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

1. The facility failed to inform the legal guardian and obtain consent for care and treatment from the legal guardian for one of 30 sampled patients (Patient 3) before providing care to Patient 3, in accordance with the facility's policy and procedure regarding Condition of Registration- Hospital Services and Informed Consent (a process in which patients are given important information, including possible risks and benefits about a medical procedure or treatment so that they can make well-considered decisions about their care), when Patient 3, who was identified as a minor (children under age of 18), signed the facility's Condition of Registration (COR, legal agreement between the patient and the hospital consenting to treatment, assignment of insurance benefits and accepting financial responsibility for their medical service). Patient 3 was 17 years old (considered a minor).

This deficient practice resulted in a violation of Patient 3's and Patient 3's legal representative's right to receive information regarding patients' rights (ethical principles that apply to patient care such as the right to receive information about any proposed treatment, etc.) as hospital patient and had the potential to result in Patient 3's and/or Patient 3's legal guardian's inability to effectively make decisions regarding Patient 3's care or treatment. (Refer to A-0117)

2. The facility failed to ensure one of 30 sampled patient's (Patient 25's) Condition of Registration form (legal agreement between the patient and the hospital consenting to treatment, assignment of insurance benefits and accepting financial responsibility for their medical service) was followed- up by the registration staff to ensure completion and include documentation of attempts made to obtain Patient 25's signature to indicate that Patient 25 received the form, in accordance with the facility's policy and procedure regarding Condition of Registration process.

This deficient had the potential for Patient 25 to not receive information regarding his (Patient 25) Patients' rights as well as to participate and make effective decisions regarding his (Patient 25) care and treatment, which may negatively affect Patient 25's compliance with care and treatment resulting in prolonged recovery and hospitalization. (Refer to A-0117)

3. The facility failed to indicate the correct state regulatory agency phone number for two of two sampled facility's Patients' Rights Poster posted in the emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) and in the facility's admission booklet titled, "Welcome! (Patient Handbook, a patient welcome guide designed to assist patients with simple questions on key care topics and explains patient rights and responsibilities)," for three of 30 sampled patients (Patient 3, 6 and 7), in accordance with the facility's policy and procedure regarding complaint and grievance (written or oral expression of dissatisfaction regarding the quality of care provided to a patient) management.

This deficient practice had the potential to result in Patients 3, 6 and 7, not knowing who to contact when filing a grievance, which may prevent the patients from expressing concerns they may have regarding their care and treatment, thus leading to poor compliance with treatment regimen and delayed recovery. (Refer to A-0118)

4. The facility failed to ensure for one of 30 sampled patients (Patients 19) the following:

4.a. Patient 19's environmental safety checklist (a tool that help nursing staff identify and abate environmental hazards that could increase the chance of patient suicide [thoughts of taking one's own life] or self-harm) for suicide precaution was completed, after Patient 19 was diagnosed with suicidal ideation (when a patient thinks about, consider or feel preoccupied with the idea of death and suicide), in accordance with the facility's policy and procedure regarding suicide prevention.

4.b. Patient 19's re-assessment of Columbia-Suicide Severity Rating Scale ([C-SSRS] a risk assessment intended to help establish a person's immediate risk of suicide and is used in hospital care settings) was completed, after it was determined that Patient 19 exhibited a change in condition (Patient 19 informed other ED staff members that he was suicidal), in accordance with the facility's policy and procedure regarding suicide prevention.

These deficient practices had the potential to result in self-harm or harm to others, for patients who are seen in the Emergency Department (ED, provides immediate care for patients with acute [sudden and severe in onset] illnesses or injuries) and diagnosed with suicidal ideation. (Refer to A-0144)

5. The facility failed to ensure its nursing staff developed and implemented a 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) care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) upon restraints initiation, for one of 30 sampled patients (Patient 5), in accordance with the facility's policy and procedure for restraints, when Patient 5 was placed on 5-point restraints in the Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care).

This deficient practice had the potential to result in lack of nursing intervention and monitoring while Patient 5 was restrained, which may put Patient 5 at risk for injury such as strangulation (when a person's breathing or blood circulation is impeded by applying pressure to the neck or throat), skin tear, dehydration, etc. (Refer to A-0166)

6. The facility failed to ensure the physician performed face to face assessment (in-person evaluation documented by a licensed independent practitioner or their designee to evaluate patient's response to treatment/intervention) within an hour after initiation of a violent or self-destructive 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), in accordance with the facility's policy and procedure for restraints, on one of 30 sampled patients (Patient 5), when Patient 5 was placed on 5-point (bilateral wrists, bilateral ankles and waist) restraints in the Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care).

This deficient practice had the potential to result in lack of evaluation of Patient 5's response to the behavioral restraints initiated including assessment for continued need for the restraints and/or other interventions, which may result in unnecessary use of restraints and other complications such as strangulation (when a person's breathing or blood circulation is impeded by applying pressure to the neck or throat), skin tear, dehydration, etc. (Refer to A-0178)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment, potentially placing patients at risk for a delay in care and treatment, injury, and/or death.

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

1. Inform the legal guardian and obtain consent for care and treatment from the legal guardian for one of 30 sampled patients (Patient 3) before providing care to Patient 3, in accordance with the facility's policy and procedure regarding Condition of Registration- Hospital services and Informed Consent (a process in which patients are given important information, including possible risks and benefits about a medical procedure or treatment so that they can make well-considered decisions about their care), when Patient 3, who was identified as a minor (children under age of 18), signed the facility's Condition of Registration (COR, legal agreement between the patient and the hospital consenting to treatment, assignment of insurance benefits and accepting financial responsibility for their medical service). Patient 3 was 17 years old.

This deficient practice resulted in a violation of Patient 3's and/or Patient 3's legal representative's right to receive information regarding patients' rights (ethical principles that apply to patient care such as the right to receive information about any proposed treatment, etc.) as hospital patients and had the potential to result in Patient 3's and/or Patient 3's legal guardian's inability to effectively make decisions regarding Patient 3's care or treatment.

2. Ensure one of 30 sampled patient's (Patient 25's) Condition of Registration form (legal agreement between the patient and the hospital consenting to treatment, assignment of insurance benefits and accepting financial responsibility for their medical service) was followed- up by the registration staff to ensure completion and include documentation of attempts made to obtain Patient 25's signature to indicate that Patient 25 received the form, in accordance with the facility's policy and procedure regarding Condition of Registration process.

This deficient had the potential for Patient 25 to not receive information regarding his (Patient 25) Patients' rights as well as to participate and make effective decisions regarding his care and treatment, which may negatively affect Patient 25's compliance with care and treatment resulting in prolonged recovery and hospitalization.

Findings:

1. During a review of Patient 3's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 11/6/2024, the H&P indicated Patient 3 was a 17-year-old patient admitted to the facility's Pediatrics (Peds, hospital unit with patients from very young infant to teenagers who require hospital admission for a variety of medical illnesses) unit for acute (new onset) colitis (a digestive disease that causes swelling of large intestine or colon).

During an interview on 11/14/2024 at 9:58 a.m. with the Director of Patient Access (DPAR), DPAR stated the form titled "Condition of Registration (COR, legal agreement between the patient and the hospital consenting to treatment, assignment of insurance benefits and accepting financial responsibility for their medical service)," was given to all patients to give medical consent, nursing care and authorization for the facility to treat and provide service. DPAR stated the COR also covered the personal valuables, consent for photography, non-discrimination, financial agreement and responsibility, patients' rights (ethical principles that apply to patient care such as the right to receive information about any proposed treatment, etc.) and consent for email or phone communication.

During a concurrent interview and record review on 11/14/2024 at 2:50 p.m. with the Chief Nursing Officer (CNO), Patient 3's signed copy of "Condition of Registration (COR)," dated 11/5/2024, was reviewed. The COR indicated the form was signed by Patient 3 with Patient 3's signature, printed name and indication of "I am the patient." CNO stated Patient 3 should not sign the COR since he (Patient 3) was still a minor. CNO stated a minor was considered as anyone below age of 18. CNO stated the COR form should be signed by Patient 3's legal guardian or parents.

During a review of the facility's policy and procedure (P&P) titled, "Condition of Registration - Hospital Services," dated 11/2021, the P&P indicated, "Consent is necessary prior to any treatment or procedure ... All facility admissions require the Condition of Registration (COR) form signed by patient or their authorized representative at the time of each hospital outpatient visit or bedded admission encounter ... The patient's or authorized representative's signature is obtained confirming consent for care, receiving notification of his/her Patient Rights and Responsibilities, knowledge of billing information, financial assistance ... Legal Representative ... a parent or legal guardian of a minor child."

During a review of the facility's policy and procedure (P&P) titled, "Consent and Informed Consent - [the state]," dated 1/2023, the P&P indicated, "Definitions ... minors - all persons under 18 years of age ... Conditions of Registration: upon admission or as soon as thereafter as reasonably possible the patient or a patient's legal representative will be asked to give consent to the general medical care and the general terms and conditions for receiving care from the health care facility."

2. During review of Patient 25's "Face Sheet (a document that summarizes a patient's key personal and medical information, including their name, address, date of birth, insurance details, allergies, medical history, and current medications)," dated November 2024, the Face Sheet indicated the following: Patient 22 was admitted to the hospital on 11/10/2024 for seizure (a sudden burst of abnormal electrical activity in the brain that can cause temporary changes in a person's behavior, movements, feelings, and level of consciousness [a person's degree of awareness and responsiveness to their surroundings]) and discharged from the hospital on 11/12/2024.

During review of Patient 25's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 11/2024, the "H&P," indicated the following: Patient 25 was brought to the hospital for witnessed seizure at the gym.

During a concurrent interview and record review on 11/13/2024 at 2:57 p.m. with the Associate Patient Care Executive (APCE), Patient 25's "Condition of Registration Form (CORF, legal agreement between the patient and the hospital consenting to treatment, assignment of insurance benefits and accepting financial responsibility for their medical service)," dated November 2024, was reviewed. The "CORF" indicated Patient 25 was "unable to sign due to medical condition." APCE stated the following: Confirmed Patient 25 did not sign "CORF" due to medical condition. APCE stated there were no other "CORF" in the medical chart indicating Patient 25 signed his (Patient 25) "CORF."

During an interview on 11/14/2024 at 9:58 a.m. with the Director of Patient Access Rep (DPAR), DPAR stated the following: Confirmed DPAR was responsible for the registration staff. Patient 25's CORF form was not completed correctly. The registration staff should have documented what condition patient had since Patient 25 was unable to sign. Registration staff will run a missing signature report and put in the patients account notes about attempting to get a signature from the patient. At least once a day, staff need to go timely and see the patient to get a signature and come back to document in the log if patient did not sign. There will be a time stamp. DPAR Confirmed registration staff did not document in the registration flow log that registration staff attempted to get a signature from Patient 25. DPAR will educate staff on following up with Patients regarding CORF. It was important to make sure patients know their patient rights and responsibilities.

