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Based on review of email sent by the complainant, staff interviews, and record review the facility did not provide quality nursing care to 1 of the 22 patients in the facility.

Findings include:

It was validated that the complainant had sent an email to both the Administrator and the Chief Nursing Executive (CNE). The facility conducted their own investigation and had spoken to the complainant after their investigation.

RN#1 was interviewed on August 17, 2021, at 1:35 PM. She was the assigned charge nurse when the incident happened. She mentioned that she was trying to help the staff, so she brought Patient #1 (P1) outside her room to the tent outside the hospital for a family visit. She did not know that the patient was having loose bowel movement and that the patient's shoes were covered with brownish color spots. In addition, patient's legs were covered with dried diarrhea. RN#1 acknowledged that she did not do an assessment prior to taking the patient out to the tent area. RN#1 said, "I assume that everything is ok, because she was smiling."

Medical Record review (MRR) was conducted on August 18, 2021, at 12:35 PM with the Nurse Manager (NM). The MRR revealed that P1 requires oxygen at 3L/NP. The day of the daughter's visit 8/9/2021 RN#1 brought an oxygen tank that was nearly empty, with a signage that read EMPTY. RN#1 acknowledged that it was nearly empty, but she wanted it to be used up before opening a new tank. With this reported incident, RN#1 acknowledged that she should have gotten a new tank for P1's use.

During this interview, RN#1 was asked if she is aware of P1's symptoms of headache, body ache, and diarrhea and she acknowledged she did not. RN#1 said that COVID-19 rapid testing was done, and the result was negative.

The NM was interviewed on August 18, 2021, at 1:39 PM. She was asked about her expectations regarding this incident. NM said that she expected RN#1 to have done a quick assessment before bringing P1 out for a family visit and a full tank of oxygen because the visit may run longer than the thirty minutes visitation timeframe. In addition, the Administrator and the CNE concurred with the NM's expectations.