the facility's policy and procedure (P&P) titled, "Dialysis Patient," dated 3/19/2019, indicated, " ...The patient shall sign consent for "Dialysis and Blood Transfusion...The consent is valid for the entire hospital stay ..."

A review of the facility's policy and procedure (P&P) titled, "Acute Hemodialysis Standards of Care," revised on 3/19/2022, indicated, " ...A signed consent must be in the chart prior to the first hemodialysis treatment. Written informed consent for hemodialysis must be obtained prior to the first dialysis treatment ..."

2. During an observation on 4/18/2023, at 1:50 p.m., with the Director of Quality (DOQ) and the Director of Nursing (DON), Patient 24 was observed lying in bed, alert, and oriented. Patient 24 had a peripherally inserted central catheter line (PICC line - a long thin flexible line that goes all the way up to a vein near the heart and used as intravenous access) in the left arm and Vancomycin (an antibiotic) was infusing at 60 milliliter per hour (ml/hr-a unit of measurement).

During an interview on 4/18/2023, at 1:50 p.m., with Patient 24, Patient 24 stated he (Patient 24) was admitted to the hospital because he (Patient 24) had a knee surgery from another hospital and now, he (Patient 24) was in a lot of pain. Patient 24 stated he (Patient 24) preferred Spanish language when discussing his (Patient 24) care because, "my English is not good."

During a concurrent interview and record review on 4/20/2023, at 2:42 p.m., with the DON, Patient 24 ' s medical record was reviewed. The "History & Physical (H&P -a formal and complete assessment of the patient and the problem)," indicated Patient 24 was admitted to the facility on 4/13/2023, with a chief complaint of intractable knee pain (pain that is difficult to treat or manage) due to a recent knee surgery.

A review of Patient 24's demographic information indicated the patient ' s (Patient 24) language was Spanish.

A review of Patient 24's "Authorization and Consent to Surgery or Special Diagnostic or Therapeutic Procedures," form for PICC line procedure indicated the form was provided to Patient 24 in an English version and signed by the patient (Patient 24) on 4/14/2023.

During an interview on 4/20/23, at 2:42 p.m., with the DON, the DON stated Patient 24's language was Spanish. The DON said the consent for PICC line insertion given to Patient 24 should have been the Spanish version, which was the language Patient 24 can understand.

A review of the facility's policy and procedure (P&P) titled, "Informed Consent," dated September 2022, indicated, " ...Procedures for obtaining consent from patients whose primary language is one other than English ...Consents forms are available in Spanish ...Interpreter services are available at the hospital for those patients who speak various languages ..."

Based on interview and record review, the facility failed to ensure that the care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) was developed and updated to include the use of restraints (devices that limit a patient ' s movement) for five of five sampled patients (Patients 19, 25, 26, 30, and 13).

This deficiency had the potential to result in harm to the patients' (Patients 19, 25, 26, 30, and 13) safety by not identifying the patients' needs and risks.

Findings:

1. During a concurrent interview and record review on 4/20/2023, at 1:20 p.m., with the Director of Nursing (DON), Patient 19's medical record was reviewed. The "History and Physical (H&P -a formal and complete assessment of the patient and the problem)," indicated Patient 19 was admitted to the facility on 4/11/2023, with a chief complaint of schizophrenia (a psychiatric disorder that affects a person ' s ability to think, feel, and behave clearly).

A review of Patient 19's "Emergency Medication and Restraint Order Sheet," indicated Patient 19 had a chemical restraint (a medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition) ordered and administered:

- on 4/14/2023, at 1:33 p.m., for an aggressive behavior towards his (Patient 19) roommate

- on 4/15/2023, at 1:10 p.m., for an aggressive behavior and making verbal threats against staff and other patients

A review of Patient 19's "Emergency Medication and Restraint Order Sheet," indicated the following medications were used for the chemical restraints administered to Patient 19:

-Ativan (acts on the brain and the nerves to produce a calming effect) 2 milligrams (mg) intramuscular (IM - injection into the muscle)

-Haldol (medication that works in the brain to treat schizophrenia) 10 mg IM

-Benadryl (medication that induces sedation and drowsiness) 50 mg IM.

A review of Patient 19's care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) indicated no documented evidence Patient 19's care plan was updated addressing Patient 19's need for a chemical restraint. This absence of documented evidence was confirmed by the DON.

During an interview on 4/20/2023, at 1:20 p.m., with the DON, the DON stated when a patient was put on a restraint, the patient's care plan should address/indicate the need for restraints use for the patient. The DON also said Patient 19's care plan should have been updated to indicate the patient's (Patient 19) need for a chemical restraint.

A review of the facility's policy and procedure (P&P) titled, Restraints and Seclusion Policy, dated 3/08/2019, indicated: 3. DEFINITIONS: A. "Restraint" means any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body. 4. C. Documentation 2. Patient needs will be met during restraint use:
b. The plan of care will not be compromised by the use of restraints and shall include:
· Provision of nutritional needs
· Provision of hydration needs
· Provision of elimination needs
· Provision of hygiene needs
· Provision of exercise and range of motion
· Provision of patient safety and comfort
· Discuss restraint, when practical, with patient and family around the time of use

A review of the facility's policy and procedure (P&P) titled, "Restraint and Seclusion (a medication when it is used as a restriction to manage the patient ' s behavior or restrict the patient ' s freedom of movement and is not a standard treatment or dosage for the patient ' s condition) Policy," revised on 4/18/ 2021, indicated, " ...When a restraint is implemented, the patient's plan of care must be modified to reflect this change ...Documentation ...Each episode of restraint use shall be documented in the patient ' s medical record, and shall include but not be limited to ...use of restraints must be addressed in the patient ' s modified plan of care ..."

2. During a concurrent interview and record review on 4/20/2023, at 3:34 p.m., with the Director of Nursing (DON), Patient 25's medical record was reviewed. The "History and Physical (H&P -a formal and complete assessment of the patient and the problem)," indicated Patient 25 was admitted to the facility on 4/02/2023, for psychiatric condition (a broad range of problems that disturb a person's thoughts, feelings, behavior or mood).

A review of Patient 25's "Emergency Medication and Restraint Order Sheet," indicated Patient 25 had a chemical restraint (a medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient ' s condition) ordered and administered:
- on 4/03/2023, at 1:15 a.m., for trying to kick a hospital staff
- on 4/3/2023, at 10:21 p.m., for being combative to hospital staff

A review of Patient 25's "Emergency Medication and Restraint Order Sheet," indicated the following medications were used for the chemical restraints administered to Patient 25:

- Ativan (acts on the brain and the nerves to produce a calming effect) 1 milligram (mg) intramuscular (IM - injection into the muscle)

-Haldol (medication that works in the brain to treat schizophrenia) 5 mg IM

-Benadryl (medication that induces sedation and drowsiness) 50 mg IM.

A review of Patient 25's care plan indicated no documented evidence Patient 25's care plan was updated addressing Patient 25's need for a chemical restraint. This absence of documented evidence was confirmed by the DON.

During an interview on 4/20/2023, at 3:34 p.m., with the DON, the DON stated when a patient was put on a chemical restraint, the patient's care plan should address/indicate the need for restraints use for the patient. The DON also said Patient 25's care plan should have been updated to indicate the patient's (Patient 25) need for a chemical restraint.

A review of the facility's policy and procedure (P&P) titled, Restraints and Seclusion (involuntary confinement of a patient in a room) Policy, dated 3/08/2019, indicated: 3. DEFINITIONS: A. "Restraint" means any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body. 4. C. Documentation 2. Patient needs will be met during restraint use:
b. The plan of care will not be compromised by the use of restraints and shall include:
· Provision of nutritional needs
· Provision of hydration needs
· Provision of elimination needs
· Provision of hygiene needs
· Provision of exercise and range of motion
· Provision of patient safety and comfort
· Discuss restraint, when practical, with patient and family around the time of use

A review of the facility's policy and procedure (P&P) titled, "Restraint and Seclusion Policy," revised on 4/18/ 2021, indicated, " ...When a restraint is implemented, the patient ' s plan of care must be modified to reflect this change ...Documentation ...Each episode of restraint use shall be documented in the patient ' s medical record, and shall include but not be limited to ...use of restraints must be addressed in the patient ' s modified plan of care ..."

3. During a concurrent interview and record review on 4/20/2023, at 4:30 p.m., with the Director of Nursing (DON), Patient 26' medical record was reviewed. The "History and Physical (H&P -a formal and complete assessment of the patient and the problem)" indicated Patient 26 was admitted to the facility on 3/22/2023, for psychiatric evaluation (to diagnose emotional, behavioral, or developmental disorders) and treatment.

A review of Patient 26' "Emergency Medication and Restraint Order Sheet," indicated Patient 26 had a chemical restraint (a medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition) ordered and administered:

- on 3/25/2023, at 10:36 a.m., for being verbally aggressive

- on 3/27/2023, at 3:10 p.m., for spitting at the hospital staff

A review of Patient 26' "Emergency Medication and Restraint Order Sheet," indicated the following medications were used for the chemical restraints administered to Patient 26:

- Ativan (acts on the brain and the nerves to produce a calming effect) 2 milligrams (mg) intramuscular (IM - injection into the muscle)

-Haldol (medication that works in the brain to treat schizophrenia) 5 mg IM

-Benadryl (medication that induces sedation and drowsiness) 50 mg IM.

A review of Patient 26' care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) indicated no documented evidence Patient 26' care plan was updated addressing Patient 26' need for a chemical restraint. This absence of documented evidence was confirmed by the DON.

During an interview on 4/20/2023, at 4:30 p.m., with the DON, the DON stated when a patient was put on a restraint, the patient's care plan should address/indicate the need for restraints use for the patient. The DON also said Patient 26' care plan should have been updated addressing the patient's (Patient 26) need for a chemical restraint.

A review of the facility's policy and procedure (P&P) titled, Restraints and Seclusion (involuntary confinement of a patient in a room) Policy, dated 3/08/2019, indicated: 3. DEFINITIONS: A. "Restraint" means any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body. 4. C. Documentation 2. Patient needs will be met during restraint use:
b. The plan of care will not be compromised by the use of restraints and shall include:
· Provision of nutritional needs
· Provision of hydration needs
· Provision of elimination needs
· Provision of hygiene needs
· Provision of exercise and range of motion
· Provision of patient safety and comfort
· Discuss restraint, when practical, with patient and family around the time of use

A review of the facility's policy and procedure (P&P) titled, "Restraint and Seclusion (involuntary confinement of a patient in a room) Policy," revised on 4/18/ 2021, indicated, " ...When a restraint is implemented, the patient's plan of care must be modified to reflect this change ...Documentation ...Each episode of restraint use shall be documented in the patient ' s medical record, and shall include but not be limited to ...use of restraints must be addressed in the patient ' s modified plan of care ..."

4. During a concurrent interview and record review on 4/21/2023, at 9:25 a.m., with the Director of Nursing (DON), Patient 30 ' s medical record was reviewed. The "History and Physical (H&P -a formal and complete assessment of the patient and the problem)," indicated Patient 30 was admitted to the facility for evaluation of generalized weakness and psychiatric decompensation (a breakdown in an individual ' s defense mechanisms [unconscious strategies whereby people protect themselves from anxious thoughts or feelings], resulting in progressive loss of normal functioning or worsening of psychiatric symptoms [example: excessive fears/worries, extreme mood changes, etc.]).

A review of Patient 30's "Non-Violent, Non-Behavioral Medical Restraint Order Form," indicated Patient 30 had bilateral soft wrist restraints (a device that is used on the wrists or ankle to prevent excessive movement of a patient's body part to which the restraints are attached) on 4/16/2023, at 5 p.m. because Patient 30 was trying to climb out of bed.

A review of Patient 30's care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) indicated no documented evidence Patient 30's care plan was updated addressing Patient 30's need for a soft wrist restraint. The absence of a care plan regarding Patient 30's use of restraints was confirmed by the DON on 4/21/2023.

During an interview on 4/21/2023, at 9:25 a.m., with the DON, the DON stated when a patient was put on a restraint, the patient's care plan should address/indicate the need for restraints use for the patient. The DON also said Patient 30's care plan should have been updated addressing the patient's (Patient 30) need for a bilateral soft wrist restraint.