During a review of the facility's policy and procedure (P&P) titled, "Condition of Registration - Hospital Services," dated November 2021, the "P&P" indicated the following: 1. Conditions of Registration (COR): The COR is a legal agreement between the patient and the hospital consenting to treatment, assignment of insurance benefits and accepting financial responsibility for their medical services. A. Conditions of Registration 1. All Patient Access associates must be informed and understand the principles and requirements for completing the COR document. 2. Every patient has a legal right to decide upon the medical treatment that they are to receive. The COR provides important information including but not limited to Consent to Treatment, Patient Rights, Patient Privacy Practices, Assignment of Insurance Benefits and Permission to Bill for Services. D. If a patient's medical/mental condition prevents the patient from being able to sign the document, the patient's legal representative or family member may sign on the patient's behalf. If no legal representative or family member is available, Patient Access is responsible to follow up and obtain signatures prior to patient discharge if possible. All attempts to obtain signatures will be documented in the patient record.

Based on observation, interview, and record review, the facility failed to indicate the correct state regulatory agency phone number for two of two sampled facility's Patients' Rights Poster posted in the emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) and in the facility's admission booklet titled, "Welcome! (Patient Handbook, a patient welcome guide designed to assist patients with simple questions on key care topics and explains patient rights and responsibilities)," for three of 30 sampled patients (Patient 3, 6 and 7), in accordance with the facility's policy and procedure regarding complaint and grievance (written or oral expression of dissatisfaction regarding the quality of care provided to a patient) management.

This deficient practice had the potential to result in Patients 3, 6 and 7, not knowing who to contact when filing a grievance, which may prevent the patients from expressing concerns they may have regarding their care and treatment, thus leading to poor compliance with treatment regimen and delayed recovery.

Findings:

During a review of Patient 3's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 11/6/2024, the H&P indicated Patient 3 was a 17-year-old patient admitted to the facility's Pediatrics (Peds, hospital unit with patients from very young infant to teenagers who require hospital admission for a variety of medical illnesses) unit for acute (new onset) colitis (a digestive disease that causes swelling of large intestine or colon).

During a review of Patient 6's "History and Physical (H&P)," dated 11/12/2024, the H&P indicated Patient 6 was admitted to the facility with diagnoses including but not limited to sepsis (a body's overwhelming and life-threatening response to infection) and cholecystitis (inflammation of gallbladder).

During a review of Patient 7's "History and Physical (H&P)," dated 11/12/2024, the H&P indicated, Patient 7 was admitted to the facility with diagnoses including but not limited to anaphylaxis (a severe, lift-threatening allergic reaction), hypotension (low blood pressure) and acute (new onset) renal failure (the sudden and rapid loss of kidney's ability to filter waste and balance fluid in blood).

During an observation on 11/12/2024 at 1:15 p.m. in the emergency department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care) lobby, there were two posters titled, "Patients' Rights" posted in the lobby, one in English and one in Spanish. The posters listed an address and phone number under item number 23 "File a complaint with the [state] Department of Public Health (a state regulatory agency) regardless of whether you use the hospital's grievance (written or oral expression of dissatisfaction regarding the quality of care provided to a patient) process."

During a concurrent observation and interview on 11/12/2024 at 1:16 p.m. in the ED lobby with the Nursing Data Strategist (NDS), surveyor called the phone number listed on the posters, heard a person answer the phone and stated, "This is the Department of Public Health Laboratory." NDS stated the phone number listed on the posters was incorrect. NDS stated it was not the right phone number for patients to call to file complaints with the state regulatory agency.

During an interview on 11/12/2024 at 1:37 p.m. with the charge nurse (CN 2) in ED, CN 2 stated the Patient Access Representative (staff responsible for processing patients when they arrive at the hospital) was responsible to provide patients' rights information to the patients during registration.

During an interview on 11/12/2024 at 2:01 p.m. with the Patient Access Representative (PAR 1), PAR 1 stated she (PAR 1) was not sure what was included in patients' rights.

During an interview on 11/14/2024 at 9:58 a.m. with the Director of Patient Access (DPAR), DPAR stated the Patient Access Representative was responsible to provide patients' rights information by providing the facility's admission booklet titled, "Welcome! (Patient Handbook, a patient welcome guide designed to assist patients with simple questions on key care topics and explains patient rights and responsibilities)," to all patients admitted to the facility.

During a concurrent record review and interview on 11/14/2024 at 10:10 a.m. with DPAR, the facility's admission booklet titled, "Welcome! (Patient Handbook), undated, was reviewed. The "Patient Handbook" indicated, on page 10, patients' rights and responsibilities ... file a complaint with the [state] Department of Public Health regardless of whether you use the hospital's grievance process. The "Patient Handbook" also indicated a phone number of the [state] Department of Public Health. DPAR stated all patients had rights to file complaint to the state regulatory agency if they were not happy with the care provided by the facility. DPAR stated it was important to have the correct information on the "Patient Handbook."

During a concurrent observation and interview on 11/14/2024 at 10:12 a.m. with the Manager of Accreditation & Regulatory Compliance (MARC) at the facility's conference room, MARC called the phone number listed on the Patient Handbook, page 10 for the [state] Department of Public Health and received a voice message of "you have reached [a person name] voicemail." MARC stated this was not the correct phone number for the [state] Department of Public Health. MARC also stated patients would not be able to file complaint with the [state] Department of Public Health with the wrong phone number.

During a review of the facility's policy and procedure (P&P) titled, "Patient-Related Complaint and Grievance Management," dated 11/2022, the P&P indicated, "[the facility] is committed to providing patients and the patient's legal representative a complaint and grievance mechanism within the facility designed to promptly resolve patient complaints and grievances regarding the care and service they have received. It was the goal that these complaints and grievances are thoroughly addressed in a timely manner and handled in a way that supports the patient's right to receive respectful and supportive care ... notifying the patient of their right to file a complaint or grievance. A patient or their legal representative will be notified of their right ... to express complaints or grievances regarding patient care, abuse or neglect. Issues related to the facility's compliance ... file a grievance with the State Agency responsible for licensing the facility."

Based on interview and record review, the facility failed to ensure for one of 30 sampled patients (Patients 19) the following:

1. Patient 19's environmental safety checklist (a tool that help nursing staff identify and abate environmental hazards that could increase the chance of patient suicide [thoughts of taking one's own life] or self-harm) for suicide precaution was completed, after Patient 19 was diagnosed with suicidal ideation (when a patient thinks about, consider or feel preoccupied with the idea of death and suicide), in accordance with the facility's policy and procedure regarding suicide prevention.

2. Patient 19's re-assessment of Columbia-Suicide Severity Rating Scale ([C-SSRS] a risk assessment intended to help establish a person's immediate risk of suicide and is used in hospital care settings) was completed, after it was determined that Patient 19 exhibited a change in condition (Patient 19 informed other ED staff members that he was suicidal), in accordance with the facility's policy and procedure regarding suicide prevention.

These deficient practices had the potential to result in self-harm or harm to others for patients who are seen in the Emergency Department (ED, provides immediate care for patients with acute [sudden and severe in onset] illnesses or injuries) and diagnosed with suicidal ideation.

Findings:

1. During a review of Patient 19's "ED (Emergency Department) Physician Notes," dated 11/12/2024, the "ED Note" indicated, Patient 19 was a 29 year old male with past medical history of schizophrenia (a chronic mental disorder that impacts how a person thinks, perceives reality, and interacts socially) that presented to the Emergency Department with chief complaint of headache for the past 10 hours. Patient initially told triage (process used to assess patient's injuries or illnesses and determine the priority of care) nurse that he (Patient 19) lost his medication and wants a refill for his Vistaril (a medication used as a sedative to treat anxiety [a feeling of fear or uneasiness] and tension) and Depakote (medication used to treat seizure disorders [a sudden burst of abnormal electrical activity in the brain that can cause temporary changes in a person's behavior, movements, and level of consciousness [a person's awareness and understanding of what is happening in his or her surroundings]). Patient 19 then stated that he (Patient 19) was hearing voices and asked to be put on a 5150 hold (also known as a 72-hour hold, is a legal process that allows for the involuntary detention of an adult in a psychiatric [branch of medicine that focuses on mental, emotional, and behavioral disorders] hospital for up to 72 hours) because he (Patient 19) was also suicidal (thoughts of taking one's own life).

During a concurrent observation and interview on 11/12/2024 at 2:38 p.m. with the Registered Nurse 5 (RN5), Patient 19 was observed in the emergency department (ED) room 10. RN5 stated that Patient 19 was identified as suicidal and that the patient (Patient 19) was moved from room 14 to room 10 at around 6:42 a.m. this morning (11/12/2024). RN5 added that an environmental safety checklist was completed for when Patient 19 was in room 14, but there was no environmental safety checklist done when Patient was moved to room 10. It was the facility's policy and practice that an environmental safety checklist must be done every time a suicidal patient was transferred or moved to a different room. The environmental safety checklist guides the nurse to identify environmental hazard that may be in the room that a suicidal patient may use to self-harm or harm others.

During a review of the facility's policy and procedure (P&P) titled, "Suicide Prevention," last revised 4/27/2020, the P&P indicated the following:
Interventions for Moderate Risk:
Document the plan/actions used to mitigate the risk for suicide for the patient to include at minimum:
II. Physical environment. Clinician or PSA will use an environmental checklist to document risk items removed. See Attachment G for an example of the minimum information that should be documented. Items that remain will be justified, for example, oxygen tubing due to pulmonary Issues.
- Remove ligature risks (any item that can be used to tie or bind something tightly. Example: Shoelaces, belts, etc.) that can be removed and are not required for the patient's care.
- Identify ligature risks that cannot be removed and ensure they are part of the risk status report during hand-off. Ill. Remove medications, needles, sharps and other potentially dangerous objects from the patient's area/room.
- Inventory and secure patient's belongings ensuring there are no potentially dangerous Items in the patient's area/room.
- Verify items brought into the patient's area/room by visitors that may be used for self-harm by the patient. Explain to visitors the items deemed at risk must be removed. Visitors deemed to exacerbate or antagonize the patient's mental status may lose their ability to visit the patient.
- Notify Nutritional Services to serve finger foods on disposable/paper products.


2. During a review of Patient 19's "ED (Emergency Department) Physician Notes," dated 11/12/2024, the "ED Note" indicated, Patient 19 was a 29 year old male with past medical history of schizophrenia (a chronic mental disorder that impacts how a person thinks, perceives reality, and interacts socially) that presented to the Emergency Department with chief complaint of headache for the past 10 hours. Patient initially told triage (process used to assess patient's injuries or illnesses and determine the priority of care) nurse that he (Patient 19) lost his medication and wants a refill for his (Patient 19) Vistaril (a medication used as a sedative to treat anxiety [a feeling of fear or uneasiness] and tension) and Depakote (medication used to treat seizure disorders [a sudden burst of abnormal electrical activity in the brain that can cause temporary changes in a person's behavior, movements, and level of consciousness [a person's awareness and understanding of what is happening in his or her surroundings]). Patient 19 then stated that he (Patient 19) was hearing voices and asked to be put on a 5150 hold (also known as a 72-hour hold, is a legal process that allows for the involuntary detention of an adult in a psychiatric [branch of medicine that focuses on mental, emotional, and behavioral disorders] hospital for up to 72 hours) because he (Patient 19) is also suicidal (thoughts of taking one's own life).

