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Based on medical record review, and staff interview it was determined the hospital failed to ensure care was provided in a safe setting. This directly impacted the quality of care of 2 of 6 patients (Patient #1 and #2) whose record were reviewed. This resulted in incomplete patient care and had the potential to affect all patients receiving care at the hospital.

Findings include:

1. Patient #2 was a 76 year old female admitted to the hospital on 12/15/24 with an admitting diagnosis of Osteomyelitis of her left heel.

Patient #2's medical record was reviewed. It included nursing note dated 12/22/24 signed by an RN. The note included, "The family for the patient had called with concerns about the care of her mother. The patient had called and complained about the care that she was getting. They had complaints about how the sheets have not been changed in the days she had been here, that she had not gotten a bath, and how there was an earring that was found under her mother and found to injure her skin."

Patient #2's medical record included a nursing flowsheet that documented daily cares and hygiene. The nursing flowsheet was reviewed, there was no documented hygiene care provided for Patient #2 from 12/19/24 at 7:53 PM until 12/22/24 at 12:22 PM. The nursing flowsheet included on 12/21/24 at 9:32 AM that Patient #2 refused "Hygiene." There was no documentation of what specific cares she refused. Additionally, there was no follow up on why Patient #2 refused or if care was offered later in the nursing shift.

The RN Manager was interviewed 1/22/25 beginning at 1:00 PM and Patient #2's medical record was reviewed in her presence. When asked if the hospital had a policy on daily cares or standards for hygiene care she stated hygiene care should be offered and completed every shift. She confirmed there was no documentation Patient #2 was provided hygiene care between 12/19/24 at 7:53 PM and 12/22/24 at 12:22 PM. Additionally, she stated when Patient #2 refused hygiene care on 12/21/24, the medical record should have documentation on why care was refused and follow up at a different time to perform hygiene care.

The hospital failed to provide daily cares and hygiene care for Patient #2.

2. The orders for Patient #1 were not followed.

Patient #1 was a 72 year old male admitted to the facility for back pain from ER on 1/18/25. Patient #1's medical record was reviewed. Patient #1's medical record included orders, "Turn patient q2h [every two hours]," dated 1/21/25 at 1:19 PM. Patient #1's medical record included "Mobility - Activity level of assistance: maximum assist", dated 1/21/25 at 7:00 AM. Patient #1's medical record included flow sheet documentation of repositioning. Repositioning was documented at 1/21/25 at 1:32 PM and again at 1/21/25 at 8:45 PM, representing 7 hours and 13 minutes between repositioning.

Patient #1's medical record also included order for "Vital Signs ... Every 4 hours" dated 1/18/25 at 5:41 PM. Patient #1's medical record flow sheets were reviewed. Patient #1's medical record documented vital signs at 1/22/25 at 7:33 AM and 1/22/25 at 3:39 PM, representing 8 hours and 6 minutes between vitals sign documentation. Patient #1's medical record also included documented vital sign at 1/21/25 at 3:01 AM and next at 1/21/25 at 8:50 PM, representing 17 hours and 49 minutes between vital sign documentation.

The RN Manager was interviewed on 1/22/24 beginning at 2:30 PM. The RN Manager confirmed 7 hours and 13 minutes, elapsed between turns. The RN Manager also confirmed orders were for turns every 2 hours. Additionally, The RN Manager confirmed 8 hours and 6 minutes and 17 hours and 49 minutes, elapsed between vital sign documentation. The RN Manager also confirmed that orders were for vital signs every 4 hours.

The orders for Patient #1 were not followed.

Based on record review, policy review, and staff interview, it was determined the hospital failed to ensure nursing staff met the needs of patients in accordance with standards of care established by hospital policy and expectation. Additionally, the hospital failed to ensure care was provided in a safe setting. This had the potential to result in unmet patient needs and affect all patients receiving care at the hospital. Findings include:

Refer to A-144 as it relates to the failure of the hospital to provide care in a safe setting.

Refer to A-395 as it relates to the failure of the hospital to ensure staff followed hospital policy and standards of care related to the use of external catheters.

These systemic failures significantly impeded the ability of the hospital to provide safe nursing care.

Based on record review, policy review, and staff interview, it was determined the hospital failed to ensure nursing staff met the needs of patients in accordance with standards of care established by hospital policy and expectation for 2 of 6 patients (Patient #4 and #6) whose records were reviewed. This had the potential to result in unmet patient needs. Findings include:

A hospital policy titled " External Urinary Management Systems" Stated, "Purpose; To ensure the appropriate and safe use of External urinary management systems ..."

..." Contraindications:

c. Redness irritation or open skin on pubic, genital, or perineal areas ...

...f. Fecal incontinence or frequent loose stools that are not contained with a fecal management system.

This policy was not followed. Examples included:

1. Patient #4 was a 80 year old female admitted to the hospital on 1/15/25 with an admitting diagnosis of Atrial Fibrillation. Additionally, she had 2 wounds, one in her perirectal area and one in her sacral area.

Patient #4's medical record was reviewed. It included on her wound care flowsheet that she was fitted with an external urinary catheter upon admission on 1/15/25.

Patient #4's medical record included a wound care note on 1/15/25 at at 4:08 PM. The note included that Patient #4 's had a red rash in her perirectal and vaginal area.

Patient #4's medical record included a nursing note on 1/18/25 at 5:40 AM. The note included "Primary RN was called into pts room d/t [due to] wound vac being soiled by stool."

Patient #4's medical record included a wound care note documented 1/20/25 by the wound care PT. The note included "patient found in bed with purewick [external catheter] in place but large amount of urine under buttock on pad."

The RN Manager was interviewed on 1/22/25 beginning at 9:00 AM and Patient #4's medical record was reviewed in her presence. When asked when the external urinary catheter was placed for Patient #4, she confirmed it was placed upon admission on 1/15/25. She confirmed the external catheter was contraindicated due to Patient #4's redness, irritation and open skin in her genital area, and fecal incontinence.

The hospital failed to follow standard of care policy for the use of the external catheter.



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2. Patient #6 was a 76 year old female admitted to the hospital on 1/10/25 with an admitting diagnosis of hypothermia.

Patient #6's medical record was reviewed. It included she was fitted with purwick, an external urinary catheter, upon admission on 1/10/25.

Patient #6's medical record was reviewed and did not include any indication for the use of an external urinary catheter.

The director of the 4th floor was interviewed on 1/22/2025 at 9:30 am and Patient #6's medical record was reviewed in her presence. When asked when the external urinary catheter was placed, she confirmed it was placed upon admission on 1/10/25. She confirmed there was no documented indication for Patient #6 to use the external urinary catheter.

The hospital failed to follow standard of care policy for the use of the external catheter.