A review of the facility's policy and procedure (P&P) titled, Restraints and Seclusion (involuntary confinement of a patient in a room) Policy, dated 3/08/2019, indicated: 3. DEFINITIONS: A. "Restraint" means any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body. 4. C. Documentation 2. Patient needs will be met during restraint use:
b. The plan of care will not be compromised by the use of restraints and shall include:
· Provision of nutritional needs
· Provision of hydration needs
· Provision of elimination needs
· Provision of hygiene needs
· Provision of exercise and range of motion
· Provision of patient safety and comfort
· Discuss restraint, when practical, with patient and family around the time of use

A review of the facility's policy and procedure (P&P) titled, "Restraint and Seclusion Policy," revised on 4/18/ 2021, indicated, " ...When a restraint is implemented, the patient ' s plan of care must be modified to reflect this change ...Documentation ...Each episode of restraint use shall be documented in the patient ' s medical record, and shall include but not be limited to ...use of restraints must be addressed in the patient ' s modified plan of care ..."

5. A review of Patient 13's History and Physical (H&P -a formal and complete assessment of the patient and the problem), dated 4/11/2023, indicated Patient 13 was admitted to the facility on 4/11/2023 with chief complaint of Schizophrenia (a psychiatric disorder that affects a person ' s ability to think, feel, and behave clearly).

During a concurrent observation and interview on 4/20/2023, at 9:19 a.m., in the presence of the Director of Information Services Registered Nurse (DIS RN), the Behavioral Health Unit Manager (BHUM), and the Case Manager Utilization Review Registered Nurse (CMUR RN), in the South Unit, Patient 13 was observed with frizzy, unbrushed hair, eye liner around eyes was put on messily, and lipstick was bright red and smeared over natural lip line. Patient 13 stated she (Patient 13) takes her (Patient 13) medications but does not want to.

During a concurrent interview and record review, on 4/20/2023, at 9:45 a.m., with DIS RN, BHUM, and CMUR RN, Patient 13's "Chemical Restraint (a medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition) /Emergency IM's," record was reviewed. The Chemical Restraint/Emergency IM's (Intramuscular- injection into the muscle) record indicated Patient 13 received a chemical restraint (a medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient ' s condition) on 4/17/2023 at 9:45 a.m. and on 4/18/2023 at 9:05 a.m. due to "threat of imminent, serious, physical harm to others." DIS RN confirmed the patient (Patient 13) received a chemical restraint on those days (4/17/2023 and 4/18/2023). Chemical restraint administered was Geodon (medicine used to treat schizophrenia [a psychiatric disorder that affects a person ' s ability to think, feel, and behave clearly]), 20 milligrams (mg-a unit of measurement), intramuscular (IM-injection into the muscle).

During a concurrent interview and record review on 4/20/2023, at 3:00 p.m., with DIS RN, Patient 13's "Interdisciplinary (health professionals from different disciplines working collaboratively as a team) Care Plan (provides a framework for evaluating and providing patient care needs related to the nursing process)," dated 4/11/2023 and 4/17/2023, was reviewed. The "Interdisciplinary Care Plan," indicated Patient 13 did not have Care Plans initiated as per the facility's Restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) and Seclusion (involuntary confinement of a patient in a room) Policy. The DIS RN stated that a care plan regarding the use of restraints should have been initiated on 4/17/2023 for Patient 13.

A review of the facility's policy and procedure (P&P) titled, Restraints and Seclusion (involuntary confinement of a patient in a room) Policy, dated 3/8/2019, indicated, 3. DEFINITIONS: A. "Restraint" means any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body. 4. C. Documentation 2. Patient needs will be met during restraint use:
b. The plan of care will not be compromised by the use of restraints and shall include:
· Provision of nutritional needs
· Provision of hydration needs
· Provision of elimination needs
· Provision of hygiene needs
· Provision of exercise and range of motion
· Provision of patient safety and comfort
· Discuss restraint, when practical, with patient and family around the time of use

A review of the facility's policy and procedure (P&P) titled, "Restraint and Seclusion Policy," revised on March 18, 2021, the P&P indicated, " ...When a restraint is implemented, the patient ' s plan of care must be modified to reflect this change ...Documentation ...Each episode of restraint use shall be documented in the patient ' s medical record, and shall include but not be limited to ...use of restraints must be addressed in the patient ' s modified plan of care ..."

Based on interview and record review, the facility failed to ensure the physician's telephone order for chemical restraints (a medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition [Ativan-acts on the brain and the nerves to produce a calming effect, Haldol-medication that works in the brain to treat schizophrenia (a psychiatric disorder that affects a person ' s ability to think, feel, and behave clearly), Benadryl-medication that induces sedation and drowsiness]) was co-signed, validated and authenticated by the ordering physician within 48 hours for one of 4 sampled patients (Patient 19).

This deficiency had the potential to result in an inappropriate, unnecessary, and prolonged use of chemical restraints.

Findings:

During a concurrent interview and record review on 4/20/2023, at 1:20 p.m., with the Director of Nursing (DON), Patient 19's medical record was reviewed. The "History and Physical (H&P -a formal and complete assessment of the patient and the problem)" indicated, Patient 19 was admitted to the facility on 4/11/2023, with a chief complaint of schizophrenia (a psychiatric disorder that affects a person ' s ability to think, feel, and behave clearly).

A review of Patient 19's "Emergency Medication and Restraint Order Sheet," indicated a Registered Nurse 1 (RN 1) received a telephone order for Patient 19's chemical restraint (a medication when it is used as a restriction to manage the patient ' s behavior or restrict the patient ' s freedom of movement and is not a standard treatment or dosage for the patient ' s condition) on 4/14/2023, at 12:57 p.m., and on 4/15/2023, at 12:16 p.m. Indication for the chemical restraints was for Patient 19's aggressive behavior.

A review of Patient 19's "Emergency Medication and Restraint Order Sheet," indicated the following medications were used for the chemical restraints administered to Patient 19:

-Ativan (acts on the brain and the nerves to produce a calming effect) 2 milligrams (mg) intramuscular (IM - injection into the muscle)

-Haldol (medication that works in the brain to treat schizophrenia) 10 mg IM

-Benadryl (medication that induces sedation and drowsiness) 50 mg IM.

A review of Patient 19 ' s telephone orders for chemical restraint indicated:
- on 4/14/2023, at 12:57 p.m., the telephone order was not signed by Physician 2

- on 4/15/2023, at 12:16 p.m., the telephone order was not signed by Physician 3

During an interview on 4/20/2023, at 1:20 p.m., with the DON, the DON stated Patient 19's telephone orders for chemical restraint should have been signed within 24 hours. The DON stated the telephone orders were not valid without the physicians' (Physician 2 and 3) signature.

A review of the facility's policy and procedure (P&P) titled, "Restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) and Seclusion (involuntary confinement of a patient in a room) Policy," revised on 3/18/2021, indicated " ...Obtain order from a provider or other provider authorized by medical staff and in accordance with law and regulation ..."

A review of the facility's policy and procedure (P&P) titled, "Medication Administration," revised in July 2020, indicated, " ...Telephone orders must include ...Physician authentication must be obtained within 48 hours ..."

Based on interview and record review, the facility failed to ensure three of four sampled patients' (Patients 19, 25, and 26) condition were assessed and have the assessment documented in the patients' records after chemical restraints (a medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition) were administered..

This deficiency had the potential to result in inappropriate, unnecessary, and prolonged use of chemical restraints, and had the potential to violate the patients' rights.

Findings:

1. During a concurrent interview and record review on 4/20/2023, at 1:20 p.m., with the Director of Nursing (DON), Patient 19's medical record was reviewed. The "History and Physical (H&P -a formal and complete assessment of the patient and the problem)," indicated Patient 19 was admitted to the facility on 4/11/2023, with a chief complaint of schizophrenia (a psychiatric disorder that affects a person ' s ability to think, feel, and behave clearly).

A review of Patient 19's "Emergency Medication and Restraint Order Sheet" indicated, Patient 19 had a chemical restraint (a medication when it is used as a restriction to manage the patient ' s behavior or restrict the patient ' s freedom of movement and is not a standard treatment or dosage for the patient ' s condition) administered:

- on 4/14/2023, at 1:33 p.m., for an aggressive behavior towards his (Patient 19) roommate

- on 4/15/2023, at 1:10 p.m., for an aggressive behavior and making verbal threats.

A review of Patient 19's "Emergency Medication and Restraint Order Sheet," indicated the following medications were used for the chemical restraints administered to Patient 19:

-Ativan (acts on the brain and the nerves to produce a calming effect) 2 milligrams (mg) intramuscular (IM - injection into the muscle)

-Haldol (medication that works in the brain to treat schizophrenia) 10 mg IM

-Benadryl (medication that induces sedation and drowsiness) 50 mg IM.

A review of Patient 19's "Seclusion (involuntary confinement of a patient in a room) and/or Restraint: Documentation Flow Sheet," indicated Patient 19's restraint monitoring was initiated on 4/15/2023, at 1:25 p.m. The Flow Sheet also indicated Patient 19 was observed and assessed for skin breakdown (an area of the skin or underlying tissue that is damaged due to loss of blood flow to the area), level of consciousness, behavior, and vital signs. The Flow Sheet further indicated Patient 19 was next assessed at 2:40 p.m. on 4/15/2023 (a total of one hour and 15 mins after the last restraint monitoring was recorded).

During an interview on 4/20/2023, at 1:20 p.m., with the DON, the DON stated when a patient was put on restraint for behavioral reason, the patient should be monitored/assessed every 15 minutes to ensure the patient's safety and to assess for any change of condition. The DON also said Patient 19's restraint monitoring and documentation should have been every 15 minutes.

A review of the facility's policy and procedure (P&P) titled, "Restraint and Seclusion Policy," revised on 4/18/2021, indicated " ...RN assessments are documented on the Restraint Flowsheet following the Observation and Monitoring guidelines ...Violent restraint Track ...Constant Observer with real time documentation of assessment of restrained patient at least every 15 minutes ..."

2. During a concurrent interview and record review on 4/20/2023, at 3:34 p.m., with the Director of Nursing (DON), Patient 25's medical record was reviewed. The "History and Physical (H&P -a formal and complete assessment of the patient and the problem)," indicated Patient 25 was admitted to the facility, on 4/2/2023, for psychiatric condition (a broad range of problems that disturb a person ' s thoughts, feelings, behavior or mood).

A review of Patient 25's "Emergency Medication and Restraint Order Sheet" indicated Patient 25 had a chemical restraint (a medication when it is used as a restriction to manage the patient's behavior or restrict the patient ' s freedom of movement and is not a standard treatment or dosage for the patient's condition) administered on 4/03/2023, at 10:21 p.m. for being combative toward hospital staff.

A review of Patient 25's "Emergency Medication and Restraint Order Sheet," indicated the following medications were used for the chemical restraints administered to Patient 25:

- Ativan (acts on the brain and the nerves to produce a calming effect) 1 milligram (mg) intramuscular (IM - injection into the muscle)

-Haldol (medication that works in the brain to treat schizophrenia) 5 mg IM

-Benadryl (medication that induces sedation and drowsiness) 50 mg IM.

A review of Patient 25's "Seclusion (involuntary confinement of a patient in a room) and/or Restraint: Documentation Flow Sheet," indicated Patient 25 ' s restraint monitoring was initiated on 4/15/2023, at 11 p.m. (40 minutes after the chemical restraint was initiated). The Flow Sheet also indicated Patient 25 was observed and assessed for skin breakdown (an area of the skin or underlying tissue that is damaged due to loss of blood flow to the area), level of consciousness, behavior, and vital signs.

During an interview on 4/20/2023, at 3:34 p.m., with the DON, the DON stated when a patient was put on restraint for behavioral reason, the patient should be monitored/assessed every 15 minutes to ensure the patient ' s safety and to assess for any change of condition. The DON also said Patient 25's restraint monitoring and documentation should have been every 15 minutes.

A review of the facility's policy and procedure (P&P) titled, "Restraint and Seclusion Policy," revised on 4/18/2021, indicated " ...RN assessments are documented on the Restraint Flowsheet following the Observation and Monitoring guidelines ...Violent restraint Track ...Constant Observer with real time documentation of assessment of restrained patient at least every 15 minutes ..."

3. During a concurrent interview and record review on 4/20/2023, at 4:30 p.m., with the Director of Nursing (DON), Patient 26's medical record was reviewed. The "History & Physical (H&P -a formal and complete assessment of the patient and the problem)," indicated Patient 26 was admitted to the facility on 3/22/2023, for psychiatric evaluation (to diagnose emotional, behavioral, or developmental disorders) and treatment.