During a concurrent interview and record review on 11/13/2024 at 3:26 p.m. with the Nurse Manager 5 (NM5), Patient 19's electronic medical record (EMR, a digital version of paper charting), was reviewed. Patient 19's EMR indicated that an initial CSSRS (Columbia-Suicide Severity Rating Scale ([C-SSRS] a risk assessment intended to help establish a person's immediate risk of suicide and is used in hospital care settings) screen was completed by the ED (Emergency Department) RN (Registered Nurse) on 11/12/2024 at 12:46 a.m., identifying patient (Patient 19) not at risk for suicide. That same nurse (ED RN) indicated later at 3:54 a.m., that patient (Patient 19) told a provider and other staff members of having suicidal thoughts. Patient (Patient 19) was placed with 1:1 sitter (also known as a one-on-one attendant, provides continuous monitoring and is used to reduce the risk and incidence of harm to patient). NM5 stated that there was no re-screen of a CSSRS at 3:54 a.m., EDRN should have done a reassessment of a CSSRS screen after documenting that there had been a change in behavior (at 3:54 a.m.) where patient (Patient 19) was now determined to be suicidal.

During a record review of the facility's policy and procedure (P&P) titled, "Suicide Prevention," last revised 4/27/20, the P&P indicated the following:
Rescreen: If there is a moderate or high risk of suicide Identified, rescreen using the C-SSRS Frequent Screener tool every shift. In addition, rescreen any time there are changes in the patient's behavior.
Re-screening risk level may increase the interventions. Notify the LIP of any increase in risk level.
Interventions should only be decreased using clinical judgement after collaboration with LIP. The LIP must authorize and document any change to the interventions.
If patient was initially low risk but changes in behavior led to rescreening that identified a higher risk, refer to E. Lifetime/Recent Assessment and ensure assessment is completed appropriately.

Based on observation, interview and record review, the facility failed to ensure its nursing staff developed and implemented a 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) care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) upon restraints initiation, for one of 30 sampled patients (Patient 5, in accordance with the facility's policy and procedure for restraints, when Patient 5 was placed on 5-point restraints in the Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care).

This deficient practice had the potential to result in lack of nursing intervention and monitoring while Patient 5 was restrained, which may put Patient 5 at risk for injury such as strangulation (when a person's breathing or blood circulation is impeded by applying pressure to the neck or throat), skin tear, dehydration, etc.

Findings:

During a concurrent observation and interview on 11/12/2024 at 1:40 p.m. with the Emergency Medical Technician (EMT 1) in the facility's Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care), Patient 5 was observed sleeping in the gurney with eyes closed. EMT 1 stated Patient 5 had 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) earlier but he (Patient 5) was sedated (medications was given to calm someone or to make someone sleep) now.

During an interview on 11/12/2024 at 1:45 p.m. with Registered Nurse (RN) 7, RN 7 stated Patient 5 was on restraints and was given injectable medications of Haldol (medication treats mental disorder) 5 milligrams (mg, unit of measurement), Benadryl (medication causes drowsiness) 50 mg and Versed (a medication that helps someone relax or sleep) 5 mg.

During a review of Patient 5's "Emergency Department Reports (ED report, ED physicians progress notes including patient assessment and care provided)," dated 11/12/2024, the ED report indicated, Patient 5 was brought to the facility's Emergency Department via law enforcement for the complaint of 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) due to suicidal (killing self) ideation. The ED report also indicated Patient 5 presented harm to himself (Patient 5) as he (Patient 5) was given injectable medications of Versed, Haldol and Benadryl and was started on physical restraints in the ED.

During a concurrent interview and record review on 11/13/2024 at 11:07 a.m. with the Emergency Department Supervisor (EDS), Patient 5's "Violent or Self Destructive Behavior Restraints - Assessment Flow Sheet, (behavioral restraints flowsheet)," dated 11/12/2024, was reviewed. The behavioral restraints flowsheet indicated, Patient 5 was placed on locked 5-points restraints on 11/12/2024 at 11:50 a.m. with injectable medications of Haldol 5 mg, Benadryl 50 mg and Versed 5 mg given on 11/12/2024 at 12:22 p.m. EDS stated the following: the locked 5-points restraints was applied to Patient 5's bilateral wrists, bilateral ankles and waist. Patient 5 was chemically restrained with the injectable medications. EDS stated there was no care plan related to restraints initiated and developed for Patient 5. EDS stated care plan was used to identify nursing intervention to resolve a problem.

During a concurrent interview and record review on 11/14/2024 at 11:20 a.m. with the Nursing Director of ED (ND 1), the facility's policy and procedure (P&P) titled, "Patient Plan of Care," dated 5/2022, was reviewed. The P&P indicated, "All in-patients will have a plan of care developed that includes assessment based on comprehensive patient needs, treatment and goals ... Plans of Care will also be developed (initiate, implemented and evaluated) in the following areas: Emergency Department." ND 1 stated care plan could be initiated in ED per facility's policy.

During a review of the facility's policy and procedure (P&P) titled, "Restraint Management (Mechanical, Chemical, Seclusion)," dated 1/2021, the P&P indicated, "General considerations - restraints/ seclusion (the involuntary confinement of a patient alone in a room where they are physically prevented from leaving) ... assessment/ re-assessment ... use of restraint and/or seclusion are in accordance with initiation and modification(s) to patient's plan of care ... ongoing monitoring/documentation ... documentation of restraint and/or seclusion episode(s) to include, but not limited to: assessments/re-assessments, interventions, care plan/ plan of care modifications, response to interventions, criteria met for discontinuation."

Based on observation, interview and record review, the facility failed to ensure the physician performed face to face assessment (in-person evaluation documented by a licensed independent practitioner or their designee to evaluate patient's response to treatment/intervention) within an hour after initiation of violent or self-destructive 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), in accordance with the facility's policy and procedure for restraints, on one of 30 sampled patients (Patient 5), when Patient 5 was placed on 5-point (bilateral wrists, bilateral ankles and waist) restraints in the Emergency Department (ED, hospital department provides unscheduled outpatient services to patients whose condition requires immediate care).

This deficient practice had the potential to result in lack of evaluation of Patient 5's response to the behavioral restraints initiated including assessment for continued need for the restraints and/or other interventions, which may result in unnecessary use of restraints and other complications such as strangulation (when a person's breathing or blood circulation is impeded by applying pressure to the neck or throat), skin tear, dehydration, etc.

Findings:

During a concurrent observation and interview on 11/12/2024 at 1:40 p.m. with the Emergency Medical Technician (EMT 1) in the facility's Emergency Department (ED, hospital department that provides unscheduled outpatient services to patients whose condition requires immediate care), Patient 5 was observed sleeping in the gurney with eyes closed. EMT 1 stated Patient 5 had 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) earlier but he (Patient 5) was sedated (medications was given to calm someone or to make someone sleep) now.

During an interview on 11/12/2024 at 1:45 p.m. with Registered Nurse (RN) 7, RN 7 stated Patient 5 was on restraints and was given with injectable medications of Haldol (medication treats mental disorder) 5 milligrams (mg, unit of measurement), Benadryl (medication causes drowsiness) 50 mg and Versed (a medication that helps someone relax or sleep) 5 mg.

During a review of Patient 5's "Emergency Department Reports (ED report, ED physicians progress notes including patient assessment and care provided)," dated 11/12/2024, the ED report indicated, Patient 5 was brought to the facility's Emergency Department via law enforcement for the complaint of 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) due to suicidal (killing self) ideation. The ED report also indicated Patient 5 also presented harm to himself (Patient 5) as he (Patient 5) was given injectable medications of Versed, Haldol and Benadryl and was started on physical restraints in the ED.

During a concurrent interview and record review on 11/13/2024 at 11:07 a.m. with the Emergency Department Supervisor (EDS), Patient 5's "Violent or Self-Destructive Behavior Restraints - Assessment Flow Sheet, (behavioral restraints flowsheet)," dated 11/12/2024, was reviewed. The behavioral restraints flowsheet indicated, Patient 5 was placed on locked 5-points restraints on 11/12/2024 at 11:50 a.m. along with injectable medications of Haldol 5 mg, Benadryl 50 mg and Versed 5 mg given on 11/12/2024 at 12:22 p.m. EDS stated the following: the locked 5-points restraints was applied to Patient 5's bilateral wrists, bilateral ankles and waist. Patient 5 was also chemically restrained with the injectable medications.

During an interview on 11/14/2024 at 11:09 a.m. with EDS, EDS stated the ED physician would be the one to perform the face-to-face assessment (in-person evaluation documented by a licensed independent practitioner or their designee to evaluate patient's response to treatment/intervention) on patients placed on violent or self-destructive behavioral restraints to assess patient's behavior, need for continuation of restraints or alternatives, and patient's response to the restraints.
During a concurrent interview and record review on 11/14/2024 at 11:15 a.m. with the Nursing Director of ED (ND 1), Patient 5's Emergency Department Reports (ED Reports), dated 11/12/2024, was reviewed. The ED Reports indicated, at 11:45 a.m. "patient (Patient 5) now moved from EMS (Emergency Medical Services, ambulance crew) to now ED gurney physical restraints applied at approximately this time as well." ND 1 stated there was no documentation from the ED physician that a face-to-face assessment was conducted after initiation of restraints for Patient 5.

During a review of the facility's policy and procedure (P&P) titled, Restraint Management (Mechanical, Chemical, Seclusion)," dated 1/2021, the P&P indicated, "Restraints considerations - violent/self-destructive ... this type of restraint/seclusion order is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff or others ... after the initial intervention, patients shall be seen face-to-face within one hour by a quailed licensed independent practitioner (LIP), registered nurse or physician assistant who has received education in accordance with requirements to evaluate: a. patient's immediate situation, b. reaction to intervention, c. medical and behavioral condition, d. need to continue or terminate the restraint(s) or seclusion."

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

1. The facility failed to ensure for one out of 30 sampled patients (Patient 8), nursing care was provided when:

1.a. Patient 8's admission orders were not carried out timely while waiting in the Emergency Department (ED, provides immediate care to patients with acute [sudden and severe in onset] illnesses or injuries) to be admitted in the Medical-Surgical/Telemetry unit (MST, a specialized unit for the patients that needed continuous heart monitoring), in accordance with the facility's policy on Provision of Patient Care Services.

1.b. Patient 8 did not have a complete physical assessment (head to toe evaluation) by a Registered Nurse (RN) while in the ED, in accordance with the facility's policy regarding Provision of Patient Care Services and Emergency Department Triage.

1.c. Patient 8's high Blood Pressure (BP, amount of force the blood needs to move through the vessels) readings in the ED were not addressed, in accordance with the facility's policy regarding Provision of Patient Care Services.

These deficient practices resulted in delayed treatment and also had the potential to cause a delay in determining Patient 8's change of condition and/or provision of care needed, which could worsen the patients' condition and may result in death. (Refer to A-0395)

2. The facility failed to initiate and develop an individualized care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for one of 30 sampled patients (Patient 4), to address Patient 4's diaper rash, in accordance with the facility's policy and procedure regarding care planning.

This deficient practice had the potential to result in the delay of care and evaluation of Patient 4's response to treatment and intervention, by not identifying Patient 4's needs and risks, which may result in worsening of Patient 4's condition and may prolong hospitalization. (Refer to A-0396)

3. The facility failed to develop and implement an individualized nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) related to dialysis (procedure that cleans the blood by removing extra fluids and waste), for one of 30 sampled patients (Patient 14), in accordance with the facility's policy and procedure regarding care planning.

This deficient practice had the potential to result in delayed provision of treatment by not identifying Patient 14's needs and risks pertaining to dialysis, which may result in complications for Patient 14 such as difficulty in breathing due to excessive fluids in the body, irregular heartbeat, confusion, and/or death. (Refer to A-0396)

4. The facility failed to develop and implement an individualized nursing care plan to address issues with bleeding for one of 30 sampled patients (Patient 16), in accordance with the facility's policy and procedure regarding care planning.

