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Based on interview and record review, the hospital failed to provide written evidence a patient has the right to formulate an advance directive (a written instruction for health care) for one of 30 sampled patient (Patient 30). This failure had the potential for patient to not have their healthcare rights and wishes known and honored.

Findings:

Patient 30 was admitted to the hospital on 12/2/24 for status epilepticus (a seizure that lasts more than five minute, or two or more seizures without regaining consciousness between them).

During a concurrent interview and record review on 12/5/24 at 9:57 a.m., with the Clinical Informatics Program Manager (CIPM), the CIPM reviewed Patient 30's medical record and she confirmed there was no advance directive on file and had no indication the hospital inquired or provided the patient or patient's representative with information regarding advance directive. The CIPM confirmed there was no documentation in the medical record that Patient 30 was offered an advance directive.

During a review of the hospital's policy and procedure (P&P), titled "Healthcare Individual Instructions and Advance Directives/PSDA/POLST", date approved 4/19/22, indicated "Provide to each individual, at the time of admission as an inpatient or outpatient ...written information regarding an individual's rights ... and to formulate advance directives. Document in the individual's medical record whether or not the individual has been offered or has executed an Advance Directive."

Based on interview and record review, the hospital failed to ensure the registered nurse evaluated the nursing care for eight of 30 sampled patients (Patient 4, 5, 9, 12, 13, 15, 16, and 19) when pain reassessment was not done. This failure had the potential for patients to have continued pain.

Findings:

Patient 4 was admitted to the hospital on 11/30/24 for right femur fracture (a type of hip fracture that occurs in the upper part of the thigh bone).

During a concurrent interview and record review, on 12/4/24 at 10:29 a.m., with the Clinical Informatics Program Manager (CIPM), Patient 4's pain was assessed and rated at 7 of 10 on 12/4/24 at 7:54 a.m., and Oxycodone 10 milligrams (mg, unit of measurement) tablet was administered. The CIPM confirmed pain reassessment documentation performed at 10:17 a.m.

Patient 5 was admitted to the hospital on 11/24/24 for acute abdominal pain (a sudden and severe pain in the abdomen).

During a concurrent interview and record review, on 12/4/24 at 10:48 a.m., with the CIPM, Patient 5's pain was assessed prior to administration of hydromorphone (Dilaudid, used to treat severe pain) on 11/24/24 at 8:12 p.m., 11/25/24 at 8:40 a.m., 11/25/24 at 11:58 a.m., 11/26/24 at 6:20 a.m., 11/27/24 at 8:25 a.m., 11/27/24 at 11;53 a.m., 11/27/24 at 2:50 p.m., 11/229/24 at 7:21 a.m., 11/29/24 at 1:22 p.m., 11/30/24 at 8:50 a.m., 11/30/24 at 11:03 a.m., 11/30/24 at 1:58 p.m., 12/1/24 at 7:58 a.m., 12/1/24 at 1:28 p.m., 12/2/24 at 7:53 a.m., 12/2/24 at 9:31 p.m., and 12/3/24 at 7:25 a.m. The CIPM confirmed there was no pain reassessment done.

Patient 9 was admitted to the hospital on 12/3/24 for femoral neck fracture (a break in the thighbone that occurs one to two inches from the hip joint).

During a concurrent interview and record review, on 12/4/24 at 12:55 p.m., with the CIPM, Patient 9's pain was assessed and rated at 7 of 10 and morphine (used to treat moderate to severe pain) 6 milligrams (mg, unit of measurement) intravenous push (IVP, a process of introducing a medication directly into the bloodstream) was administered. The CIPM confirmed no pain reassessment was done.

Patient 12 was admitted to the hospital on 11/30/24 for right femur fracture (a type of hip fracture that occurs in the upper part of the thigh bone).

During a concurrent interview and record review, on 12/4/24 at 1:55 p.m., with the CIPM, Patient 12's pain was assessed on 12/1/24 at 8:14 a.m., and 12/1/24 at 2:26 p.m. and acetaminophen-hydrocodone (Norco, used to treat for pain) 5-325 mg tablet was administered. The CIPM confirmed there was no pain reassessment done.

Patient 13 was admitted to the hospital on 12/3/24 for cervical myelopathy (compression of the spinal cord in the neck).

During a concurrent interview and record review on 12/4/24 at 2:25 p.m., with the CIPM, Patient 13's pain was assessed on 12/3/24 at 5:23 p.m., and 12/3/24 at 9:20 p.m. prior to administration of acetaminophen-oxycodone (Percocet, used to treat moderate to severely moderate pain) 325/5 mg tablet. The CIPM confirmed there was no pain reassessment done.

Patient 15 was admitted to the hospital on 12/3/24 for sacral abscess (an infection that occurs at the base of the spine)

During a concurrent interview and record review, on 12/4/24 at 2:50 p.m., with the CIPM, Patient 15's pain was assessed on 12/3/24 at 1:10 p.m. and rated at 8 of 10 prior to administration of acetaminophen-hydrocodone tablet. The CIPM confirmed no pain reassessment was done.

Patient 16 was admitted to the hospital on 12/1/24 for femur fracture.