A review of Patient 26' "Emergency Medication and Restraint Order Sheet" indicated Patient 26 had a chemical restraint administered on 3/26/2023, at 10:36 a.m. for being verbally aggressive.

A review of Patient 26' "Emergency Medication and Restraint Order Sheet," indicated the following medications were used for the chemical restraints (a medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition) administered to Patient 26:

- Ativan (acts on the brain and the nerves to produce a calming effect) 2 milligrams (mg) intramuscular (IM - injection into the muscle)

-Haldol (medication that works in the brain to treat schizophrenia) 5 mg IM

-Benadryl (medication that induces sedation and drowsiness) 50 mg IM.

A review of patient 26' "Seclusion (involuntary confinement of a patient in a room) and/or Restraint: Documentation Flow Sheet" indicated Patient 26' restraint monitoring/assessment was initiated on 3/25/223, at 11:20 a.m. (45 minutes after the chemical restraint was initiated). The Flow Sheet also indicated Patient 26 was observed and assessed for skin breakdown (an area of the skin or underlying tissue that is damaged due to loss of blood flow to the area, level of consciousness, and behavior.

During an interview on 4/20/2023, at 4:30 p.m., the DON stated when a patient was put on restraint for behavioral reason, the patient should be monitored/assessed every 15 minutes to ensure the patient's safety and to assess for any change of condition. The DON also said Patient 26' restraint monitoring and documentation should have been every 15 minutes.

A review of the facility's policy and procedure (P&P) titled, "Restraint and Seclusion Policy," revised in March 18, 2021, indicated, " ...RN assessments are documented on the Restraint Flowsheet following the Observation and Monitoring guidelines ...Violent restraint Track ...Constant Observer with real time documentation of assessment of restrained patient at least every 15 minutes ..."

Based on interview and record review, the facility failed to ensure that a trained Registered Nurse (RN) conducted the face to face assessment for three of four sampled patients (Patients 19, 25, and 26), within one hour, after the initiation of a restraint (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) to manage violent or self-destructive behavior.

This deficiency had the potential to result in an inaccurate in-person evaluation and assessment of the patients' physical and psychological status after restraints were applied.

Findings:

1. A review of Patient 19's History and Physical (H&P - a formal and complete assessment of the patient and the problem), indicated Patient 19 was admitted to the facility on 4/11/2023, with a chief complaint of schizophrenia (a psychiatric disorder that affects a person's ability to think, feel, and behave clearly).

A review of Patient 19's "Emergency Medication and Restraint Order Sheet" indicated, Patient 19 had a chemical restraint (a medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition) ordered and administered:

-on 4/14/2023, at 1:33 p.m., for an aggressive behavior towards his (Patient 19) roommate

-on 4/15/2023, at 1:10 p.m., for an aggressive behavior and making verbal threat

A review of Patient 19's "Emergency Medication and Restraint Order Sheet," indicated the following medications were used for the chemical restraints administered to Patient 19:

-Ativan (acts on the brain and the nerves to produce a calming effect) 2 milligrams (mg) intramuscular (IM - injection into the muscle)

-Haldol (medication that works in the brain to treat schizophrenia) 10 mg IM

-Benadryl (medication that induces sedation and drowsiness) 50 mg IM.

A review of Patient 19's "S/R (seclusion (involuntary confinement of a patient in a room)/restraint) Face to Face Assessment Within One Hour" form, indicated House Supervisor Registered Nurse 2 (HS RN 2) performed the face-to-face assessment for Patient 19 on 4/14/2023 and on 4/15/2023.

During an interview on 4/20/2023, at 1:35 p.m., with House Supervisor Registered Nurse 2 (HS RN 2), HS RN 2 stated she (HS RN 2) was the one who performed the face-to-face assessment for Patient 19 on 4/14/2023 and on 4/15/2023. HS RN 2 said she (HS RN 2) had training on restraint use but not specific on face-to-face assessment when a medication is administered to manage violent or self-destructive behavior. HS RN 2 further said it had been awhile since her (HS RN 2) last restraint training because she (HS RN 2) was on medical leave for a year, and she (HS RN 2) just came back to work this year (2023). HS RN 2 further stated she (HS RN 2) did not have any restraint training when she (HS RN 2) came back from her (HS RN 2) medical leave.

During an interview on 4/20/2023, at 3 p.m., with the Director of Nursing (DON), the DON stated there were selected Registered Nurses (RN), mostly the House Supervisor Registered Nurse (HS RN), who performs face-to-face assessment within one hour on the patient who had restraints for behavioral reason. The DON stated the RNs performing the face-to-face assessment on the patients (Patients 19, 25, and 26) who were put on restraint for behavioral reasons did not receive the appropriate training needed to perform the face-to-face assessment. The DON also said HS RN 2 was not qualified to perform the face-to-face assessment for Patient 19 on 4/14/2023 and on 4/15/2023.

A review of the facility's policy and procedure (P&P) titled, "Restraint and Seclusion Policy," revised on March 18, 2021, indicated, " ...Violent Restraint Track ...Additional assessment by a provider or trained RN required within 1 hour of order regardless of removal of restraint/seclusion ..."

2. A review of Patient 25's History and Physical (H&P -a formal and complete assessment of the patient and the problem), indicated Patient 25 was admitted to the facility on 4/02/2023, for psychiatric condition (a broad range of problems that disturb a person's thoughts, feelings, behavior or mood).

A review of Patient 25's "Emergency Medication and Restraint Order Sheet" indicated Patient 25 had a chemical restraint (a medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition) on 4/03/2023, at 1:15 a.m., and at 10:21 p.m. for being combative toward hospital staff.

A review of Patient 25's "Emergency Medication and Restraint Order Sheet," indicated the following medications were used for the chemical restraints administered to Patient 25:

- Ativan (acts on the brain and the nerves to produce a calming effect) 1 milligram (mg) intramuscular (IM - injection into the muscle)

-Haldol (medication that works in the brain to treat schizophrenia) 5 mg IM

-Benadryl (medication that induces sedation and drowsiness) 50 mg IM.

A review of Patient 25's "S/R (seclusion (involuntary confinement of a patient in a room)/restraint) Face to Face Assessment Within One Hour," indicated the House Supervisor Registered Nurse (HS RN) performed the face-to-face assessment for Patient 25 on 4/03/2023, at 1:15 a.m., and at 10:21 p.m.

During an interview on 4/20/2023, at 3 p.m., with the Director of Nursing (DON), the DON stated there are selected Registered Nurses (RN), mostly the HS RN, who performs face-to-face assessment within one hour on the patient who had restraints for behavioral reason. The DON stated the RNs performing the face-to-face assessment on the patients (Patient 19, 25 and 26) who were put on restraint for behavioral reasons did not receive the appropriate training needed to perform the face-to-face assessment. The DON also said the HS RN was not qualified to perform the face-to-face assessment for Patient 25 on 4/03/2023, at 1:15 a.m., and at 10:21 p.m.

A review of the facility's policy and procedure (P&P) titled, "Restraint and Seclusion Policy," revised on March 18, 2021, indicated, " ...Violent Restraint Track ...Additional assessment by a provider or trained RN required within 1 hour of order regardless of removal of restraint/seclusion ..."

3. A review of Patient 26' History and Physical (H&P -a formal and complete assessment of the patient and the problem) indicated, Patient 26 was admitted to the facility on 3/22/2023 for psychiatric evaluation (to diagnose emotional, behavioral, or developmental disorders) and treatment.

A review of Patient 26' "Emergency Medication and Restraint Order Sheet" indicated Patient 26 had a chemical restraint (a medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition):

-on 3/25/2023, at 10:36 a.m., for being verbally aggressive

-on 3/27/2023, at 3:10 p.m., for spitting at the hospital staff

A review of Patient 26' "Emergency Medication and Restraint Order Sheet," indicated the following medications were used for the chemical restraints administered to Patient 26:

- Ativan (acts on the brain and the nerves to produce a calming effect) 2 milligrams (mg) intramuscular (IM - injection into the muscle)

-Haldol (medication that works in the brain to treat schizophrenia) 5 mg IM

-Benadryl (medication that induces sedation and drowsiness) 50 mg IM.

A review of Patient 26' "S/R (seclusion (involuntary confinement of a patient in a room)/restraint) Face to Face Assessment Within One Hour," indicated House Supervisor Registered Nurse 2 (HS RN 2) performed the face-to-face assessment for Patient 26 on 3/25/2023 and on 3/27/2023.

During an interview on 4/20/2023, at 1:35 p.m., with HS RN 2, HS RN 2 stated she (HS RN 2) was the one who performed the face-to-face assessment for Patient 26 on 3/25/2023 and on 3/27/2023. HS RN 2 said she (HS RN 2) had training on restraint use but not specific on face-to-face assessment when a medication is administered to manage violent or self-destructive behavior. HS RN 2 further said it had been awhile since her (HS RN 2) last restraint training because she (HS RN 2) was on medical leave for a year, and she (HS RN 2) just came back to work this year (2023). HS RN 2 further stated she (HS RN 2) did not have any restraint training when she (HS RN 2) came back from her (HS RN 2) medical leave.

During an interview on 4/20/2023, at 3 p.m., with the Director of Nursing (DON), the DON stated there were selected Registered Nurses (RN), mostly the House Supervisor Registered Nurse (HS RN), who performed face-to-face assessment within one hour on the patient who had restraints for behavioral reason. The DON stated the RNs performing the face-to-face assessment on the patients (Patient 19, 25 and 26) who were put on restraint for behavioral reasons did not receive the appropriate training needed to perform the face-to-face assessment. The DON also said the HS RN was not qualified to perform the face-to-face assessment for Patient 26 on 3/25/2023 and on 3/27/2023.

A review of the facility's policy and procedure (P&P) titled, "Restraint and Seclusion Policy," revised on March 18, 2021, the P&P indicated, " ...Violent Restraint Track ...Additional assessment by a provider or trained RN required within 1 hour of order regardless of removal of restraint/seclusion ..."

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

1. The vital signs (VS - temperature, heart rate [HR], respiratory rate [RR], and blood pressure [BP]) was taken every four hours as ordered by the physician for one of 14 sampled patients (Patient 18). This deficient practice had the potential to cause a delay in determining Patient 18's change in condition and a delay of emergent patient treatment for Patient 18. (Refer to A-395)

2. An appropriate pain intervention was provided to manage pain for one of 14 sampled patients (Patient 24). This deficient practice resulted in delay of patient treatment and uncontrolled pain for Patient 24. (Refer to A-395)

3. The physician was notified when blood pressure medications (hydralazine, labetalol, and amlodipine-medications used to lower blood pressure) were held and not administered due to patient refusal or due to the parameters (indicates when to administer the BP medication) indicated in the physician's order for two of 14 sampled patients (Patient 18 and patient 28). This deficient practice had the potential to delay treatment and necessary adjustments in the patients ' (Patient 18 and patient 28) treatment plan. (Refer to A-395)

4. The blood sugar level was checked as ordered by the physician for one of 14 sampled patients (Patient 30). This deficient practice had the potential to result in delay of treatment and had the potential to cause adverse health outcomes to Patient 30 for untreated low or high blood sugar levels. (Refer to A-395)

5. A care plan was developed and implemented to prevent skin breakdown (an area of the skin or underlying tissue that is damaged due to loss of blood flow to the area) for two of 14 sampled patients (Patients 3 and 5), who were at high risk of developing a pressure injury (injuries to the skin and underlying tissue due to prolonged pressure). This deficient practice had a potential for Patients 3 and 5 developing a pressure injury by not identifying the patients' (Patient 3 and 5) needs and risks. (Refer to A-396)

6. A comprehensive care plan was developed and implemented to address the patient's pain and foley catheter (FC - a flexible tube inserted into the bladder to drain urine) care for one of 14 sampled patients (Patient 20). This deficient practice had the potential to result in delay of pain treatment and a delay in the implementation of interventions to prevent foley catheter related infection for Patient 20. (Refer to A-396)

7. A comprehensive care plan was developed to address the patient's peripherally inserted central catheter line (PICC line - a long thin flexible line that goes all the way up to a vein near the heart and used as intravenous access) care and the patient ' s infection for one of 14 sampled patients (Patient 24). This deficient practice had the potential to result in worsening of infection for Patient 24. (Refer to A-396)