This deficient practice had the potential to result in delayed treatment by not identifying Patient 16's needs and risks pertaining to bleeding, which may result in excessive blood loss, hypotension (low blood pressure), and/or death. (Refer to A-0396)

5. The facility failed to implement the care plan developed regarding seizure (a sudden burst of abnormal electrical activity in the brain that can cause temporary changes in a person's behavior, movements, and level of consciousness [a person's awareness and understanding of what is happening in his or her surroundings]) precautions for one of 30 sampled patients (Patient 25), in accordance with the facility's policy regarding care planning, when seizure pads were not documented being placed on Patient 25's bed's siderails.

This deficient had the potential for Patient 25 to sustain an injury in case of a seizure episode, which may include fracture (break in the bone), contusion (bruise), etc., and may result in prolonged hospitalization and recovery. (Refer to A-0396)

6. The facility failed to ensure staff followed the facility's "Central Venous Catheter Management Policy," for one of 30 sampled patients (Patient 24), when Patient 24 had a PICC line (Peripheral Inserted Central Catheter, is an intravenously [into the vein] placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava [a large vein that carries blood from the head, neck, arms, and chest], and used for intravenous treatment that is required over a long period) placement done and staff did not obtain an order that it was okay to use the PICC line prior to using the PICC line for medication administration.

This deficient practice had the potential for misplaced PICC line to lead to serious complications like infection, bleeding, pneumothorax (when air leaks from the lung into the space between the lung and the chest wall), or arrythmias (abnormal heart rhythm). (Refer to A-0398)

7. The facility failed to ensure one of 30 sampled patient's (Patient 12) Code Status (type of lifesaving emergency treatment someone wants, which can or cannot include chest compressions, a breathing tube, and medications) was verified and physician was notified regarding the absence of documented order for Patient 12's code status, and ensure documentation of code status order in Patient 12's medical record, within 24 hours after admission, in accordance with the facility's policy and procedure regarding Code status.

This deficient practice had the potential for Patient 12 to receive inappropriate emergency life sustaining measures, and/or delay the care for Patient 12, which could lead to serious harm and/or death. (Refer to A-0398)

8. The facility failed to ensure one of 30 sampled patients (Patients 17) operating room nursing staff adhered to the facility's policy and procedure regarding chain of command (a formal process that hospital staff use to escalate concerns about patient safety or other issues to the appropriate levels of authority), when it was identified that the surgeon continued and completed surgical skin closure (the final step in a surgical procedure that involves repairing the skin and deeper layers of tissue to promote healing) after being told that the surgical count (a crucial procedure that ensures no surgical items are left behind in a patient after surgery) was incorrect.

This deficient practice resulted in Patient 17 having to undergo another surgical procedure to retrieve a surgical sponge that was left unintentionally inside Patient 17's abdominal cavity. This deficient practice also had the potential to cause complications such as infection, uncontrolled bleeding, and psychological distress for Patient 17. (Refer to A-0398)

9. The facility failed to ensure for two of 30 sampled patients (Patients 8 and 9), the following:

9.a. For Patient 8, Amlodipine (medication used to lower blood pressure [BP, amount of force blood uses to move through the body]) was given as ordered by the physician.

This deficient practice had the potential for Patient 8's blood pressure to remain elevated, which may result in complications such as heart attack and stroke (formation of blood clots in the brain), leading to paralysis (loss of function in part or all of the body) and/or death. (Refer to A-0405)

9.b. For Patient 8, Hydralazine (medication used to lower BP) was given as ordered by the physician.

This deficient practice had the potential for Patient 8's blood pressure to remain elevated, which may result in complications such as heart attack and stroke (formation of blood clots in the brain), leading to paralysis (loss of function in part or all of the body) and/or death. (Refer to A-0405)

9.c. For Patient 8, Lactated Ringers (LR, intravenous fluid given through the vein to help balance electrolyte [minerals that carry an electric charge found in the body which are important for bodily functions such as heart rate and rhythm, blood pressure, etc.] levels) was given as ordered by the physician.

This deficient practice had the potential for Patient 8 to have a low blood volume or low blood pressure, which may result in complications such as hypovolemic shock (a life-threatening medical condition where a significant loss of blood or bodily fluids prevents the heart from pumping enough blood to adequately supply the body with oxygen, leading to organ dysfunction and potentially causing death if not treated promptly), thus leading to prolonged hospitalization and/or death. (Refer to A-0405)

9.d. For Patient 9, Lamotrigine (a medication to prevent seizures [a sudden burst of abnormal electrical activity in the brain that can cause temporary changes in a person's behavior, movements, feelings, and level of consciousness- used to describe a person's awareness and understanding of what is happening in his or her surroundings]) was given as ordered by the physician.

This deficient practice had the potential to result in persistent seizure episodes, which may lead to permanent injury or death for Patient 9. (Refer to A-0405)

10. The facility failed to ensure one of 30 sampled patient's (Patient 13) vital signs (VS, set of blood pressure, temperature, heart rate, breathing rate, and oxygen measurements), were frequently checked and monitored during blood transfusions (critical procedure that moves blood or blood products into a person who has low blood levels, and can carry risks such as an allergic reaction, heart and lung problems, and death), in accordance with the facility's policy and procedure regarding blood administration.

This deficient practice had the potential to cause a delay in determining Patient 13's change of condition such as the presence of an allergic reaction, irregular heart rhythm, etc. and/or a delay in the provision of emergent treatment needed which could worsen Patient 13's condition and may result in death. (Refer to A-0410)

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 for one out of 30 sampled patients (Patient 8), nursing care was provided when:

1. Patient 8's admission orders were not carried out timely while waiting in the Emergency Department (ED, provides immediate care to patients with acute [sudden and severe in onset] illnesses or injuries) to be admitted in the Medical-Surgical/Telemetry unit (MST, a specialized unit for the patients that needed continuous heart monitoring), in accordance with the facility's policy on Provision of Patient Care Services.

2. Patient 8 did not have a complete physical assessment (head to toe evaluation) by a Registered Nurse (RN) while in the ED, in accordance with the facility's policy regarding Provision of Patient Care Services and Emergency Department Triage.

3. Patient 8's high Blood Pressure (BP, amount of force the blood needs to move through the vessels) readings in the ED were not addressed, in accordance with the facility's policy regarding Provision of Patient Care Services.

These deficient practices resulted in delayed treatment and had the potential to cause a delay in determining Patient 8's change of condition and/or provision of care needed, which could worsen the patients' condition and may result in death.

Findings:

During a review of Patient 8's "ED (Emergency Department) Depart Summary," dated 7/17/2024, the record indicated Patient 8 presented to the ED on 7/16/2024 for abdominal pain, nausea (the urge to throw up), vomiting and headache for two weeks. The record further indicated Patient 8 had a medical history of pneumonia (lung infection) and hypertension (HTN, high BP [blood pressure]). The record indicated Patient 8 was triaged (first evaluation of the patient to determine the level and urgency of care needed) on 7/16/2024 at 1:12 p.m.

During a review of Patient 8's "Admission Status" order, dated 7/16/2024 at 4:21 p.m., the order indicated Patient 8 was admitted as an "Inpatient (patient will be admitted to the facility for further care)," to the Medical-Surgical/Telemetry unit (MST, a specialized unit for the patients that needed continuous heart monitoring) unit.

1. During a review of Patient 8's order for "Telemetry Monitoring (device used for continuous remote measurements of the heart's activity)," dated 7/16/2024 at 4:22 p.m., the order indicated for Patient 8 to be placed on a telemetry monitoring.
During a concurrent interview and record review on 11/14/2024 at 9:58 a.m. with the Emergency Department Supervisor (EDS), the EDS stated when Patient 8 had an order to be admitted in the MST unit, ED did not have an open bed and Patient 8 was placed in the ED waiting room while waiting for a bed in the MST unit.

In the same interview and record review on 11/14/2024 at 9:58 a.m., the EDS stated Patient 8's telemetry monitoring was not initiated as ordered because Patient 8 was placed in the ED waiting room until a bed was available for the patient's (Patient 8) admission to the MST unit. The EDS also stated that when a patient in the ED needed a bed, the House Supervisor (HS) should be notified by the nursing staff so that the HS would arrange a bed for the patient. There was no documented evidence the HS arranged a bed for Patient 8 when the patient (Patient 8) had an order to be admitted to the MST unit and needed to be on telemetry monitoring.

During a review of the facility's policy and procedure (P&P) titled, "Admission of Patient Nursing," dated 5/24/2022, the P&P indicated, "Inpatient and Observation Patients: Initiate continuous cardiac (heart) monitoring for patients with orders for telemetry or ICU (Intensive Care Unit [provides critical care and life support for patients with life-threatening injuries or illnesses]) admissions."

During a review of the facility's policy and procedure (P&P) titled, "Hospital Plan for the Provision of Patient Care Services," dated 7/18/2024, the P&P indicated, "Goals for patient care are...provide timely and appropriate services including assessments, procedures, interventions, and reassessments to the individualized needs of the patients."

2. During a concurrent interview and record review on 11/14/2024 at 9:58 a.m. with the Emergency Department Supervisor (EDS), the EDS verified Patient 8's "System Assessments," dated 7/16/2024 through 7/17/2024 did not have Patient 8's complete physical assessment by an RN (Registered Nurse).

In the same interview and record review on 11/14/2024 at 9:58 a.m., the EDS stated a complete physical assessment (head to toe evaluation) should be done every two hours to monitor for changes while the patient was in the ED (Emergency Department). The EDS verified Patient 8 did not have a complete physical assessment done by the nurse, from the time Patient 8 was triaged (a system used to prioritize patients based on the severity of their condition and the need for immediate care) in the ED (7/16/2024 at 12:36 p.m.) to when Patient 8 was discharged (released) from the ED (7/17/2024 at 4:16 a.m.). Patient 8 did not have a complete physical assessment for 15 hours while in the ED.

During a review of the facility's policy and procedure (P&P) titled, "Hospital Plan for the Provision of Patient Care Services," dated 7/18/2024, the P&P indicated, "Goals for patient care are...provide timely and appropriate services including assessments, procedures, interventions, and reassessments to the individualized needs of the patients."

During a review of the facility's policy and procedure (P&P) titled, "Emergency Department Triage," dated 11/14/2024, the P&P indicated "Reassessment of patients in the waiting room should occur approximately every two (2) hours or sooner if indicated by changes in the patient condition. Any change in patient status while waiting shall be documented in the medical record."

During a review of the facility's policy and procedure (P&P) titled, "Assessment and Reassessment Nursing Services," dated 8/28/2024, the P&P indicated, "On admission, patients will receive a comprehensive physical and psychosocial assessment by a Registered Nurse (RN) ...Reassessment: The minimum timeframes for nursing reassessment are as follows: ED, every 2 hours or as needed."

During a review of the facility's policy and procedure (P&P) titled, "Admission of Patient, Nursing," dated 5/24/2022, the P&P indicated, "Inpatient and Observation Patients ...Physical assessment (initial upon admission) ...Perform a physical assessment with a focus on the areas of complaints ...Perform a complete skin/body check and document findings."