During a concurrent interview and record review, on 12/4/24 at 2:45 p.m., with the CIPM, Patient 16's pain was assessed on 12/1/24 at 2:14 p.m., 12/1/24 at 4:16 p.m., 12/2/24 at 7:53 a.m., 12/2/24 at 12:21 p.m., 12/2/24 at 2:00 p.m., 12/3/24 at 10:58 a.m., and 12/3/24 at 3:55 p.m. prior to administration of Fentanyl (a narcotic used to treat severe pain) injection, hydromorphone, and oxycodone tablet. The CIPM confirmed no pain reassessment was done.

Patient 19 was admitted to the hospital on 11/9/24 for discitis (infection of the spinal discs).

During a concurrent interview and record review, on 12/4/24 at 3;24 p.m., with the CIPM, Patient 19's pain was assessed on 11/17/24 at 12:17 a.m., 11/17/24 at 2:24 p.m., 11/19/24 at 8:43 a.m., 11/19/24 at 2:45 p.m., 11/19/24 at 8:57 p.m., 11/24/24 at 10:15 p.m., 11/25/24 at 6:11 p.m., 11/27/24 at 5:46 p.m., 11/27/24 at 11:44 p.m., 11/28/24 at 12:01 p.m., 11/28/24 at 8:47 p.m., 11/29/24 at 8:20 p.m., and 12/4/24 at 6:27 p.m. prior to administration of acetaminophen-hydrocodone tablet and hydromorphone 2 mg tablet. The CIPM confirmed no pain reassessment was done.

During the review of the hospital's policy and procedure (P&P), titled "Core Nursing standards of Practice for Med/Surg, TCU, Oncology, and Acute Rehab", date approved 8/12/21, indicated "pain reassessment within 30 minutes for all PO medications or within 15 minutes for IV medication administered for pain."

Based on interview and record review, the hospital failed to ensure nursing staff developed individualized and updated care plans (a tool used to provide nursing care to patients) related to pain for three of 30 sampled patients (Patient 12, 13 and 15). This failure had the potential to result in lack of, or delay in appropriate care and monitoring of these patients.

Findings:

Patient 12 was admitted to the hospital on 11/30/24 for right intertrochanteric femur fracture (a type of hip fracture that occurs in the upper part of the thigh bone) status post intermedullary rodding (a patient has recently undergone surgery where a metal rod was inserted in the bone to stabilize a fracture).

During a concurrent interview and record review, on 12/4/24 at 1:55 p.m., with the Clinical Informatics Program Manager (CIPM), the CIPM confirmed Patient 12's care plan was not initiated upon admission and after pain assessment and administration of Acetaminophen-Hydrocodone (Norco, used to relieve moderate to severe pain).

During a concurrent interview and record review, on 12/4/24 at 2:10 p.m., with Chief Nursing Officer (CNO), the CNO confirmed Patient 12's care plan was not initiated upon admission.

Patient 13 was admitted to the hospital on 12/3/24 for cervical myelopathy (compression of the spinal cord in the neck).

During a concurrent interview and record review, on 12/4/24 at 2:25 p.m., with the CIPM, the CIPM confirmed Patient 13's care plan was not initiated on admission and after pain assessment and administration of Acetaminophen-Oxycodone (Percocet, used to relieve moderate to severe pain).

Patient 15 was admitted to the hospital on 12/3/24 for sacral abscess (an infection at the base of the spine).

During a concurrent interview and record review, on 12/4/24 at 2:50 p.m., with the CIPM, the CIPM confirmed Patient 15's care plan for pain was not initiated after pain assessment and administration of Acetaminophen-Hydrocodone (Norco, used to relieve moderate to severe pain).

During a review of the hospital's policy and procedure (P&P), titled "Core Nursing Standards of Practice for Med/Surg, TCU, Oncology, and Acute Rehab", date approved 8/12/21, indicated "Standard 1: Nursing Process 4. Plan of Care - The registered nurse develops a plan that prescribes strategies to attain expected, measurable outcomes. The registered nurse: h. Document implementation, modifications, and evaluation of goals; including changes or omissions, of the identified plan. i. The plan of care is reviewed and updated at a minimum of every shift and PRN."

During a review of the hospital's policy and procedure (P&P), titled "Core Nursing Standards of Practice for Med/Surg, TCU, Oncology, and Acute Rehab", date approved 8/12/21, indicated "Appendix A: Standard of Practice: Assessment & Charting for Med/Surg minimum frequency of nursing interventions and documentation: Plan of Care - upon admission."

Based on observation, interview, and record review, the hospital failed to implement infection prevention and control measures when a Certified Nursing Assistant (CNA) was observed entering patient rooms without removing, cleaning and/or disinfecting the face shield.
This failure had the potential to result in transmission and spread of infectious diseases to staff, patients , and visitors.

Findings:

During an observation on 12/5/24 at 10:31 a.m., in a Medical-Surgical unit, a CNA was observed wearing a face shield entering patient rooms without removing, cleaning, and/or disinfecting the face shield.

During a concurrent observation and interview, on 12/5/24 at 10:35 a.m., with Infection Prevention Director (IPD), the ICD stated face shield should be cleaned before and after entering a patient room.

During a review of the hospital's policy and procedure (P&P), titled "Personal Protective Equipment (PPE), date approved 9/21/22, indicated "Personal Protective Equipment (PPE) is worn to protect healthcare workers from exposure to potentially infectious microorganisms. The outside of goggles or face shield is considered contaminated. Remove PPE at doorway before leaving patient room and discard inside room."