8. A comprehensive care plan was developed to address the patient's diabetes (a chronic [long-lasting] health condition that affects how the body turns food into energy causing high blood sugar) for one of 14 sampled patients (Patient 30). This deficient practice had the potential to result in the delay of treatment by not identifying the patient's (Patient 30) needs and risks. (Refer to A-396)

9. The patient's daily weight was taken prior to hemodialysis (HD - a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatment for one of 14 sampled patients (Patient 18) in accordance with the facility ' s policy and procedure. This deficient practice had the potential to negatively impact the patient's (Patient 18) HD treatment resulting in extra fluid build-up to not be monitored which may lead to complications affecting the patient's heart and lungs, and deterioration of the patient's condition. (Refer to A-398)

10. A physician's order was written for the insertion of a foley catheter (FC- a flexible tube inserted into the bladder to drain urine) for one of 14 sampled patients (Patient 20) in accordance with the facility's policy and procedure. This deficient practice had the potential to result in inappropriate, unnecessary, and prolonged use of a foley catheter, which may lead to an increased risk for Patient 20 acquiring Urinary Tract Infection (UTI-infection in any part of the urinary system such as the kidneys, bladder, etc.). (Refer to A-398)

11. A chest x-ray (an imaging test to look at structures of organs in the chest) was immediately completed following the insertion of a peripherally inserted central catheter (PICC line - a long thin flexible line that goes all the way up to a vein near the heart and used as intravenous access) line to verify correct placement of the PICC line prior to the administration of an antibiotic in accordance with the facility ' s policy and procedure for one of 14 sampled patients (Patient 24). This deficient practice resulted in the delay of treatment and administration of intravenous (IV-administered through the vein) antibiotic (used to treat infection) infusion which may lead to deterioration of Patient 24's medical condition. (Refer to A-398)

12. Medications (hydralazine, labetalol, and amlodipine [BP medications used to treat hypertension - defined as blood pressure [BP] above 140/90 and is considered severe if the BP is above 180/120]) were administered timely for two of 14 sampled patients (Patient 18 and Patient 30) as ordered by the physician. Patient 18 had an order to receive hydralazine, labetalol, and amlodipine (BP medications used to treat hypertension - defined as blood pressure (BP) above 140/90 and is considered severe if the BP is above 180/120). Patient 30 had an order to receive Humalog (type of insulin - used for treatment of diabetes [high blood sugar]). This deficient practice resulted in a delay of treatment and had the potential to cause adverse health outcomes which could negatively affect the patient's (Patients 18 and 30) health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death. (Refer to A - 405)

13. A physician's order was obtained for one of 14 sampled patients (Patient 18) when the patient's (Patient 18) blood pressure (BP) medications (hydralazine, labetalol, and amlodipine-BP medications used to treat hypertension- defined as blood pressure above 140/90 and is considered severe if the BP is above 180/120) were not given on the days the patient (Patient 18) was scheduled for hemodialysis (HD - a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). This deficient practice had the potential to cause adverse health outcomes which could negatively affect the patient's health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death. (Refer to A - 405)

14. Pain medication was administered for two of 14 sampled patients (Patient 20 and Patient 24) as ordered by the physician. This deficient practice resulted in delay of treatment of the patients' (Patient 20 and Patient 24) pain and had the potential to cause adverse health outcomes which could negatively affect the patient's health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death. (Refer to A - 405)

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

Based on observation, interview, and record review, the facility failed to ensure appropriate nursing care was provided for four of 14 sampled patients (Patients 18, 24, 28, and 30) when:

1. Patient 18's vital signs (VS - temperature, heart rate [HR], respiratory rate [RR], and blood pressure [BP]) was not taken every four hours as ordered by the physician. This deficient practice had the potential to cause a delay in determining Patient 18's change in condition and a delay of emergent patient treatment for Patient 18.

2. An appropriate pain intervention was not provided to manage Patient 24's pain. This deficient practice resulted in delay of patient treatment and uncontrolled pain for Patient 24.

3a. The physician was not notified when Patient 18's Blood Pressure (BP) medications (hydralazine, labetalol, and amlodipine-medications used to lower blood pressure) were held due to parameters (indicates when to administer the BP medication) as indicated in the physician's order. This deficient practice had the potential to delay treatment and necessary adjustments in the patient's (Patient 18) treatment plan.

3b. The physician was not notified when Patient 28's BP medication (metoprolol-used to lower blood pressure) was held due to the patient's (Patient 28) refusal or due to the parameters indicated in the physician's order. This deficient practice had the potential to delay treatment and necessary adjustments in the patient's (Patient 28) treatment plan.

4. Patient 30's blood sugar level was not checked as ordered by the physician. This deficient practice had the potential to result in delay of treatment and had the potential to cause adverse health outcomes to Patient 30 for untreated low or high blood sugar levels.

Findings:

1. During a concurrent interview and record review, on 4/19/2023, at 8:40 a.m., with the Director of Nursing (DON), Patient 18 ' s medical record was reviewed. The "History and Physical (H&P -a formal and complete assessment of the patient and the problem)," indicated Patient 18 was admitted to the facility on 4/07/2023, due to uncontrolled hypertension (defined as blood pressure (BP) above 140/90 and is considered severe if the BP is above 180/120). Patient 18's medical history included end stage renal disease (ESRD - loss of kidney function) and needed hemodialysis (HD - a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly).

A review of Patient 18's physician's order, dated 4/07/2023, indicated for Patient 18 to have Vital signs (VS-temperature, heart rate [HR], respiratory rate [RR], and blood pressure [BP]) taken every four hours.

A review of Patient 18's "Flowsheet Chart" indicated the following:

-on 4/09/2023, at 4:20 a.m., Patient 18's BP was 136/69.

The next BP reading for Patient 18 was at 3:24 p.m. (a total of 11 hours since the last BP was checked); Patient 18's BP reading at 3:24 p.m. was 136/69.

-on 4/10/2023, at 2:32 p.m., Patient 18's BP was 128/65.

The next BP reading for Patient 18 was prior to HD on 4/11/2023, at 11 a.m., when the BP was 190/88 (a total of one day with no documentation of Patient 18's BP);

-on 4/11/2023, at 4:10 p.m., Patient 18's BP was 142/72.

The next BP reading for Patient 18 was on 4/12/2023, at 8:27 a.m., when the BP was 183/78 (a total of 16 hours since the last BP check)

-on 4/15/2023, at 4 p.m., Patient 18's BP was 107/58.

The next BP reading for Patient 18 was on 4/16/2023, at 1:58 p.m. (a total of one day with no documentation of Patient 18's BP).

During an interview on 4/19/2023, at 8:40 a.m., with the DON, the DON stated the other VS (temperature, HR, and RR) were taken and recorded at the same time as the BP. The DON confirmed that Patient 19's VS were not taken every four hours as ordered by the physician. The DON further said there was no documentation Patient 18 left the unit or had a procedure or was on HD for the VS to not be taken as ordered. The DON stated Patient 18's VS were important to be taken every four hours to monitor the patient's medical condition especially for the fact that Patient 18 was admitted to the facility for uncontrolled hypertension.

A review of the facility's policy and procedure (P&P) titled, "Vital Signs," revised on March 2022, indicated, " ...Vital signs will be taken per unit routine unless otherwise ordered by the physician ...MS (Medical Surgical) and Telemetry - Every 4 hours and charted on Vital Signs record ..."

2. During a concurrent observation and interview, on 4/18/2023, at 1:50 p.m., with the Director of Quality (DOQ) and the Director of Nursing (DON), Patient 24 was observed lying in bed, alert, and oriented. Patient 24 stated he (Patient 24) was admitted to the hospital because he (Patient 24) had a knee surgery from another hospital and now (during time of interview), he (Patient 24) was in a lot of pain. Patient 24 also said he (Patient 24) had been asking for pain medication for hours and he (Patient 24) was not getting any pain medicine. Patient 24 stated "the pain meds they are giving is not working."

During a concurrent interview and record review on 4/20/2023, at 2:42 p.m., with the DON, Patient 24's medical record was reviewed. The "History and Physical (H&P -a formal and complete assessment of the patient and the problem)," indicated Patient 24 was admitted to the facility on 4/13/2023, with a chief complaint of intractable knee pain (type of pain that cannot be controlled with standard medical care) due to a recent knee surgery.

A review of Patient 24's Medication Administration Record (MAR) indicated that on 4/15/2023, at 2:02 p.m., Patient 24 was given tramadol (pain medication) 50 milligrams (mg-a unit of measurement) by mouth for a pain level of 8 (based on a tool to assess a person's pain level: 7-10 is severe pain).

A review of Patient 24's "Progress Note," dated 4/15/2023, at 4:20 p.m., (two hours after Patient 24 received the pain medication at 2:02 p.m.), authored by the Registered Nurse 5 (RN 5), indicated, " ...Informed (name of the Nurse Practitioner) that patient claimed that Ultram (otherwise known as tramadol-pain medication) is not working, with order, noted and carried out ..."

There was no documented evidence a new order was written, or additional pain intervention was provided to Patient 24 after the patient informed the RN that the tramadol was not working to control the patient's (Patient 24) pain. This absence of documented evidence was confirmed by the DON.

A review of Patient 24's MAR indicated a physician's order for tramadol 50 mg to be given by mouth every eight hours as needed for pain.

A review of Patient 24's MAR indicated Patient 24 received tramadol on 4/17/2023, at 8:50 a.m., for pain level of 9 (severe pain) and at 5:30 p.m., for a pain level of 9 (severe pain).

A review of Patient 24's "Progress Note," dated 4/17/2023, at 1 p.m., (four hours after Patient 24 received the pain medication), authored by the Registered Nurse (RN), indicated " ...Patient (Patient 24) asked for more pain medications. Explained to patient that he (Patient 24) can't have another pain (sic) (medicine) for two more hours. Explained that medication can only be given every 8 hours. Patient became very angry and ignored nurses ...1730 (5:30 p.m.) with encouragement, patient (Patient 24) cooperated ...and took pain medication (four hours and 30 minutes since Patient 24 asked for more pain medication at 1 p.m.) ..."

There was no documented evidence additional pain intervention was provided to Patient 24 after the patient complained of pain on 4/17/2023, at 1 p.m. This absence of documented evidence was confirmed by the DON.

During an interview on 4/20/2023, at 2:42 p.m., with the DON, the DON stated Patient 24 should have not suffered from pain. Patient 24 should have been provided additional pain intervention that would help manage the patient's (Patient 24) pain.

A review of the facility's policy and procedure (P&P) titled, "Pain Management," revised in November 2022, indicated, " ...Patients have the right to pain management. The hospital will do the following ...Treat the patient ' s pain or refer the patient for treatment...Multimodal therapies are often most effective, utilizing several classes of medication, and adding nonpharmacologic therapies ...Treatment of Pain ...all inpatients pain issue (acute or chronic) will be addressed. Treatment shall be consistent with the patient ' s clinical presentation and objective findings. The treatment modality selected shall be appropriate for the patient ' s needs. Treatment shall be provided in a timely manner ..."

3a. During a concurrent interview and record review, on 4/19/2023, at 8:40 a.m., with the Director of Nursing (DON), Patient 18's medical record was reviewed. The "History and Physical (H&P -a formal and complete assessment of the patient and the problem)," indicated Patient 18 was admitted to the facility on 4/07/2023, due to uncontrolled hypertension (defined as blood pressure (BP) above 140/90 and is considered severe if the BP is above 180/120). Patient 18's medical history included end stage renal disease (ESRD - loss of kidney function) and needed hemodialysis (HD-a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly).

A review of Patient 18's medication administration record (MAR) indicated a physician's order of hydralazine (medication to lower blood pressure) 100 milligrams (mg-a unit of measurement) to be given by mouth three times a day. The MAR also indicated "Hold the medication if systolic BP (SBP-pressure in the arteries when the heart beats) below 110 or heart rate (HR) below 60 and notify the physician."

Further review of the MAR indicated Patient 18's hydralazine was not given due to parameters (indicates when to administer the BP medication) indicated in the physician's order on the following dates:

-on 4/08/2023, at 12:56 p.m., reason, "contraindication"

- on 4/11/2023, at 4:23 p.m., reason, "hypotension (low BP)"

- on 4/14/2023, at 10:28 a.m., reason, "med on hold" and at 1:43 p.m., reason, "b/p (BP) low"

- on 4/15/2023, at 9:23 a.m., BP was 100/59, and at 3:06 p.m., BP was 96/48

- on 4/16/2023, at 12:01 p.m., SBP was 106

- on 4/17/2023, at 9:33 a.m., and at 12:04 p.m., reason, "contraindication"

- on 4/18/2023, at 9:07 a.m., and 12:01 p.m., reason, "contraindication"

- on 4/19/2023, at 8:43 a.m., BP was 93/53.