3. During a concurrent interview and record review on 11/14/2024 at 9:58 a.m. with the Emergency Department Supervisor (EDS), the EDS verified Patient 8's "Vital Signs (BP, heart rate, temperature, and oxygen levels)," dated 7/16/2024 through 7/17/2024, indicated Patient 8's BP readings were:

- On 7/16/2024 at 1:12 p.m., Patient 8's BP was 174/78 millimeters of mercury (mmHg, a unit of measurement; Normal BP range is 120/90); At 4:31 p.m., Patient 8's BP was 179/87 mm/Hg; At 8:08 p.m., Patient 8's BP was 178/78 mm/Hg; At 11:40 p.m., Patient 8's BP was 184/77 mm/Hg.

- On 7/17/2024 at 1:00 a.m., Patient 8's BP was 168/78 mm/Hg.

The EDS stated Patient 8's BP was high and not in an acceptable range. The EDS verified Patient 8's record had no documentation notifying the physician of Patient 8's high BP.

In the same interview and record review on 11/14/2024 at 9:58 a.m., the EDS stated Patient 8 had two BP medication (Amlodipine and Hydralazine, both used to lower and control BP) orders that were not given to Patient 8. The EDS verified Patient 8's record had no documentation as to why the patient's (Patient 8) BP medication were not given as ordered.

During a review of the facility's "Policy and Procedure (P&P)," titled, "Hospital Plan for the Provision of Patient Care Services," dated 7/18/2024, the P&P indicated, "Goals for patient care are...provide timely and appropriate services including assessments, procedures, interventions, and reassessments to the individualized needs of the patients."

During a review of the facility's "Policy and Procedure (P&P)" titled, "Assessment and Reassessment Nursing Services," dated 8/28/2024, the P&P indicated, "The scope and intensity of the assessment will be determined by: The level of care needed; The patient's desire for care and interventions; The patient's response to treatments, care, and interventions...Documentation: Every effort should be made to document assessments and interventions in a timely manner.

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

1. Initiate and develop an individualized care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for one of 30 sampled patients (Patient 4), to address Patient 4's diaper rash, in accordance with the facility's policy and procedure regarding care planning.

This deficient practice had the potential to result in the delay of care and evaluation of Patient 4's response to treatment and intervention, by not identifying Patient 4's needs and risks, which may result in worsening of Patient 4's condition and may prolong hospitalization.

2. Develop and implement an individualized nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) related to dialysis (procedure that cleans the blood by removing extra fluids and waste), for one of 30 sampled patients (Patient 14), in accordance with the facility's policy and procedure regarding care planning.

This deficient practice had the potential to result in delayed provision of treatment by not identifying Patient 14's needs and risks, which may result in complications for Patient 14 such as difficulty in breathing due to excessive fluids in the body, irregular heartbeat, confusion, and/or death.

3. Develop and implement an individualized nursing care plan to address issues with bleeding for one of 30 sampled patients (Patient 16), in accordance with the facility's policy and procedure regarding care planning.

This deficient practice had the potential to result in delayed treatment by not identifying Patient 16's needs and risks, which may result in excessive blood loss, hypotension (low blood pressure), and/or death.

4. Implement the care plan developed regarding seizure (a sudden burst of abnormal electrical activity in the brain that can cause temporary changes in a person's behavior, movements, and level of consciousness [a person's awareness and understanding of what is happening in his or her surroundings]) precautions for one of 30 sampled patients (Patient 25), in accordance with the facility's policy regarding care planning, when seizure pads were not documented being placed on Patient 25's bed's siderails.

This deficient had the potential for Patient 25 to sustain an injury in case of a seizure episode, which may include fracture (break in the bone), contusion (bruise), etc., and may result in prolonged hospitalization and recovery.

Findings:

1. During a review of Patient 4's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 11/6/2024, the H&P indicated, Patient 4 was an 11-day-old infant (baby) admitted to the facility with diagnosis of diaper dermatitis (diaper rash). The H&P also indicated Patient 4 had extensive erythema (reddening of the skin) on convex (curved or rounded) skin surfaces of his (Patient 4's) buttocks and groin, and clusters of papules (inflammatory form of acne)/pustules (blister-like sores) on the right and left inner thigh.

During a concurrent interview and record review on 11/13/2024 at 4:12 p.m. with the Nurse Manager (NM2) of Pediatrics (Peds, hospital unit with patients from very young infant to teenagers who require hospital admission for a variety of medical illnesses) and Neonatal Intensive Care Unit (NICU, hospital unit that provides specialized care for sick or premature newborn babies), Patient 4's "Care plans (care plan, provides a framework for evaluating and providing patient care needs related to the nursing process)," dated 11/6/2024, was reviewed. The care plan indicated a care plan related to problems of infection, fall (unplanned descent to the floor with or without injury to the patient) risk and knowledge deficit (lack of) related to discharge, were developed on 11/6/2024. NM2 stated there was no care plan developed to address Patient 4's problem with diaper rash or skin issue that Patient 4 came in with. NM 2 stated the care plan should be customized to Patient 4's active problem to provide nursing intervention focusing on the skin issue and to evaluate the wound or rashes healing. NM2 stated lack of care plan development to address the active problem could cause delay of care due to lack of wound healing monitoring and may prolong hospital stay.

During a review of the facility's policy and procedure (P&P) titled, "Patient Plan of Care," dated 5/2022, the P&P indicated, "All in-patient will have a plan of care developed that includes assessment based on comprehensive patient needs, treatment and goals ... The care plan must be initiated within the first eight (8) hours after admission by the Registered Nurse ... It is the responsibility of the RN to develop the plan of care ... the problems will be based on the nursing admission assessment and additional data contributed by other members of the health care team and the patient."

2. During a review of Patient 14's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 11/8/2024, the H&P indicated Patient 14 was admitted to the facility for a right foot wound and gangrene (dead tissue due to the lack of blood supply). The H&P further indicated Patient 14 had a medical history of End Stage Renal Disease (ESRD, irreversible kidney failure) on hemodialysis (HD, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed).

During a review of Patient 14's "Care Plans: Medical," the record indicated Patient 14 received HD on 11/9/2024 and 11/12/2024.

During a concurrent interview and record review on 11/13/2024 at 10:30 a.m. with Nurse Manager 4 (NM 4) and the Program Specialist (PS), NM 4 and the PS both verified that Patient 14's "Care Plans" did not include a plan for Patient 14's management and needs for HD. NM 4 stated there should have been a care plan related to Patient 14's HD. NM 4 stated Patient 14's care plan was for everyone to know what the plan was for Patient 14's management of HD.

During a review of the facility's "Policy and Procedure (P&P)" titled, "Patient Plan of Care," dated 5/24/2022, the P&P indicated, "The care plan must be initiated within the first 8 hours after admission by the Registered Nurse ...It is the responsibility of the RN to develop the plan of care ...Nursing Services: Plan of care are reviewed every shift, revised as needed, and when there is a change in the patient's condition, level of care, outcomes, problems or needs."

3. During a review of Patient 16's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 11/5/2024, the H&P indicated Patient 16 was admitted to the facility for weakness and dizziness for six days, and lower leg swelling and rectal bleeding (bleeding from the lower colon or rectum) for two months. The H&P further indicated Patient 16 had a medical history of anemia (condition where the body does not have enough healthy red blood cells), alcohol abuse (when a person continuous to consume alcohol despite the adverse consequences. Example: liver disease, mental and behavioral problems), and anxiety (a feeling of fear or uneasiness).

During a review of Patient 16's "Order Information for Transfusion (procedure that moves whole or partial blood parts into the body)," dated 11/5/2024 and 11/11/2024, the orders indicated the following:

- On 11/5/2024, Patient 16 had an order to receive six units (bags) of red blood cell (important part of the blood that carries oxygen throughout the body) transfusions and one unit of plasma (liquid part of the blood). Patient 16 received the blood transfusions.

-On 11/11/2024, Patient 16 had an order to receive one unit of platelets (part of the blood that forms a clot to stop bleeding). Patient 16 received the blood transfusion.

During a concurrent interview and record review on 11/13/2024 at 11:06 a.m. with Nurse Manager 4 (NM 4) and the Program Specialist (PS), NM 4 and the PS both verified Patient 16's "Care Plans," did not have a plan related to bleeding or blood transfusions. The PS stated a "Risk for Bleeding/Hemorrhage" care plan should have been added. NM 4 stated it was important to know what the plan and interventions were to manage Patient 16's bleeding.

During a review of the facility's "Policy and Procedure (P&P)" titled, "Patient Plan of Care," dated 5/24/2022, the P&P indicated, "The care plan must be initiated within the first 8 hours after admission by the Registered Nurse ...It is the responsibility of the RN to develop the plan of care ...Nursing Services: Plan of care are reviewed every shift, revised as needed, and when there is a change in the patient's condition, level of care, outcomes, problems or needs."

4. During review of Patient 25's "Face Sheet (a document that summarizes a patient's key personal and medical information, including their name, address, date of birth, insurance details, allergies, medical history, and current medications )," dated November 2024, the Face Sheet indicated the following: Patient 22 was admitted to the hospital on 11/10/2024 for seizure (a sudden burst of abnormal electrical activity in the brain that can cause temporary changes in a person's behavior, movements, and level of consciousness [a person's awareness and understanding of what is happening in his or her surroundings]) and was discharged from the hospital on 11/12/2024.

During review of Patient 25's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated November 2024, the "H&P," indicated the following: Patient 25 was brought to the hospital for witnessed seizure at the gym.

During a concurrent interview and record review on 11/13/2024 at 3:10 p.m. with the Associate Patient Care Executive (APCE), Patient 25's "ADL (Activities of Daily Living, basic self-care tasks that people perform regularly such as toileting, hygiene, feeding, etc.) Flow Sheet," dated November 2024, was reviewed. The ADL Flowsheet indicated the following: On 11/10/2024 at 3 p.m. to 11/11/2024 at 10 p.m., there was no documentation that seizure pads were used for Patient 25's safety. APCE confirmed that there was no documentation seizure padded equipment was used for Patient 25. APCE also said the staff need to document the use of seizure pads in the medical chart for patients with seizure to indicate implementation of the seizure precaution (which includes the application of seizure pads on side rails) for patient. APCE stated it was important to utilize the seizure pads to protect the patient from injuring self during a seizure episode. APCE also said the staff should document the use of the seizure pads as part of the seizure precaution care plan implementation.

During a review of Patient 25's "Care Plan," dated November 2024, the Care Plan indicated the following: Patient 25 had a care plan selected for Seizure that indicated to initiate seizure precautions which included padded side rails/suction device (a medical device used to remove fluids such as vomit, mucus, blood, etc.) and Oxygen at bedside.

During a review of the facility's policy and procedure (P&P) titled, "Patient Plan of Care," dated 5/2022, the "P&P" indicated the following: Patient Plan of Care: The patient's plan of care and goals are developed with the patient/family and reflect individualized care and treatment provided by the multidisciplinary team. A. The patient record, in its entirety, reflects the plan of care for the patient. All in-patients will have a plan of care developed that includes assessment based on comprehensive patient needs, treatments and goals. Qualified members of the Health Care team will be responsible for documenting the plan of care whenever a need is identified. Revisions, updates or resolutions will also be documented whenever there is a significant change in the patient's diagnosis or condition. 1.Nursing Services: Plan of care are reviewed every shift, revised as needed, and when there is a change in the patient's condition, level of care, outcomes, problems or needs.

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

1. Ensure staffed followed the facility's "Central Venous Catheter Management Policy," for one of 30 sampled patients (Patient 24), when Patient 24 had a PICC line (Peripheral Inserted Central Catheter, is an intravenously [into the vein] placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava [a large vein that carries blood from the head, neck, arms, and chest], and used for intravenous treatment that is required over a long period) placement done and staff did not obtain an order that it was okay to use the PICC line prior to using the PICC line for medication administration.

This deficient practice had the potential for misplaced PICC line to lead to serious complications like infection, bleeding, pneumothorax (when air leaks from the lung into the space between the lung and the chest wall), or arrythmias (abnormal heart rhythm).

2. Ensure one of 30 sampled patient's (Patient 12) Code Status (type of lifesaving emergency treatment someone wants, which can or cannot include chest compressions, a breathing tube, and medications) was verified and physician was notified regarding the absence of documented order for Patient 12's code status, and ensure documentation of code status order in Patient 12's medical record, within 24 hours after admission, in accordance with the facility's policy and procedure regarding Code status.

This deficient practice had the potential for Patient 12 to receive inappropriate emergency life sustaining measures, and/or delay the care for Patient 12, which could lead to serious harm and/or death.

3. Ensure one of 30 sampled patients (Patients 17) operating room nursing staff adhered to the facility's policy and procedure regarding chain of command (a formal process that hospital staff use to escalate concerns about patient safety or other issues to the appropriate levels of authority), when it was identified that the surgeon continued and completed surgical skin closure (the final step in a surgical procedure that involves repairing the skin and deeper layers of tissue to promote healing) after being told that the surgical count (a crucial procedure that ensures no surgical items are left behind in a patient after surgery) was incorrect.

This deficient practice resulted in Patient 17 having to undergo another surgical procedure to retrieve a surgical sponge that was left unintentionally inside Patient 17's abdominal cavity. This deficient practice also had the potential to cause complications such as infection, uncontrolled bleeding, and psychological distress for Patient 17.

Findings:

1. During a review of Patient 24's "Face Sheet (a document that summarizes a patient's key personal and medical information, including their name, address, date of birth, insurance details, allergies, medical history, and current medications)," dated November 2024, the Face Sheet indicated Patient 24 was admitted to the facility unit on 11/11/2024.

During a review of Patient 24's "ED (Emergency Department, provides immediate care for patients with acute [sudden and severe in onset] illnesses or injuries) Physician Notes ," dated November 2024, the ED Physician Notes indicated the following: Patient 24 was brought in by ambulance for generalized weakness with abdominal pain, vomiting, and hypotension (low blood pressure). Patient 24 had a history of gastric cancer (cancer of the stomach) and had a PICC (Peripheral Inserted Central Catheter, is an intravenously [into the vein] placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is positioned in a location at the superior vena cava [a large vein that carries blood from the head, neck, arms, and chest], and used for intravenous treatment that is required over a long period) line. Medical plan was to admit Patient 24 to the Intensive Care Unit (ICU, provides critical care and life support for patients who are very sick or injured).

During a review of Patient 24's "Chest X Ray (an imaging test to create pictures of the organs and structures in the chest) Report ," dated November 2024, the Chest X-ray report indicated the following: Patient 24 with PICC line terminating in the right atrium (the upper chamber on the right side of the heart that receives oxygen-poor blood from the body and then pumps it into the right ventricle to be sent to the lungs for oxygenation).

During a concurrent interview and record review on 11/12/2024 at 1:55 p.m. with the Associate Patient Care Executive (APCE), Patient 24's "Medication Administration Record (MAR)," dated November 2024, was reviewed. The "MAR" indicated the following: On 11/11/2024 at 12:41 p.m., gastrointestinal (refers to the stomach and the intestines) bleed medication "Octreotide" was administered to Patient 24 at 1:58 p.m., pain medication "Hydromorphone" and nausea medication "Zofran," was administered to Patient 24. APCE confirmed the 3 medications (Octreotide, Hydromorphone, & Zofran) were administered by staff using the PICC line without obtaining an "okay to use" order from the physician. APCE said the staff should not administer the 3 medications to Patient 24, using the PICC line, without an okay to use PICC line order from the doctor. APCE confirmed the X ray report for Patient 24 did not say okay to use PICC line and during the times 3 medications were administered, there was no okay to use PICC line order or documentation. APCE stated it was dangerous to give medication using the PICC line without knowing or confirming the location because it can cause harm to the patient if not in the correct location for use. APCE said staff did not follow the policy regarding PICC line use and will provide education to the staff.

During a review of the facility's policy and procedure (P&P) titled, "Central Venous Catheter Management," dated December 2024, the "P&P" indicated following: POLICY SUMMARY/INTENT: To provide evidence-based and standardized practices for central venous catheter insertion. management and maintenance aimed at the prevention of central line-associated bloodstream Infections (CLABSI). This policy does not intend to replace critical decision-making by the provider inserting the central venous catheter; consideration should be given to the entire clinical circumstance and the goals to prevent potential harm or infection. 8. Peripherally Inserted Central Catheter (PICC): A type of long catheter that is inserted through a peripheral vein, often In the arm, into a larger vein in the body, used when intravenous treatment is required over a long period. Because of tip location, PICC lines are considered central vascular access devices. E. Verification of line placement: 1. All central lines should have an 'insertion' or 'may use' order (e.g., "May use central line'), which documents necessity. 2. If a patient arrives to the hospital with a central line in place - A. Notify provider of line presence. B. Obtain an order from provider to confirm placement for central venous catheter above the diaphragm via chest x-ray. C. Obtain an order from provider to access line (e.g., "May use central line'), which documents necessity.


2. During a review of Patient 12's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 11/12/2024, the H&P indicated Patient 12 was admitted on 11/11/2024, to the facility, for nausea (urge to throw up), vomiting, and diarrhea (loose stool). The H&P further indicated Patient 12 had a medical history of diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (HTN, high blood pressure [BP, amount of force the blood needs to move through the vessels]).

During a concurrent interview and record review on 11/13/2024 at 2:00 p.m. with the Nursing Director 2 (ND 2) and the Nurse Manager 3 (NM 3), ND 2 and NM 3 both verified that Patient 12's record did not have the patient's (Patient 12) code status (type of lifesaving emergency treatment someone wants, which can or cannot include chest compressions, a breathing tube, and medications) and was documented as, "Code Status: Not Ordered (Patient 12 had been admitted to the facility for more than 24 hours).

In the same interview on 11/13/2024 at 2:00 p.m., ND 2 stated the nurses were responsible for notifying the physician that Patient 12 did not have a Code Status order. ND 2 stated the patient's code status was important to know the patient's wishes for medical treatment.

During a review of the facility's policy and procedure (P&P) titled, "Code Status and Philosophy of Care Regarding Life-Sustaining Measures," dated 6/21/2023, the P&P indicated, "A patient's code status is to be confirmed by a physician within the first 24 hours of his/her care ...The patient's code status and philosophy of care is documented in writing by the physician in the Medical Record."

3. During a concurrent interview and record review on 11/12/2024 at 1:30 p.m. with the Associate Patient Care Executive (APCE), Patient 17's medical record (MR), was reviewed. Patient 17's medical record indicated that on 7/9/2024, Patient 17 was brought in by paramedics (highly trained health care professionals who respond to emergencies to provide advanced life support and transport patients to medical facilities) for abdominal pain. Patient 17 was diagnosed with perforated gastric ulcer (also known as a ruptured ulcer, is a serious condition that occurs when an untreated stomach ulcer eats through the stomach lining and creates a hole) and underwent exploratory laparotomy (a surgical procedure that allows a doctor to examine the abdominal organs by making a cut in the abdomen) that same day (7/9/2024).

During the same interview on 11/12/2024 at 1:30 p.m. with the Associate Patient Care Executive (APCE), APCE stated that back in July 2024, the facility reported a retention of foreign object (RFO, a medical procedure unintentionally left a surgical tool or material, like a sponge or a piece of equipment, inside a patient's body after surgery, essentially leaving a foreign object behind) incident involving a patient (Patient 17). Patient 17 had exploratory laparotomy surgery on 7/9/2024. It was noted that one (1) lap sponge (also known as a laparotomy sponge or abdominal pad, is a sterile, absorbent pad used to control bleeding and keep surgical areas clear of fluids during surgical procedures) was missing, but medical doctor 5 (MD 5) continued and completed surgical skin closure (the final step in a surgical procedure that joins the edges of a wound to help it heal). An x-ray (a plain radiographs that provide doctors a way to get pictures of the inside of a patient body) was ordered, and it was found that one (1) lap sponge was left in Patient 17's abdomen. MD5 had to reopen Patient 17's surgical site and retrieve the surgical sponge. APCE said the incident was reportable and against hospital policy because the surgical count was not verified as complete, prior to the surgical skin closure. APCE stated that the operating room (OR) nursing staff was reluctant to tell MD 5 to stop surgical skin closure despite knowing and informing the surgical team that the count was not correct, and that one lap sponge was missing.

During a concurrent interview and record review on 11/12/2024 at 4:00 p.m. with the Registered Nurse 4 (RN 4), Patient 17's medical record titled, "Surgery and Procedure Reports," dated 7/9/2024 7:57 p.m., was reviewed. The report indicated "final lap sponge count's incorrect, surgeon notified. Portable x-ray ordered, lap sponge found in abdominal cavity, lap sponge removed from abdominal cavity by surgeon and final sponge count correct." RN 4 stated that MD5 started initiating skin closure at the start of the surgical count. MD5 was notified that the count was incorrect, there was a missing lap sponge. RN 4 said MD5 continued and completed surgical skin closure. RN 4 also stated MD5 should have waited until surgical count was verified as correct prior to completing the surgical skin closure. RN 4 further said that an X-ray was ordered, and it confirmed a lap sponge was left inside Patient 17's abdomen. MD5 had to reopen the surgical site and retrieved the lap sponge. RN 4 added that, MD5 continued to close even with an incorrect count because MD5 did not believe the lap sponge was left inside Patient 17's abdomen. Patient 17 was an emergency add-on case.

During a concurrent interview and record review on 11/13/2024 at 11:53 a.m. with the Nurse Manager 6 (NM6), Patient 17's medical record titled, "Surgery and Procedure Reports," dated 7/9/2024 7:57 p.m., was reviewed. The report indicated "final lap sponge counts incorrect, surgeon notified. Portable x-ray ordered, lap sponge found in abdominal cavity, lap sponge removed from abdominal cavity by surgeon and final sponge count correct." NM6 stated that she (NM6) was made aware of RFO (Retention of Foreign Object) incident involving Patient 17 on the next day post procedure on 7/10/2024. NM6 said, the facility identified the issue of not following the "chain of command," RN 4 was the assigned circulating nurse at the time of the surgery and should have reported to house supervisor that the surgeon did not stop and completed surgical skin closure even after being informed that surgical count was incorrect, and a lap sponge was missing.