There was no documented evidence the physician was notified when Patient 18's hydralazine was not given on the mentioned dates and times above. This absence of documented evidence was confirmed by the DON on 4/19/2023.

A review of Patient 18's MAR indicated a physician's order of labetalol (medication used to lower blood pressure) 100 mg to be given by mouth two times a day. The MAR also indicated "Hold the medication if systolic BP (SBP) below 110 or HR below 60 and notify the physician."

Further review of the MAR indicated Patient 18's labetalol was not given due to parameters indicated in the physician ' s order on the following dates:

- on 4/14/2023, at 10:29 a.m., reason, "med on hold"

- on 4/15/2023, at 9:23 a.m., BP was 100/59

- on 4/17/2023, at 9:33 a.m., SBP was 95

- on 4/18/2023, at 9:17 a.m., reason, "contraindication"

- on 4/19/2023, at 8:44 a.m., BP was 93/53.

There was no documented evidence the physician was notified when Patient 18's labetalol was not given on the mentioned dates and times above. This absence of documented evidence was confirmed by the DON on 4/19/2023.

A review of Patient 18's MAR indicated a physician's order of amlodipine (medication used to lower blood pressure) 10 mg to be given by mouth once a day. The MAR also indicated "Hold the medication if systolic BP (SBP) below 110 or HR below 60 and notify the physician."

Further review of the MAR indicated Patient 18's amlodipine was not given due to parameters indicated in the physician ' s order on the following dates:

- on 4/14/2023, at 10:28 a.m., BP was 105/59

- on 4/15/2023, at 9:22 a.m., BP was 100/59

- on 4/17/2023, at 9:32 a.m., SBP was 95

- on 4/18/2023, at 9:17 a.m., reason, "contraindication"

- on 4/19/2023, at 8:43 a.m., BP was 93/53.

There was no documented evidence the physician was notified when Patient 18's amlodipine was not given on the mentioned dates and times above. This absence of documented evidence was confirmed by the DON on 4/19/2023.

During an interview on 4/19/2023, at 8:40 a.m., with the DON, the DON stated the Registered Nurses (RNs) should have notified the physician when Patient 18 ' s BP medications were held due to parameters as ordered by the physician. The DON said it was important to inform the physician of Patient 18's medical condition and VS to know if a change or adjustment of the treatment plan was needed.

A review of the facility's policy and procedure (P&P) titled, "SBAR (Situation-Background-Assessment-Recommendation technique that provides a framework of communication between members of the healthcare team about a patient's condition)," dated 5/03/2022, indicated, " ...The facility must ...consult with the patient ' s physician ...when there is a change requiring such notification ...Circumstances that require a need to alter treatment. This may include due to ...acute condition ...Exacerbation of a chronic condition ...necessary to avoid decline in physical, mental, or psychosocial well-being ..."

3b. During a concurrent interview and record review on 4/21/2023, at 9:15 a.m., with the Director of Nursing (DON), Patient 28 ' s medical record was reviewed. The "History and Physical (H&P -a formal and complete assessment of the patient and the problem)," indicated Patient 28 was admitted to the facility on 4/13/2023, for abnormal laboratory results and hypokalemia (low potassium level which can result in an abnormal heart rhythms).

A review of Patient 28's medication administration record (MAR) indicated a physician's order of metoprolol (medication used to lower blood pressure) 25 milligrams (mg-a unit of measurement) to be given by mouth two times a day. The MAR also indicated "Hold the medication if systolic BP (SBP-pressure in the arteries when the heart beats) below 120 or HR below 50 and notify the physician."

Further review of Patient 28's MAR indicated Patient 28's metoprolol was not given due to parameters (indicates when to administer the BP medication) indicated in the physician's order on the following dates:

- on 4/15/2023, at 9:07 p.m., reason: patient refused

- on 4/16/2023, at 8:30 p.m., BP was 109/64

- on 4/17/2023, at 8:37 a.m., BP was 108/63 and at 8:50 p.m., BP was 107/71.

There was no documented evidence the physician was notified when Patient 28's metoprolol was not given on the mentioned dates and times above. This absence of documented evidence was confirmed by the DON on 4/21/2023.

During an interview on 4/21/2023, at 9:15 a.m., with the DON, the DON stated the Registered Nurses (RNs) should have notified the physician when Patient 28 ' s metoprolol was held due to the patient's (Patient 28) refusal and due to the parameters ordered by the physician. The DON also said it was important to inform the physician of Patient 28's medical condition and VS to know if a change or adjustment of the treatment plan was needed.

A review of the facility's policy and procedure (P&P) titled, "SBAR (Situation-Background-Assessment-Recommendation technique that provides a framework of communication between members of the healthcare team about a patient ' s condition)," dated 5/03/2022, indicated, " ...The facility must ...consult with the patient ' s physician ...when there is a change requiring such notification ...Circumstances that require a need to alter treatment. This may include due to ...acute condition ...Exacerbation of a chronic condition ...necessary to avoid decline in physical, mental, or psychosocial well-being ..."

4. During a concurrent interview and record review on 4/21/2023, at 9:25 a.m., with the Director of Nursing (DON), Patient 30 ' s medical record was reviewed. The "History and Physical (H&P -a formal and complete assessment of the patient and the problem)," indicated Patient 30 was admitted to the facility on 4/16/2023 for evaluation of generalized weakness and psychiatric decompensation (a breakdown in an individual's defense mechanisms [unconscious strategies whereby people protect themselves from anxious thoughts or feelings], resulting in progressive loss of normal functioning or worsening of psychiatric symptoms [example: excessive fears/worries, extreme mood changes, etc.]).

A review of Patient 30's History and Physical (H&P), indicated Patient 30 had diabetes (a chronic [long-lasting] health condition that affects how the body turns food into energy causing high blood sugar). Patient 30's treatment plan was to continue insulin (medication used to move sugar from the blood into other body tissues where it is used for energy) medication and perform Accu-Check (quantitatively measures glucose in the blood) with insulin sliding scale (varies the dose of insulin administered based on blood glucose level).

A review of Patient 30's medication administration record (MAR) indicated a physician's order of Humalog (a type of insulin) 100 units to be given, per sliding scale, subcutaneous (injection under the skin) with meals and at bedtime.

A review of Patient 30's MAR indicated Patient 30 refused the insulin:
-on 4/16/2023, at 7:13 p.m.

- on 4/19/2023, at 12:49 a.m., 5:38 a.m., and 8:56 p.m.

- on4/20/2023, at 7:12 a.m.

There was no documented evidence Patient 30's blood sugar was checked, or the patient refused the Accu-Check on the above dates mentioned. This absence of documented evidence was confirmed by the DON.

During an interview on 4/21/2023, at 9:25 a.m., with the DON, the DON stated Patient 30's blood sugar should have been checked as part of the physician's order to know the insulin dose to give to the patient (Patient 30). The DON said the MAR indicated Patient 30's refusal of the insulin and not the blood sugar check. The DON stated if Patient 30 refused the blood sugar check, it (the blood sugar check) should be documented as well in Patient 30's medical record.

A review of the facility's policy and procedure (P&P) titled, "SBAR (Situation-Background-Assessment-Recommendation technique that provides a framework of communication between members of the healthcare team about a patient's condition)," dated 5/03/2022, indicated, " ...The facility must ...consult with the patient ' s physician ...when there is a change requiring such notification ...Circumstances that require a need to alter treatment. This may include due to ...acute condition ...Exacerbation of a chronic condition ...necessary to avoid decline in physical, mental, or psychosocial well-being ..."

A review of the facility's policy and procedure (P&P) titled, "Insulin Administration Level III," dated September 2019, indicated, " ...Steps in the Procedure (Insulin Injection via Syringes) ...Check blood glucose per physician order or facility protocol ...Documentation ...The resident ' s blood glucose result, as ordered ...Notify your supervisor if the resident refuses the insulin injection ..."

Based on observation, interview, and record review, the facility failed to ensure a comprehensive care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) was developed and implemented upon admission for five of 14 sampled patients (Patients 3, 5, 20, 24, and 30) when:

1. Patients 3 and 5, who were at high risk of developing a pressure injury (injuries to the skin and underlying tissue due to prolonged pressure), did not have a care plan to prevent skin breakdown (an area of the skin or underlying tissue that is damaged due to loss of blood flow to the area). This deficient practice had a potential for patients 3 and 5 developing a pressure injury by not identifying the patients ' (Patient 3 and 5) needs and risks.

2. Patient 20 did not have a comprehensive care plan developed to address the patient's (Patient 20) pain and foley catheter (FC - a flexible tube inserted into the bladder to drain urine) care. This deficient practice had the potential to result in delay of pain treatment and a delay in the implementation of interventions to prevent foley catheter related infection for Patient 20.

3. Patient 24 did not have a comprehensive care plan developed to address the patient's (Patient 24) peripherally inserted central catheter line (PICC line - a long thin flexible line that goes all the way up to a vein near the heart and used as intravenous access) care and the patient's (Patient 24) infection. This deficient practice had the potential to result in worsening of infection for Patient 24.

4. Patient 30 did not have a comprehensive care plan developed to address the patient's (Patient 30) diabetes (a chronic [long-lasting] health condition that affects how the body turns food into energy causing high blood sugar). This deficiency had the potential to result in the delay of treatment by not identifying the patient's (Patient 30) needs and risks.

Findings:

1a. A review of Patient 3's History and Physical (H&P -a formal and complete assessment of the patient and the problem), dated 4/14/2023, indicated Patient 3 was admitted to the facility on 4/14/23 with chief complaint of mental health disorder (a group of illnesses that may include symptoms that can affect a person's thinking, perceptions, mood or behavior), aggressive behavior, and noncompliance with medication regimen. Patient 3 also had a past medical history of a stroke (when a blood vessel that carries oxygen and nutrients to the brain is blocked resulting in damage to a part of the brain, which can cause long-term disability or death) affecting the right side of her (Patient 3) body.

During a concurrent observation and interview on 4/18/2023, at 1:35 p.m., with the Director of Information Services Registered Nurse (DIS RN), inside Patient 3's room, Patient 3 was lying in bed with both legs elevated on a pillow, and not moving her (Patient 3) right side of the body. Patient 3 said she (Patient 3) would like to be repositioned (to change position either from lying on back to either right side or left side).

During a concurrent observation and interview on 4/19/2023, at 3:35 p.m., with DIS RN and Registered Nurse 3 (RN 3), inside Patient 3's room, Patient 3 attempted to turn on her (Patient 3) side but was unsuccessful. RN 3 said that Patient 3 had a history of stroke affecting the right side of her (Patient 3) body.

During a concurrent interview and record review on 4/20/2023, at 2:00 p.m., with the DIS RN, Patient 3's Admission Assessment record, dated 4/14/2023 was reviewed. The Admission Assessment record indicated, Patient 3 was bedbound (confined to bed) and Patient 3's "Braden Scale Score (a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk of developing pressure injuries) was 12, High Risk (for developing pressure injuries)." DIS RN stated the Braden Scale should be assessed every shift, a turning schedule should have been implemented upon admission, and a care plan should have been initiated upon admission per the facility's policy for Patient 3.

A review of the facility's policy and procedure (P&P) titled, Pressure Injury, dated 3/2019, indicated, "OBJECTIVE: To provide guidelines for assessment of skin integrity, determine risk of developing pressure injuries and develop a plan of care for prevention of pressure injuries to those patients determined to be at risk and provide guidelines for individual treatment.
POLICY: 1. All patients will have skin integrity assessed during admission assessment, and each shift, using the Braden Risk Assessment Scale Tool. 2. Risk Prevention interventions will be initiated as indicated according to the Braden Scale Intervention Guidelines by Risk Score or physician orders.
THE BRADEN SCALE INTERVENTION GUIDELINES BY RISK SCORE: HIGH RISK (10 - 12)
FREQUEST TURNING (EVERY 2 HOURS)
MAXIMAL MOBILIZATION
PROTECT HEELS (FLOAT)
MANAGE MOISTURE, NUTRITION, FRICTION AND SHEAR
PRESSURE-REDUCTION SUPPORT
SURFACE IF BED - OR CHAIR-BOUND SUPPLEMENT WITH SMALL SHIFT IN POSITION USE SUPPORT FOR 30?
LATERAL POSITIONING"

A review of the facility's policy and procedure (P&P) titled, "Care Planning - Interdisciplinary," revised on 3/18/2022, indicated, " ...A comprehensive care plan for each patient is developed within 24 hours upon admission ...Interdisciplinary care plan includes the minimum ...Problem identified, interventions, goals ...Care plan is updated / reviewed whenever there is a condition change or as needed ..."