During a review of the facility's policy and procedure (P&P) titled, "Chain of Command," last revised 12/22/21, the P&P indicated the following:

Clinical Issues
a. The chain of command for clinical issues must be accessed in a timely manner to prevent delay of treatment. If the situation cannot be resolved at the lowest possible level, the next level should be accessed.
b. Any licensed caregiver who has reason to doubt the appropriateness of the medical care being provided to a patient should discuss the situation starting with the first individual listed below:
Step 1: Discuss with individual directly involved (Resident / Physician Assistant or Nurse Practitioner, if involved).
Step 2: If Step 1 was with someone other than Attending and it is unresolved, discuss with Attending.
Step 3: If the problem cannot be resolved by Steps 1 or 2, the staff member should notify the Shift Leader (i.e., Shift Coordinator, Charge Nurse, etc.). The Shift Leader will then assume responsibility.
Step 4: Discuss with Residency Program Director (only when Resident is involved). In the event that the Residency Program Director is notified, the Shift Leader should also notify his/her Manager or Department Director (or House Supervisor).
Step 5: Discuss with Medical Director. If there is not Medical Director, go to Step 6. In the event that the Medical Director is notified, the Shift Leader should also notify his/her Department Director (or House Supervisor).

Based on interview and record review, the facility failed to ensure for two of 30 sampled patients (Patients 8 and 9), the following:

1.a. For Patient 8, Amlodipine (medication used to lower blood pressure [BP, amount of force blood uses to move through the body]) was given as ordered by the physician.

This deficient practice had the potential for Patient 8's blood pressure to remain elevated, which may result in complications such as heart attack and stroke (formation of blood clots in the brain), leading to paralysis (loss of function in part or all of the body) and/or death.

1.b. For Patient 8, Hydralazine (medication used to lower BP) was given as ordered by the physician.

This deficient practice had the potential for Patient 8's blood pressure to remain elevated, which may result in complications such as heart attack and stroke (formation of blood clots in the brain), leading to paralysis (loss of function in part or all of the body) and/or death.

1.c. For Patient 8, Lactated Ringers (LR, intravenous fluid given through the vein to help balance electrolyte [minerals that carry an electric charge found in the body which are important for bodily functions such as heart rate and rhythm, blood pressure, etc.] levels) was given as ordered by the physician.

This deficient practice had the potential for Patient 8 to have a low blood volume or low blood pressure, which may result in complications such as hypovolemic shock (a life-threatening medical condition where a significant loss of blood or bodily fluids prevents the heart from pumping enough blood to adequately supply the body with oxygen, leading to organ dysfunction and potentially causing death if not treated promptly), thus leading to prolonged hospitalization and/or death.

2. For Patient 9, Lamotrigine (a medication to prevent seizures [a sudden burst of abnormal electrical activity in the brain that can cause temporary changes in a person's behavior, movements, feelings, and level of consciousness- used to describe a person's awareness and understanding of what is happening in his or her surroundings]) was given as ordered by the physician.

This deficient practice had the potential to result in persistent seizure episodes, which may lead to permanent injury or death for Patient 9.

Findings:

1. During a review of Patient 8's "ED (Emergency Department) Depart Summary," dated 7/17/2024, the record indicated Patient 8 presented to the ED on 7/16/2024 for abdominal pain, nausea (urge to throw up), vomiting and headache for two weeks. The record further indicated Patient 8 had a medical history of pneumonia (lung infection) and hypertension (HTN, higher BP ranges than the normal BP of less than 120/80).

During a concurrent interview and record review on 11/13/2024 at 9:58 a.m. with the Emergency Department Supervisor (EDS), the EDS verified that on 7/16/2024 at 4:21 p.m., Patient 8 was admitted to the facility as an "Inpatient (patient will be admitted to the facility for further care)," to the "Medical-Surgical/Telemetry unit (MST, a specialized unit for the patients that need continuous heart monitoring)." The EDS stated Patient 8 remained in the ED while waiting for an inpatient bed.

1.a. During a concurrent interview and record review on 11/14/2024 at 9:58 a.m. with the EDS, the EDS verified Patient 8's "Vital Signs (BP, heart rate, temperature, and oxygen levels)," dated 7/16/2024 through 7/17/2024, indicated Patient 8's BP readings were:

- On 7/16/2024 at 1:12 p.m., Patient 8's BP was 174/78 millimeters of Mercury (mmHg, a unit of measurement; Normal BP range is 120/80); at 4:31 p.m., Patient 8's BP was 179/87 mmHg; at 8:08 p.m., Patient 8's BP was 178/78 mmHg; at 11:40 p.m., Patient 8's BP was 184/77 mmHg.

- On 7/17/2024 at 1:00 a.m., Patient 8's BP was 168/78 mmHg.

In the same interview and record review on 11/14/2024 at 9:58 a.m., the EDS verified Patient 8's "Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a patient)," dated 7/16/2024, included a physician's order of Amlodipine (medication to lower blood pressure) 5 milligrams (mg, metric unit of measurement, used for medication dosage and/or amount) to be given orally once a day, with a start date of 7/16/2024 at 8:19 p.m.

Subsequently, the EDS verified Patient 8's MAR, dated 7/17/2024 at 2:51 a.m., indicated the Amlodipine was not given, and was documented as "Not done: start with next dose," (Amlodipine was ordered to be given on 7/16/2024 at 8:19 p.m.).

During the same interview on 11/14/2024 at 9:58 a.m. with the EDS, the EDS stated Patient 8's Amlodipine was not given as ordered by the physician. The EDS stated Patient 8's BP was high and not in an acceptable range. The EDS verified Patient 8's record had no documentation as to why the patient's BP medication was not given as ordered.

During a review of the facility's policy and procedures (P&P) titled, "Medication Administration - In-Patient (Nursing)," dated 07/16/2024, the P&P indicated, "For the nursing staff ...follow the 6 rights of medication administration: Right patient (with 2 patient identifiers);Right time; Right drug; Right dose; Right route; Right documentation ...If a medication is not given, the reason must be documented on the MAR (Medication Administration Record), and communicated to the prescriber."

During a review of the facility's policy and procedure (P&P) titled, "Hospital Plan for the Provision of Patient Care Services," dated 7/18/2024, the P&P indicated, "Goals for patient care are...provide timely and appropriate services including assessments, procedures, interventions, and reassessments to the individualized needs of the patients."


1.b. During a concurrent interview and record review on 11/14/2024 at 9:58 a.m. with the Emergency Department Supervisor (EDS), the EDS verified Patient 8's "Vital Signs (BP, heart rate, temperature, and oxygen levels)," dated 7/16/2024 through 7/17/2024, indicated Patient 8's BP readings were:

- On 7/16/2024 at 1:12 p.m., Patient 8's BP was 174/78 millimeters of Mercury (mmHg, a unit of measurement; Normal BP range is 120/80; At 4:31 p.m., Patient 8's BP was 179/87 mmHg; At 8:08 p.m., Patient 8's BP was 178/78 mmHg; At 11:40 p.m., Patient 8's BP was 184/77 mmHg.

- On 7/17/2024 at 1:00 a.m., Patient 8's BP was 168/78 mmHg.

In the same interview and record review on 11/14/2024 at 9:58 a.m., the EDS verified Patient 8's "Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a patient)," dated 7/16/2024, included a physician's order of Hydralazine (medication to lower blood pressure) 25 milligrams (mg, metric unit of measurement, used for medication dosage and/or amount) to be given by mouth three times a day, with a start date and time of 7/16/2024 at 9:00 p.m.

Subsequently, the EDS verified Patient 8's MAR, dated 7/17/2024 at 2:51 a.m., indicated the Hydralazine was not given, and was documented as "Order discontinued/duplicated."

During the same interview on 11/14/2024 at 9:58 a.m. with the EDS, the EDS stated Patient 8's Hydralazine order was not duplicated and should have been given as ordered. The EDS stated Patient 8's BP was high and not in an acceptable range. The EDS verified Patient 8's record had no documentation as to why the patient's BP medication was not given as ordered.

During a review of the facility's policy and procedures (P&P) titled, "Medication Administration - In-Patient (Nursing)," dated 07/16/2024, the P&P indicated, "For the nursing staff ...follow the 6 rights of medication administration: Right patient (with 2 patient identifiers);Right time; Right drug; Right dose; Right route; Right documentation ...If a medication is not given, the reason must be documented on the MAR (Medication Administration Record), and communicated to the prescriber."

During a review of the facility's policy and procedure (P&P) titled, "Hospital Plan for the Provision of Patient Care Services," dated 7/18/2024, the P&P indicated, "Goals for patient care are...provide timely and appropriate services including assessments, procedures, interventions, and reassessments to the individualized needs of the patients."

1.c. During a concurrent interview and record review on 11/14/2024 at 9:58 a.m. with the Emergency Department Supervisor (EDS), the EDS verified Patient 8's "Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a patient)," dated 7/16/2024, included a physician's order of LR (Lactated Ringer's, intravenous fluid given through the vein to help balance electrolyte [minerals that carry an electric charge found in the body which are important for bodily functions such as heart rate and rhythm, blood pressure, etc.] levels) intravenous (IV, through the veins) fluids to be given continuously at 80 milliliters per hour (mL/hr, a unit of measurement), with a start date of 7/16/2024 at 7:27 p.m. The EDS verified Patient 8's LR IV fluids was initiated on 7/17/2024 at 5:15 a.m. (a total of 9 hours and 48 minutes after LR was ordered to be given).

In the same interview and record review, on 11/14/2024 at 9:58 a.m., the EDS stated, when Patient 8 had an order to be admitted in the MST (Medical-Surgical Telemetry) unit, ED did not have an open bed and Patient 8 was placed in the ED waiting room while waiting for a bed in the MST unit.

In the same interview on 11/14/2024 at 9:58 a.m., the EDS stated patients in the ED waiting room were not allowed to have IV fluids and/or medications. The EDS verified Patient 8 did not receive the LR IV fluid until Patient 8 was transferred to the MST unit on 7/17/2024 at 4:16 a.m.

During a review of the facility's policy and procedures (P&P) titled, "Medication Administration - In-Patient (Nursing)," dated 07/16/2024, the P&P indicated, "For the nursing staff ...follow the 6 rights of medication administration: Right patient (with 2 patient identifiers);Right time; Right drug; Right dose; Right route; Right documentation ...If a medication is not given, the reason must be documented on the MAR (Medication Administration Record), and communicated to the prescriber."

During a review of the facility's policy and procedure (P&P) titled, "Hospital Plan for the Provision of Patient Care Services," dated 7/18/2024, the P&P indicated, "Goals for patient care are...provide timely and appropriate services including assessments, procedures, interventions, and reassessments to the individualized needs of the patients."

2. During a review of Patient 9's "Emergency Department (ED) Physician Notes," dated 11/12/2024, the record indicated, Patient 9 was seen in the ED for a possible unwitnessed seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), noted by abnormal behavior during dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). The note further indicated that Patient 9 had a medical history of End Stage Renal Disease (ESRD, irreversible kidney failure) and seizures.

During a review of Patient 9's "ED Physician Notes," dated 11/12/2024, the record indicated, on 11/12/2024 at 7:03 a.m., Patient 9 had an order to be admitted to the Medical-Surgical/Telemetry unit (MST, a specialized unit for the patients that need continuous heart monitoring).

During an interview on 11/14/2024 at 9:58 a.m., with the Emergency Department Supervisor (EDS), the EDS stated, if a patient was in ED waiting for an inpatient bed, the ED nurses were responsible for carrying out the inpatient orders.