1b. A review of Patient 5's History and Physical (H&P -a formal and complete assessment of the patient and the problem), dated 4/17/2023, indicated Patient 5 was admitted to the facility on 4/17/2023 with chief complaint of Paranoid Schizophrenia (a psychiatric disorder that affects a person's ability to think, feel, and behave clearly), Mental disorder (a group of illnesses that may include symptoms that can affect a person's thinking, perceptions, mood or behavior), and non-compliant behavior.

During a concurrent observation and interview on 4/19/2023, at 3:22 p.m., with the Director of Information Services Registered Nurse (DIS RN) and Registered Nurse 3 (RN 3), inside Patient 5's room, Patient 5 was observed unable to turn herself (Patient 5) independently. RN 3 said she (RN 3) had not seen Patient 5 turn herself (Patient 5) independently. When RN 3 was asked if Patient 5 was on a turning schedule, RN 3 stated there was no need for a turning schedule since there was no physician order.

During a concurrent interview and record review, on 4/20/2023, at 2:00 p.m., with DIS RN, Patient 5's Admission Assessment record, dated 4/17/2023 was reviewed. The Admission Assessment record indicated, Patient 5 was bedbound (confined in bed) and the Braden Scale score (a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk of developing pressure injuries) was 11, High Risk (for developing pressure injuries). DIS RN stated the Braden Scale score should be assessed every shift, a turning schedule should have been implemented upon admission, and a care plan should have been initiated per the facility's policy for Patient 5.

A review of the facility's policy and procedure titled, Pressure Injury, dated 3/2019, indicated, "OBJECTIVE: To provide guidelines for assessment of skin integrity, determine risk of developing pressure injuries and develop a plan of care for prevention of pressure injuries to those patients determined to be at risk and provide guidelines for individual treatment.
POLICY: 1. All patients will have skin integrity assessed during admission assessment, and each shift, using the Braden Risk Assessment Scale Tool. 2. Risk Prevention interventions will be initiated as indicated according to the Braden Scale Intervention Guidelines by Risk Score or physician orders.
THE BRADEN SCALE INTERVENTION GUIDELINES BY RISK SCORE: HIGH RISK (10 - 12)
FREQUEST TURNING (EVERY 2 HOURS)
MAXIMAL MOBILIZATION
PROTECT HEELS (FLOAT)
MANAGE MOISTURE, NUTRITION, FRICTION AND SHEAR
PRESSURE-REDUCTION SUPPORT
SURFACE IF BED - OR CHAIR-BOUND SUPPLEMENT WITH SMALL SHIFT IN POSITION USE SUPPORT FOR 30?
LATERAL POSITIONING"

A review of the facility's policy and procedure (P&P) titled, "Care Planning - Interdisciplinary," revised on 3/18/2022, indicated, " ...A comprehensive care plan for each patient is developed within 24 hours upon admission ...Interdisciplinary care plan includes the minimum ...Problem identified, interventions, goals ...Care plan is updated / reviewed whenever there is a condition change or as needed ..."

2. During a concurrent observation and interview on 4/18/2023, at 1:10 p.m. with the Director of Nursing (DON), Patient 20 was observed to be alert and oriented, sitting on the side of the bed, calling out for the nurse to come, stating she (Patient 20) was in pain, asking for pain medication and stating no one is coming to help her (Patient 20). Likewise, Patient 20 had a cast (used to hold a broken bone in place and allows healing) on her (Patient 20) right leg and had a Foley catheter (FC-a flexible tube inserted into the bladder to drain urine) with the FC drainage bag lying flat on the floor. Patient 20 stated she (Patient 20) had pain all over her (Patient 20) body. Patient 20 also said she (Patient 20) had an accident that fractured (a break in the bone) her (Patient 20) leg which added more to her (Patient 20) pain.

During a concurrent interview and record review on 4/19/2023, at 2:40 p.m., with the Director of Nursing (DON), Patient 20's medical record was reviewed. The "History and Physical (H&P -a formal and complete assessment of the patient and the problem)," indicated Patient 20 was admitted to the facility on 4/11/2023, for psychiatric condition (a broad range of problems that disturb a person's thoughts, feelings, behavior or mood). Patient 20's medical history included fibromyalgia (a disorder characterized by generalized muscle pain), chronic pain syndrome (pain that carries on longer than 12 weeks despite medication or treatment), and right lower extremity fracture secondary (due to) to a motor vehicle accident.

A review of Patient 20's "Admission Assessment," dated 4/12/2023, indicated Patient 20 arrived at the facility with a FC on 4/11/2023.

There was no documented evidence a care plan was developed upon admission to addressed Patient 20's management of pain and FC. This absence of documented evidence was confirmed by the DON.

During an interview on 4/19/2023, at 2:40 p.m., with the DON, the DON stated there should have been a care plan developed for Patient 20 addressing her (Patient 20) pain management and care of the FC.

A review of the facility's policy and procedure (P&P) titled, "Care Planning - Interdisciplinary," revised on 3/18/2022, indicated, " ...A comprehensive care plan for each patient is developed within 24 hours upon admission ...Interdisciplinary care plan includes the minimum ...Problem identified, interventions, goals ...Care plan is updated / reviewed whenever there is a condition change or as needed ..."

3. During a concurrent observation and interview on 4/18/2023, at 1:50 p.m., with the Director of Quality (DOQ) and the Director of Nursing (DON), Patient 24 was observed lying in bed, alert, and oriented. Patient 24 had a peripherally inserted central catheter (PICC line- a long thin flexible line that goes all the way up to a vein near the heart and used as intravenous access) line on the left arm and Vancomycin (an antibiotic) was infusing at 60 milliliter per hour (ml/hr-a unit of measurement).

During an interview on 4/18/2023, at 1:50 p.m., with Patient 24, Patient 24 stated he (Patient 24) was admitted to the hospital because he (Patient 24) had a knee surgery from another hospital.

A review of patient 24's "History and Physical (H&P -a formal and complete assessment of the patient and the problem)," indicated, Patient 24 was admitted to the facility on 4/13/2023, with a chief complaint of intractable knee pain (type of pain that cannot be controlled with standard medical care) due to a recent knee surgery.

A review of Patient 24's "Infectious Disease Consultation Note," dated 4/14/2023, indicated the infectious disease physician was consulted for Patient 24's leukocytosis (a high white blood cell count commonly caused by infection or inflammation) and the need for antibiotic management.

A review of Patient 24's "Authorization and Consent to Surgery or Special Diagnostic or Therapeutic Procedures," indicated Patient 24 consented for a PICC line procedure on 4/14/2023.

A review of Patient 24's medication administration record (MAR) indicated, Patient 24 had a physician's order for antibiotics (vancomycin and Rocephin-medications used to treat infection).

There was no documented evidence a care plan was developed to address Patient 24's PICC line care and infection when Patient 24 had PICC line insertion for antibiotic management. This absence of documented evidence was confirmed by the DON.

During an interview on 4/20/2023, at 2:42 p.m., with the DON, the DON stated there should have been a care plan developed for Patient 24 addressing the patient's PICC line care and infection.

A review of the facility's policy and procedure (P&P) titled, "Care Planning - Interdisciplinary," revised on 3/18/2022, indicated, " ...A comprehensive care plan for each patient is developed within 24 hours upon admission ...Interdisciplinary care plan includes the minimum ...Problem identified, interventions, goals ...Care plan is updated/reviewed whenever there is a condition change or as needed ..."

4. During a concurrent interview and record review on 4/21/2023, at 9:25 a.m., with the Director of Nursing (DON), Patient 30's medical record was reviewed. The "History and Physical (H&P -a formal and complete assessment of the patient and the problem)" indicated Patient 30 was admitted to the facility for evaluation of generalized weakness and psychiatric decompensation (a breakdown in an individual's defense mechanisms [unconscious strategies whereby people protect themselves from anxious thoughts or feelings], resulting in progressive loss of normal functioning or worsening of psychiatric symptoms [example: excessive fears/worries, extreme mood changes, etc.]).

A review of Patient 30's History and Physical (H&P ) indicated, Patient 30 had diabetes (a chronic [long-lasting] health condition that affects how the body turns food into energy causing high blood sugar). Patient 30's treatment plan was to continue insulin (medication used to move sugar from the blood into other body tissues where it is used for energy) medication and perform Accu-Check (quantitatively measures glucose in the blood) with insulin sliding scale (varies the dose of insulin administered based on blood glucose level).

There was no documented evidence a care plan was developed upon admission to address Patient 30's diabetes. This absence of documented evidence was confirmed by the DON.

During an interview on 4/21/2023, at 9:25 a.m., with the DON, the DON stated there should have been a care plan developed for Patient 30 addressing the patient's (Patient 30) diabetes management.

A review of the facility's policy and procedure (P&P) titled, "Care Planning - Interdisciplinary," revised on 3/18/2022, indicated, " ...A comprehensive care plan for each patient is developed within 24 hours upon admission ...Interdisciplinary care plan includes the minimum ...Problem identified, interventions, goals ...Care plan is updated/reviewed whenever there is a condition change or as needed ..."

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

1. Ensure the patient's daily weight was taken prior to hemodialysis (HD - a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatment for one of 14 sampled patients (Patient 18) in accordance with the facility's policy and procedure. This deficient practice had the potential to negatively impact the patient's (Patient 18) HD treatment resulting in extra fluid build-up to not be monitored which may lead to complications affecting the patient ' s heart and lungs, and deterioration of the patient's condition

2. Ensure a physician's order was written for the insertion of a foley catheter (FC - a flexible tube inserted into the bladder to drain urine) for one of 14 sampled patients (Patient 20) in accordance with the facility ' s policy and procedure. This deficient practice had the potential to result in inappropriate, unnecessary, and prolonged use of a foley catheter, which may lead to an increased risk for Patient 20 acquiring Urinary Tract Infection (UTI-infection in any part of the urinary system such as the kidneys, bladder, etc.)

3. Ensure a chest x-ray (an imaging test to look at structures of organs in the chest was immediately completed following the insertion of a peripherally inserted central catheter (PICC line - a long thin flexible line that goes all the way up to a vein near the heart and used as intravenous access) line to verify correct placement of the PICC line prior to the administration of an antibiotic in accordance with the facility ' s policy and procedure for one of 14 sampled patients (Patient 24). This deficient practice resulted in the delay of treatment and administration of intravenous (IV-administered through the vein) antibiotic (used to treat infection) infusion which may lead to deterioration of Patient 24's medical condition.

Findings:

1. During a concurrent interview and record review, on 4/19/2023, at 11:45 a.m., with the Director of Nursing (DON), Patient 18 ' s medical record was reviewed. The History and Physical (H&P -a formal and complete assessment of the patient and the problem) indicated Patient 18 was admitted to the facility on 4/07/2023 due to uncontrolled hypertension (defined as blood pressure (BP) above 140/90 and is considered severe if the BP is above 180/120). Patient 18's medical history included end stage renal disease (ESRD - loss of kidney function) and needing hemodialysis (HD - a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatment.

A review of Patient 18's physician's order, dated 4/07/2023, indicated Patient 18 to have daily weight taken.

A review of Patient 18's "Flowsheet Chart" indicated, Patient 18's weight was taken on 4/07/2023, 4/10/2023, and 4/17/2023.

A review of Patient 18's "Hemodialysis Flowsheet" also indicated Patient 18's weight was taken pre (before) and post (after) HD on April 8, 11, 13, 15, and 18, 2023.

There was no documented evidence Patient 18's weight was taken on April 9, 10, 12, 14, 16, and 17, 2023. This absence of documented evidence was confirmed by the DON.

During an interview on 4/19/2023, at 11:45 a.m., with the DON, the DON stated all HD patients should have a daily weight to monitor the patients ' blood volume (amount of blood circulating in the body) and fluid balances (equal intake and output [loss of fluid] of fluid in the body), and to check for any volume deficit (condition where the fluid output exceeds the fluid intake) after HD treatment. The DON also said Patient 18 should have been weighed daily as ordered by the physician and in accordance with the facility's policy and procedure.

A review of the facility's policy and procedure (P&P) titled, "Vital Signs (VS - temperature, heart rate [HR], respiratory rate [RR], and blood pressure [BP])," revised in March 2022, the indicated, " ...All patients on dialysis ...shall be weighed on a daily basis ..."

2. During an observation on 4/18/2023, at 1:10 p.m., with the Director of Nursing (DON), Patient 20 was observed to be alert, oriented, and was sitting on the side of the bed. Patient 20 had a cast (used to hold a broken bone in place and allows healing) on her right leg and a Foley catheter (FC- a flexible tube inserted into the bladder to drain urine) with the FC drainage bag lying flat on the floor.

During a concurrent interview and record review on 4/19/2023, at 2:40 p.m., with the Director of Nursing (DON), Patient 20's record was reviewed. The "History and Physical (H&P -a formal and complete assessment of the patient and the problem)," indicated Patient 20 was admitted to the facility on 4/11/2023 for psychiatric condition (a broad range of problems that disturb a person ' s thoughts, feelings, behavior or mood).

A review of Patient 20's "Admission Assessment," dated 4/11/2023, indicated, Patient 20 "came in with a FC."

There was no documented evidence a physician's order was written for Patient 20's FC upon Patient 20's admission on 4/11/2023. This absence of documented evidence was confirmed by the DON.

During an interview on 4/19/2023, at 2:40 p.m., with the DON, the DON stated when a patient was admitted with a FC, a physician's order should be obtained for continued use of the FC and to insert a new FC when it is scheduled to be changed. The DON said Patient 20 did not have a FC order written when the patient was admitted to the facility.

A review of the facility's policy and procedure (P&P) titled, "Foley Cath Urinary Tract Infection Prevention," dated November 7, 2022, the P&P indicated, " ...Foley catheter will be inserted upon order by the physician ...Patients admitted with chronic indwelling catheter from home or nursing home ...The collection system will remain closed. The bag can be replaced if contaminated or accidentally disconnected. The drainage tubing will be secured properly (fixative device), and the bag will be maintained in a dependent position without kinks or loops to prevent urine backflow ..."

3. During a concurrent observation and interview, on 4/18/2023, at 1:50 p.m., with the Director of Quality (DOQ) and the Director of Nursing (DON), Patient 24 was observed lying in bed, alert, and oriented. Patient 24 had a peripherally inserted central catheter (PICC-line a long thin flexible line that goes all the way up to a vein near the heart and used as intravenous access) line on the left arm and an Intravenous (administered through the vein) Piggyback (IVPB-a small bag of antibiotic solution attached to a primary infusion line to deliver medication over a specific period of time) Vancomycin (an antibiotic) was infusing at 60 milliliter per hour (ml/hr-a unit of measurement).

During a concurrent interview and record review on 4/20/2023, at 2:42 p.m., with the DON, Patient 24's medical record was reviewed. The "History and Physical (H&P -a formal and complete assessment of the patient and the problem)," indicated, Patient 24 was admitted to the facility on 4/13/2023, with a chief complaint of intractable knee pain (type of pain that cannot be controlled with standard medical care) due to a recent knee surgery.

A review of Patient 24's "Infectious Disease Consultation Note," dated 4/14/2023, indicated the infectious disease physician was consulted for Patient 24's leukocytosis (a high white blood cell count commonly caused by infection or inflammation) and for antibiotic management.

A review of Patient 24's "Authorization and Consent to Surgery or Special Diagnostic or Therapeutic Procedures," indicated, Patient 24 consented for a PICC line procedure on 4/14/2023.

A review of Patient 24's physician's order, dated 4/16/2023, at 7:17 p.m., indicated, Patient 24 to have a chest x-ray to confirm PICC line placement.

A review of Patient 24's "Radiology Result Report," dated 4/17/2023, at 2:26 p.m., (a total of 19 hours passed since Patient 24 had the chest x-ray) indicated appropriate PICC line placement.

A review of Patient 24's medication administration record (MAR) indicated vancomycin 750 milligram (mg) IVPB to be given IV every 12 hours, was ordered by the physician on 4/15/2023, at 4:19 p.m., and for the Vancomycin to be started on 4/16/2023, at 9 a.m.

A review of Patient 24's MAR indicated the following:

-on 4/16/2023, at 8:35 p.m., vancomycin not given to Patient 24 because the PICC line was not ready to use

-on 4/17/2023, at 8:09 a.m., vancomycin not given to Patient 24 because of no IV access

-on 4/17/2023, at 11:50 p.m., vancomycin was given to Patient 24 (a total of two days had passed, from the initial scheduled dose, before the antibiotic was given).

During an interview on 4/20/2023, at 2:42 p.m., with the DON, the DON stated, after the PICC line was placed, chest x-ray would be ordered to confirm PICC line placement prior to use. The DON also said the chest x-ray should be ordered STAT (immediately) and the result should be read immediately so that the PICC line could be used. The DON stated Patient 24's chest x-ray was not ordered STAT, and there was a delay in reading the results that led to a delay in starting the patient's (Patient 24) IV antibiotic.

A review of the facility's policy and procedure (P&P) titled, "Insertion of Peripherally Inserted Central Catheter (PICC) Lines," dated 6/14/2021, indicated, " ...Confirmation of Tip Location ...Chest x-ray is always required after PICC line placement. PICC catheter tip location must be confirmed by Stat CXR before the catheter is used ..."

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

1. Ensure medications were administered timely (within 1 hour of scheduled administration time) for two of 14 sampled patients (Patient 18 and Patient 30) as ordered by the physician. Patient 18 had an order to receive hydralazine, labetalol, and amlodipine (BP medications used to treat hypertension - defined as blood pressure (BP) above 140/90 and is considered severe if the BP is above 180/120). Patient 30 had an order to receive Humalog (type of insulin - used for treatment of diabetes [high blood sugar]). This deficient practice resulted in the delay of treatment and had the potential to cause adverse health outcomes which could negatively affect the patients ' health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death for Patients 18 and 30.

2. Ensure a physician's order was obtained for one of 14 sampled patients (Patient 18) when the patient's (Patient 18) blood pressure (BP) medications (hydralazine, labetalol, and amlodipine-BP medications used to treat hypertension- defined as blood pressure above 140/90 and is considered severe if the BP is above 180/120) were not given on the days the patient (Patient 18) was scheduled for hemodialysis (HD - a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). This deficient practice had the potential to cause adverse health outcomes which could negatively affect the patient's health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death.

3. Ensure pain medication was administered for two of 14 sampled patients (Patient 20 and Patient 24) as ordered by the physician. This deficient practice resulted in delay of treatment of the patients' (Patient 20 and Patient 24) pain and had the potential to cause adverse health outcomes which could negatively affect the patient's health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death.

Findings:

1a. During a concurrent interview and record review, on 4/19/2023, at 11:45 a.m., with the Director of Nursing (DON), Patient 18's medical record was reviewed. The History and Physical (H&P -a formal and complete assessment of the patient and the problem) indicated Patient 18 was admitted to the facility on 4/07/2023 due to uncontrolled hypertension (defined as blood pressure (BP) above 140/90 and is considered severe if the BP is above 180/120). Patient 18's medical history included end stage renal disease (ESRD - loss of kidney function) and needing hemodialysis (HD- a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatment.

A review of Patient 18's medication administration record (MAR) indicated a physician's order for hydralazine (medication to lower blood pressure) 100 milligrams (mg) to be given by mouth three times a day. The MAR also indicated, "Hold the medication if systolic BP (SBP- pressure in the arteries when the heart beats) below 110 or HR below 60 and notify the physician." The MAR further indicated, the physician ' s order was received on 4/07/2023, at 7:40 a.m., and was verified by pharmacy on 4/07/2023, at 7:47 a.m.

A review of Patient 18's MAR indicated, Patient 18's first dose of hydralazine 100 mg was scheduled on 4/07/2023, at 9 a.m. The MAR indicated Patient 18 received the first dose of hydralazine 100 mg by mouth on 4/07/2023, at 10:30 p.m. (a total of 13 hours and 30 mins from the scheduled first dose).

A review of Patient 18's "Flowsheet Chart" indicated, Patient 18's BP on 4/07/2023, at 9:09 a.m., was 183/89 and at 9:17 a.m., Patient 18's BP was 175/84.

A review of Patient 18's MAR indicated a physician's order for labetalol (medication used to lower blood pressure) 100 mg to be given by mouth two times a day. The MAR also indicated, "Hold the medication if systolic BP (SBP) below 110 or HR below 60 and notify the physician." The MAR indicated that the physician's order was received on 4/07/2023, at 7:40 a.m., and the order was verified by pharmacy on 4/07/2023, at 7:49 a.m.

A review of Patient 18's MAR indicated Patient 18's first dose of labetalol 100 mg was scheduled on 4/07/2023, at 9 a.m. The MAR also indicated Patient 18 received the first dose of labetalol 100 mg by mouth on April 7, 2023, at 10:30 p.m. (a total of 13 hours and 30 mins from the scheduled first dose).

A review of Patient 18's "Flowsheet Chart" indicated, Patient 18's BP on 4/07/2023, at 9:09 a.m., was 183/89 and at 9:17 a.m., Patient 18's BP was 175/84.

A review of Patient 18's MAR indicated a physician's order for amlodipine (medication used to lower blood pressure) 10 mg to be given by mouth once a day. The MAR also indicated, "Hold the medication if systolic BP (SBP) below 110 or HR below 60 and notify the physician." The MAR indicated that the physician ' s order was received on 4/07/2023, at 7:40 a.m., and the order was verified by pharmacy on 4/07/2023, at 7:47 a.m.

A review of Patient 18's MAR indicated Patient 18's first dose of amlodipine 10 mg was scheduled on 4/07/2023, at 9 a.m. The MAR indicated Patient 18 received the first dose of amlodipine 10 mg by mouth on 4/08/2023, at 9:45 a.m. (a total of one day passed from the scheduled first dose).

A review of Patient 18's "Flowsheet Chart" indicated, Patient 18's BP on 4/07/2023, at 9:09 a.m., was 183/89 and at 9:17 a.m., Patient 18's BP was 175/84.

During an interview on 4/19/2023, at 11:45 a.m., with the DON, the DON stated the BP medications (hydralazine, labetalol, and amlodipine) should have been administered on the scheduled initial dose because Patient 18's BP was high.

During an interview on 4/20/2023, at 12:46 p.m., with the Pharmacy Manager (PM), the PM stated when a new medication was ordered, the pharmacy would receive the order and would need to verify the order prior to dispensing the medication. The PM said once the pharmacist verified the medication order, the nurse would be able to get the medication in the pyxis (a secured medication storage) to give to the patient. The PM also stated the initial dose schedule for new medication orders would appear in the MAR. The PM said if there was a concern or question regarding the initial dose schedule the nurse should consult with the pharmacy to assist in adjusting the schedule dose if needed for patient care. The PM stated Patient 18's MAR indicated the BP medication orders were verified by the pharmacist in a timely manner. The PM stated there was no documentation in Patient 18's record indicating the BP medications should not be given as scheduled. Likewise, the PM said Patient 18's BP was high at the time the initial dose for the BP medications were scheduled to be given. The PM stated Patient 18 should have been given the BP medications on time to help with the patient's (Patient 18) high BP.

A review of the facility's policy and procedure (P&P) titled, "Medication Administration (Procedures & Timing of Administration)," revised on July 2020, indicated, " ...medications shall be safely and timely administered to patients by licensed staff upon the order of a physician ...Before administering any drug, the following 8 (Eight) Rights must be adhered to ...Right Time To ensure adherence to the prescribed frequency, time of administration ...Right Reason To ensure that the medication being given to the patient matches the therapeutic goals of treatment ...Scheduled Medication Administration Times The goal of this scheduling is to achieve and maintain therapeutic blood levels of the prescribed medication over a period of time. Unless otherwise noted in this policy, medications shall be administered at the following scheduled times ...HS (at bedtime) 2100 ...Use of Professional Judgement. Staff are expected to use their professional judgement ...to assure that medications are delivered in a safe and timely manner ...staff must take into account ...The indications for which they are prescribed. The clinical situations in which they are administered. The needs of the patients receiving them ..."