During a concurrent interview and record review on 11/14/2024 at 10:35 a.m. with the EDS, the EDS verified Patient 9's "Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a patient)," dated 11/12/2024, included a physician's order of Lamotrigine (a medication to prevent seizures) 150 milligrams (mg, metric unit of measurement, used for medication dosage and/or amount) to be given by mouth twice a day, with a start date and time of 11/12/2024 at 10:41 a.m.

In the same interview and record review on 11/14/2024 at 10:35 a.m., the EDS verified Patient 9's MAR dated 11/12/2024 at 4:21 p.m., indicated Lamotrigine was not given, and "Patient [was] not available/off unit," (a total of six hours after Lamotrigine was ordered to be given).

During the same interview on 11/14/2024 at 10:35 a.m., the EDS stated Patient 9 should have received Lamotrigine. The EDS stated the Registered Nurse (RN) responsible for Patient 9's care should have notified the physician of the late or missed dose, and/or should have the medication rescheduled. The EDS verified Patient 9's record did not have documentation the physician was notified of the late or missed dose of Lamotrigine.

During a review of the facility's "Policy and Procedure (P&P)" titled, "Medication Administration - In-Patient (Nursing)," dated 07/16/2024, the P&P indicated, "For the nursing staff ...follow the 6 rights of medication administration: Right patient (with 2 patient identifiers);Right time; Right drug; Right dose; Right route; Right documentation ...If a medication is not given, the reason must be documented on the MAR (Medication Administration Record), and communicated to the prescriber."

Based on interview and record review, the facility failed to ensure one of 30 sampled patient's (Patient 13) vital signs (VS, set of blood pressure, temperature, heart rate, breathing rate, and oxygen measurements), were frequently checked and monitored during blood transfusions (critical procedure that moves blood or blood products into a person who has low blood levels, and can carry risks such as an allergic reaction, heart and lung problems, and death), in accordance with the facility's policy and procedure regarding blood administration.

This deficient practice had the potential to cause a delay in determining Patient 13's change of condition such as the presence of an allergic reaction, irregular heart rhythm, etc. and/or a delay in the provision of emergent treatment needed which could worsen Patient 13's condition and may result in death.

Findings:

During a review of Patient 13's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 11/11/2024, the H&P indicated Patient 13 was admitted to the facility on 11/10/2024 for a rectal bleed (lower colon or rectum bleeding). The H&P further indicated Patient 13 had a medical history of Gastrointestinal (GI, digestive system) bleed.

During a review of the physician's order, dated 11/12/2024, the order indicated for Patient 13 to have 2 units (bags) of Packed Red Blood Cells (PRBC, part of the blood that carries oxygen from the lungs to the body tissue) transfused for a Hemoglobin (Hgb, part of the red blood cell that carries oxygen) level of less than 7.

1.a. During a concurrent interview and record review on 11/14/2024 at 3:53 p.m. with the Nurse Manager 3 (NM 3), NM 3 verified Patient 13's "Blood Product Administration," dated 11/12/2024, Patient 13 received one unit of PRBC (first bag) from 11:03 a.m. through 3:01 p.m.

In the same interview and record review on 11/14/2024 at 3:53 p.m., NM 3 verified Patient 13's vital signs (VS) for Patient 13's first blood transfusion was taken on 11/12/2024 at the following times:

- at 11:03 a.m. (the beginning of PRBC transfusion);

- at 11:30 a.m. (27 minutes after the start of PRBC transfusion);

- at 11:34 a.m. (31 minutes after the start of PRBC transfusion); and,

- at 3:02 p.m. (the end of PRBC transfusion).

NM 3 stated when a patient was being transfused, the patient's VS should be checked before the blood transfusion starts; at the time when the blood transfusion started; 15 minutes after the blood transfusion started; an hour after the blood transfusion started; and when the blood transfusion was completed.

During the same interview on 11/14/2024 at 3:53 p.m., NM 3 verified Patient 13's VS were not checked on 11/12/2024, before starting the blood transfusion, fifteen minutes after the blood transfusion started, and an hour after the blood transfusion started. NM 3 stated it was important to check and monitor the patient's VS for signs and symptoms of a blood transfusion reaction.

During a review of the facility's policy and procedure (P&P) titled, "Blood Administration," dated 10/20/2021, the P&P indicated, "The patient's vital signs (temperature, pulse, respiration, and blood pressure) are taken and recorded:
i. Within 30 minutes prior to starting the transfusion
ii. Fifteen (15) minutes after initiating the transfusion
iii. One (1) hour after initiating the transfusion, unless the patient's condition requires more frequent checks.
iv. When the transfusion ends ...
vi. Check the vital signs before each blood component is transfused."


1.b. During a concurrent interview and record review on 11/14/2024 at 3:53 p.m. with Nurse Manager (NM) 3, NM 3 verified Patient 13's "Blood Product Administration," dated 11/12/2024, Patient 13 received the second unit (second bag) of PRBC from 4:05 p.m. through 8:11 p.m.

In the same interview and record review on 11/14/2024 at 3:53 p.m., NM 3 verified Patient 13's vital signs (VS) for Patient 13's second blood transfusion was taken on 11/12/2024 at the following times:

-At 4:05 p.m. (the beginning of the blood transfusion);

-at 4:48 p.m. (43 minutes after the start of the blood transfusion);

-at 7:06 p.m., and 7:07 p.m., (3 hours after the start of the blood transfusion); and,

- at 8:20 p.m. (the end of the blood transfusion).

NM 3 stated when a patient was being transfused, the patient's VS should be checked before the blood transfusion starts; at the time when the blood transfusion started; 15 minutes after the blood transfusion started; an hour after the blood transfusion started; and when the blood transfusion was completed.

During the same interview on 11/14/2024 at 3:53 p.m., NM 3 verified Patient 13's VS were not checked on 11/12/2024 (for the second blood transfusion), before starting the blood transfusion, fifteen minutes after the blood transfusion started, and an hour after the blood transfusion started. NM 3 stated it is important to check and monitor the patient's VS for signs and symptoms of a blood transfusion reaction.

During a review of the facility's policy and procedure (P&P) titled, "Blood Administration," dated 10/20/2021, the P&P indicated, "The patient's vital signs (temperature, pulse, respiration, and blood pressure) are taken and recorded:
i. Within 30 minutes prior to starting the transfusion
ii. Fifteen (15) minutes after initiating the transfusion
iii. One (1) hour after initiating the transfusion, unless the patient's condition requires more frequent checks.
iv. When the transfusion ends ...
vi. Check the vital signs before each blood component is transfused."

Based on interview and record review, the facility failed to ensure one of 30 sampled patient's (Patient 13) vital signs (VS, set of blood pressure, temperature, heart rate, breathing rate, and oxygen measurements), were frequently checked and monitored during blood transfusions (critical procedure that moves blood or blood products into a person who has low blood levels, and can carry risks such as an allergic reaction, heart and lung problems, and death), in accordance with the facility's policy and procedure regarding blood administration.

This deficient practice had the potential to cause a delay in determining Patient 13's change of condition such as the presence of an allergic reaction, irregular heart rhythm, etc. and/or a delay in the provision of emergent treatment needed which could worsen Patient 13's condition and may result in death.

Findings:

During a review of Patient 13's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 11/11/2024, the H&P indicated Patient 13 was admitted to the facility on 11/10/2024 for a rectal bleed (lower colon or rectum bleeding). The H&P further indicated Patient 13 had a medical history of Gastrointestinal (GI, digestive system) bleed.

During a review of the physician's order, dated 11/12/2024, the order indicated for Patient 13 to have 2 units (bags) of Packed Red Blood Cells (PRBC, part of the blood that carries oxygen from the lungs to the body tissue) transfused for a Hemoglobin (Hgb, part of the red blood cell that carries oxygen) level of less than 7.

1.a. During a concurrent interview and record review on 11/14/2024 at 3:53 p.m. with the Nurse Manager 3 (NM 3), NM 3 verified Patient 13's "Blood Product Administration," dated 11/12/2024, Patient 13 received one unit of PRBC (first bag) from 11:03 a.m. through 3:01 p.m.

In the same interview and record review on 11/14/2024 at 3:53 p.m., NM 3 verified Patient 13's vital signs (VS) for Patient 13's first blood transfusion was taken on 11/12/2024 at the following times:

- at 11:03 a.m. (the beginning of PRBC transfusion);

- at 11:30 a.m. (27 minutes after the start of PRBC transfusion);

- at 11:34 a.m. (31 minutes after the start of PRBC transfusion); and,

- at 3:02 p.m. (the end of PRBC transfusion).

NM 3 stated when a patient was being transfused, the patient's VS should be checked before the blood transfusion starts; at the time when the blood transfusion started; 15 minutes after the blood transfusion started; an hour after the blood transfusion started; and when the blood transfusion was completed.

During the same interview on 11/14/2024 at 3:53 p.m., NM 3 verified Patient 13's VS were not checked on 11/12/2024, before starting the blood transfusion, fifteen minutes after the blood transfusion started, and an hour after the blood transfusion started. NM 3 stated it was important to check and monitor the patient's VS for signs and symptoms of a blood transfusion reaction.

During a review of the facility's policy and procedure (P&P) titled, "Blood Administration," dated 10/20/2021, the P&P indicated, "The patient's vital signs (temperature, pulse, respiration, and blood pressure) are taken and recorded:
i. Within 30 minutes prior to starting the transfusion
ii. Fifteen (15) minutes after initiating the transfusion
iii. One (1) hour after initiating the transfusion, unless the patient's condition requires more frequent checks.
iv. When the transfusion ends ...
vi. Check the vital signs before each blood component is transfused."


1.b. During a concurrent interview and record review on 11/14/2024 at 3:53 p.m. with Nurse Manager (NM) 3, NM 3 verified Patient 13's "Blood Product Administration," dated 11/12/2024, Patient 13 received the second unit (second bag) of PRBC from 4:05 p.m. through 8:11 p.m.

In the same interview and record review on 11/14/2024 at 3:53 p.m., NM 3 verified Patient 13's vital signs (VS) for Patient 13's second blood transfusion was taken on 11/12/2024 at the following times:

-At 4:05 p.m. (the beginning of the blood transfusion);

-at 4:48 p.m. (43 minutes after the start of the blood transfusion);

-at 7:06 p.m., and 7:07 p.m., (3 hours after the start of the blood transfusion); and,

- at 8:20 p.m. (the end of the blood transfusion).

NM 3 stated when a patient was being transfused, the patient's VS should be checked before the blood transfusion starts; at the time when the blood transfusion started; 15 minutes after the blood transfusion started; an hour after the blood transfusion started; and when the blood transfusion was completed.

During the same interview on 11/14/2024 at 3:53 p.m., NM 3 verified Patient 13's VS were not checked on 11/12/2024 (for the second blood transfusion), before starting the blood transfusion, fifteen minutes after the blood transfusion started, and an hour after the blood transfusion started. NM 3 stated it is important to check and monitor the patient's VS for signs and symptoms of a blood transfusion reaction.

During a review of the facility's policy and procedure (P&P) titled, "Blood Administration," dated 10/20/2021, the P&P indicated, "The patient's vital signs (temperature, pulse, respiration, and blood pressure) are taken and recorded:
i. Within 30 minutes prior to starting the transfusion
ii. Fifteen (15) minutes after initiating the transfusion
iii. One (1) hour after initiating the transfusion, unless the patient's condition requires more frequent checks.
iv. When the transfusion ends ...
vi. Check the vital signs before each blood component is transfused."