1b. During a concurrent interview and record review on 4/21/2023, at 9:25 a.m., with the DON, Patient 30's medical record was reviewed. The "History and Physical (H&P -a formal and complete assessment of the patient and the problem)" indicated Patient 30 was admitted to the facility for evaluation of generalized weakness and psychiatric decompensation (a breakdown in an individual's defense mechanisms [unconscious strategies whereby people protect themselves from anxious thoughts or feelings], resulting in progressive loss of normal functioning or worsening of psychiatric symptoms [example: excessive fears/worries, extreme mood changes, etc.]).

A review of Patient 30's History and Physical (H&P) indicated, Patient 30 had diabetes (a chronic [long-lasting] health condition that affects how the body turns food into energy causing high blood sugar). Patient 30's treatment plan was to continue insulin (medication used to move sugar from the blood into other body tissues where it is used for energy) medication and perform Accu-Check (quantitatively measures glucose in the blood) with insulin sliding scale (varies the dose of insulin administered based on blood glucose level).

A review of Patient 30's medication administration record (MAR) indicated, a physician's order for Humalog (a type of insulin) 100 units to be given to Patient 30, per sliding scale, subcutaneous (injection under the skin) with meals and at bedtime.

A review of Patient 30's MAR indicated Patient 30 refused the insulin on 4/19/2023, at 12:49 a.m. Patient 30's insulin was scheduled to be administered to the patient (Patient 30) at 9 p.m., for bedtime.

During an interview on 4/21/2023, at 9:25 a.m., with the DON, the DON stated administering Patient 30's insulin at 12:49 a.m., on 4/19/2023, was a late medication administration. The DON stated insulin should not be given to the patient at that time (referring to the 12:49 a.m. insulin administration). The DON said the bedtime schedule for the insulin medication was at 9 p.m.

A review of the facility's policy and procedure (P&P) titled, "Medication Administration (Procedures & Timing of Administration)," revised on July 2020, indicated, " ...medications shall be safely and timely administered to patients by licensed staff upon the order of a physician ...Before administering any drug, the following 8 (Eight) Rights must be adhered to ...Right Time To ensure adherence to the prescribed frequency, time of administration ...Right Reason To ensure that the medication being given to the patient matches the therapeutic goals of treatment ...Scheduled Medication Administration Times The goal of this scheduling is to achieve and maintain therapeutic blood levels of the prescribed medication over a period of time. Unless otherwise noted in this policy, medications shall be administered at the following scheduled times ...HS (at bedtime) 2100 ...Use of Professional Judgement. Staff are expected to use their professional judgement ...to assure that medications are delivered in a safe and timely manner ...staff must take into account ...The indications for which they are prescribed. The clinical situations in which they are administered. The needs of the patients receiving them ..."

2. During a concurrent interview and record review, on 4/19/2023, at 11:45 a.m., with the Director of Nursing (DON), Patient 18's medical record was reviewed. The History and Physical (H&P -a formal and complete assessment of the patient and the problem) indicated, Patient 18 was admitted to the facility on 4/07/2023 due to uncontrolled hypertension (defined as blood pressure (BP) above 140/90 and is considered severe if the BP is above 180/120). Patient 18's medical history included end stage renal disease (ESRD - loss of kidney function) and needing hemodialysis (HD- a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatment.

A review of Patient 18's medication administration record (MAR) indicated, a physician ' s order for hydralazine (medication used to lower blood pressure) 100 milligrams (mg-a unit of measurement) to be given by mouth three times a day.

A review of Patient 18's MAR indicated Patient 18's hydralazine was not given on the following dates because it was the patient's (Patient 18) day of HD:

- on 4/11/2023, at 1:09 p.m. Patient 18's morning dose of hydralazine was scheduled at 9 a.m. Patient 18's HD was from 11 a.m. to 2:30 p.m.

-on 4/13/2023, at 6 p.m. Patient 18's morning dose of hydralazine was scheduled at 9 a.m. Patient 18's HD was from 12:45 p.m. to 3:45 p.m.

There was no documented evidence a physician's order was written to hold hydralazine on days that Patient 18 had HD treatment. This absence of documented evidence was confirmed by the DON.

A review of Patient 18's MAR indicated, a physician's order of labetalol (medication used to lower blood pressure) 100 mg to be given by mouth two times a day.

A review of Patient 18's MAR indicated Patient 18's labetalol was not given on 4/13/2023, at 6:08 p.m., because it was the patient's (Patient 18) day of HD.

A review of Patient 18's MAR indicated, Patient 18's morning dose of labetalol was scheduled at 9 a.m., and Patient 18's HD was from 12:45 p.m. to 3:45 p.m.

There was no documented evidence a physician's order was written to hold labetalol on days that Patient 18 had HD treatment. This absence of documented evidence was confirmed by the DON.

A review of Patient 18's MAR indicated, a physician ' s order for amlodipine (medication used to lower blood pressure) 10 mg to be given by mouth once a day.

A review of Patient 18's MAR indicated Patient 18's amlodipine was not given on the following dates because it was the patient's (Patient 18) day of HD:

- on 4/11/2023, at 1:11 p.m. Patient 18's morning dose of amlodipine was scheduled at 9 a.m. Patient 18's HD was from 11 a.m. to 2:30 p.m.; and,

-on 4/13/2023, at 5:59 p.m. Patient 18's morning dose of amlodipine was scheduled at 9 a.m. Patient 18's HD was from 12:45 p.m. to 3:45 p.m.

There was no documented evidence a physician's order was written to hold amlodipine on days that Patient 18 had HD treatment. This absence of documented evidence was confirmed by the DON.

During an interview on 4/19/2023, at 11:45 a.m., with the DON, the DON stated not administering the BP medications to Patient 18 for HD reason was "not acceptable." The DON said the BP medication scheduled dose was prior to HD treatment and there was no physician order to hold Patient 18's medications on the patient's (Patient 18) HD days. The DON stated Patient 18's BP medications should have been given as scheduled on the dates mentioned above.

A review of the facility's policy and procedure (P&P) titled, "Medication Administration (Procedures & Timing of Administration)," revised on July 2020, indicated, " ...medications shall be safely and timely administered to patients by licensed staff upon the order of a physician ...Before administering any drug, the following 8 (Eight) Rights must be adhered to ...Right Time To ensure adherence to the prescribed frequency, time of administration ...Right Reason To ensure that the medication being given to the patient matches the therapeutic goals of treatment ...Scheduled Medication Administration Times The goal of this scheduling is to achieve and maintain therapeutic blood levels of the prescribed medication over a period of time. Unless otherwise noted in this policy, medications shall be administered at the following scheduled times ...QDAY (once a day) 0900 ...BID (twice a day) 0900, 2100 ...TID (three time a day) 0600 1400 2100 ...First time or Loading doses ...Refer to Dosing Schedule Adjustment Chart ...Use of Professional Judgement. Staff are expected to use their professional judgement ...to assure that medications are delivered in a safe and timely manner ...staff must take into account ...The indications for which they are prescribed. The clinical situations in which they are administered. The needs of the patients receiving them ..."

3a. During a concurrent observation and interview on 4/18/2023, at 1:10 p.m. with the Director of Nursing (DON), Patient 20 was observed to be alert and oriented, sitting on the side of the bed, calling out for the nurse to come, stating she (Patient 20) was in pain, asking for pain medication and stating no one is coming to help her (Patient 20). Likewise, Patient 20 had a cast (used to hold a broken bone in place and allows healing) on her (Patient 20) right leg. Patient 20 stated she (Patient 20) had pain all over her (Patient 20) body. Patient 20 also said she (Patient 20) had an accident that fractured (a break in the bone) her (Patient 20) right leg which added more to her (Patient 20) pain.

During a concurrent interview and record review on 4/19/2023, at 2:40 p.m., with the Director of Nursing (DON), Patient 20's medical record was reviewed. The "History and Physical (H&P -a formal and complete assessment of the patient and the problem)," indicated, Patient 20 was admitted to the facility on 4/11/2023, for psychiatric condition (a broad range of problems that disturb a person's thoughts, feelings, behavior or mood). Patient 20's medical history included fibromyalgia (a disorder characterized by generalized muscle pain), chronic pain syndrome (pain that carries on longer than 12 weeks despite medication or treatment), and right lower extremity fracture secondary to a motor vehicle accident.

A review of Patient 20's medication administration record (MAR), dated 4/12/2023, indicated a physician order for Motrin (pain medication) 600 milligrams (mg) to be given by mouth every six hours as needed for moderate pain (pain scale score of 4-6).

A review of Patient 20's MAR dated 4/12/2023, indicated a physician order for tramadol (pain medication) 50 mg to be given by mouth every six hours as needed for severe pain (pain scale score of 7-10).

A review of Patient 20's MAR indicated Patient 20 was given Motrin 600 mg:

-On 4/12/2023, at 11:50 a.m., for pain score of 8 (severe pain 7-10)

-On 4/15/2023, at 8:14 p.m., for pain score of 10 (severe pain)

-On 4/16/2023, at 6:34 a.m., for pain score of 10 (severe pain)

-On 4/19/2023, at 9:53 a.m., for pain score of 7 (severe pain).

During an interview on 4/19/2023, at 2:40 p.m., with the DON, the DON stated Patient 20's pain was severe, and Motrin was only ordered for moderate pain. The DON said Patient 20 did not receive the correct pain medication on the dates mentioned above. The DON further stated pain assessment should be done prior to administering the pain medication to ensure the correct medication would be given to the patient that would help with pain management.

A review of the facility's policy and procedure (P&P) titled, "Medication Administration (Procedures & Timing of Administration)," revised on July 2020, indicated, " ...medications shall be safely and timely administered to patients by licensed staff upon the order of a physician ...Before administering any drug, the following 8 (Eight) Rights must be adhered to ...Right Drug To ensure that the medication being given to the patient matches that prescribed for the patient ...Right Reason To ensure that the medication being given to the patient matches the therapeutic goals of treatment ...Use of Professional Judgement. Staff are expected to use their professional judgement ...to assure that medications are delivered in a safe and timely manner ...staff must take into account ...The indications for which they are prescribed. The clinical situations in which they are administered. The needs of the patients receiving them ..."

3b. During a concurrent observation and interview, on 4/18/2023, at 1:50 p.m., with the Director of Quality (DOQ) and the Director of Nursing (DON), Patient 24 was observed lying in bed, alert, and oriented. Patient 24 stated he (Patient 24) was admitted to the hospital because he (Patient 24) had a knee surgery from another hospital and now (the time of the interview on 4/18/2023), he (Patient 24) was in a lot of pain. Patient 24 also said he (Patient 24) had been asking for pain medication for hours and he (Patient 24) was not getting any pain medicine. Patient 24 stated, "the pain meds they are giving is not working."

During a concurrent interview and record review on 4/20/2023, at 2:42 p.m., with the DON, Patient 24's medical record was reviewed. The "History and Physical (H&P -a formal and complete assessment of the patient and the problem)" indicated, Patient 24 was admitted to the facility on 4/13/2023, with a chief complaint of intractable knee pain (type of pain that cannot be controlled with standard medical care) due to a recent knee surgery.

A review of Patient 24's MAR dated 4/14/2023, indicated a physician order for tramadol (pain medication) 50 mg to be given by mouth every eight hours as needed for severe pain (pain scale score of 7-10).

A review of Patient 24's medication administration record (MAR) dated 4/18/2023, indicated a physician order for Motrin (pain medication) 600 milligrams (mg) to be given by mouth every six hours as needed for moderate pain (pain scale score of 4-6).

A review of Patient 24's MAR indicated, Patient 24 was given Motrin 600 mg on 4/18/2023, at 1:56 p.m., for pain score of 7 (severe pain 7-10).

During an interview on 4/18/2023, at 1:50 p.m., with the DON, the DON stated Patient 24's pain was severe, and Motrin was only ordered for moderate pain. The DON said Patient 24 did not received the correct pain medication.

A review of the facility's policy and procedure (P&P) titled, "Medication Administration (Procedures & Timing of Administration)," revised on July 2020, indicated, " ...medications shall be safely and timely administered to patients by licensed staff upon the order of a physician ...Before administering any drug, the following 8 (Eight) Rights must be adhered to ...Right Drug To ensure that the medication being given to the patient matches that prescribed for the patient ...Right Reason To ensure that the medication being given to the patient matches the therapeutic goals of treatment ...Use of Professional Judgement. Staff are expected to use their professional judgement ...to assure that medications are delivered in a safe and timely manner ...staff must take into account ...The indications for which they are prescribed. The clinical situations in which they are administered. The needs of the patients receiving them ..."