HospitalInspections.org

Based on interview and record review, the hospital failed to have an organized nursing service when:

1. License Nurses did not perform pain assessment and reassessment for Patient 9 and Patient 10 and did not notify the Physician when Patient 10's temperature was 100.6 Fahrenheit (a scale of measuring temperature). (Refer to C-1006)

2. Patient 13 had a physician's order Diltiazem (drug used to treat high blood pressure [a condition where the force of blood pushing against the walls of your blood vessels are consistently high] and to control chest pain) 5 milligrams (mg-a unit of mass)/milliliter (mL-a metric unit of measurement for volume or capacity) per 25 mL vial 20 mg IVP times 1 dose stat (immediately) and License Nurse administered diltiazem to Patient 13 without monitoring Patient 13's blood pressure (the force of blood pushing against the walls of your blood vessels) every 15 minutes for the first two (2) hours and then every two (2) hours for the next six (6) hours and there was no initial Telemetry Monitoring Strips (TMS-a visual representation of a patient's heart's electrical activity) documented. Patient 13 was not monitored according to the hospital's protocol titled, "Diltiazem Infusion," the hospital's policy and procedure (P&P) titled, "Telemetry Box Placement," and P&P titled, "Telemetry Protocol." (Refer to C-1049)

3. License Nurses did not develop and updated individualized care plan for Patient (Pt) (Pt 2, Pt 3, Pt 4, Pt 5, Pt 7, and Pt 8 when:

3a. Nurses did not develop an individualized care plan for Pt 2's infection when his admitting diagnosis (the reason he was admitted to the hospital) was for an infected aortic endograph (a device used to treat an abdominal aortic aneurysm (AAA) (a bulge in the wall of the aorta, the body's main artery, that occurs in the abdominal region without open surgery. (Refer to C-1050)

3b. Nurses did not develop an individualized care plan for Pt 3's difficulty breathing when his admitting diagnosis was asthma and shortness of breath. (Refer to C-1050)

3c. Nurses did not develop an individualized care plan for Pt 4's heart failure when his admitting diagnosis was congestive heart failure (a condition that occurs when the heart can't pump enough blood to meet the body's needs. (Refer to C-1050)

3d. Nurses did not develop an individualized care plan for Pt 5's infection when his admitting diagnosis was cellulitis (a bacterial infection that affects the skin and the tissue just beneath it) in his lower left leg. (Refer to C-1050)

3e. Nurses did not develop an individualized care plan for Pt 7's infection when her admitting diagnosis was colitis (an inflammation of the intestinal tract) and she was diagnosed with Clostridioides difficile (C. diff) (an infectious bacteria). C. diff can cause mild to severe diarrhea and can be life-threatening. (Refer to C-1050)

3f. Nurses did not develop an individualized care plan for Pt 8's infection when his admitting diagnosis was a septic (sepsis - severely infected) hip. (Refer to C-1050)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care by the nursing staff.

Based on interview and record review the hospital failed to ensure:

1.Two of 13 sampled patients (Patient 9 and Patient 10) pain assessments and reassessments was not conducted and documented according to the hospital's policy and procedure (P&P) titled, "Pain Assessment, Reassessment and Management."

These failures had the potential for Patient 9 and Patient 10 to have continued and unrelieved pain which could affect their healing and psychosocial well-being.

2. One of two sampled patient's (Patient 10) primary concern was not addressed while she was in the hospital's emergency department. Patient 10 had a fever (a fever is considered to be a body temperature of 100.4 degrees Fahrenheit or higher) at triage and she continued to have a fever throughout her Emergency Department (ED) visit with no physician notification to address Patient 10's fever according to the hospital's P&P titled, "EMTALA Guidelines for ED Services,"

This failure had the potential for Patient 10's fever to continue to rise and cause clinical decline.

Findings:

1. During a concurrent interview and record review on 12/12/24 at 10:20 a.m. with RN 3, Patient 9's "History and Physical (H&P-the physician obtains a thorough medical history, performs a physical examination, and documents their findings)", dated 11/16/24 was reviewed. RN 3 stated the H&P indicated, "Patient is an 81 year old [male] with [past medical history (PMH)] of hypertension [high blood pressure-a condition where the force of blood pushing against the walls of your blood vessels are consistently too high] ...Parkinson's disease [a movement disorder that worsens over time] ...who presented to the ED earlier today for hallucinations [something that is believed to be true or real but that is actually false], decrease [by mouth] intake, generalized weakness, dizziness, with multiple falls over the last week ...He denies any focal weakness [a noticeable weakness in a specific part of the body]/numbness [partial or complete loss of feeling], headache, visual changes, head trauma [injury], and loss of consciousness [a state where a person is unaware of their surroundings and themselves] ..."

During concurrent interview and record review on 12/12/24 at 11:15 a.m. with RN 3, Patient 9's "Medication Record (MR)," dated 11/16/24 to 11/23/24 and Patient 9's "Pain Assessment Flowsheet (PAF)," dated 11/17/24 to 11/23/24 were reviewed. RN 3 stated the MR indicated, acetaminophen 325 milligrams (mg-metric unit of measurement, used for medication dosage and/or amount) tablets, 650 mg as needed every six hours for mild to moderate pain and/or fever (a body temperature that's higher than normal, which is typically 98.6 Fahrenheit (F-scale used for measuring temperature which water freezes at 32 degrees and boils at 212 degrees) was ordered at 12:03 p.m. RN 3 stated the MR indicated Patient 9 was administered acetaminophen (a drug that reduces pain and fever) on 11/17/24 at 12:16 p.m. with a reassessment at 3:13 p.m. of "Tolerated well, no adverse reaction." RN 3 stated the PAF indicated Patient 9's pain was not assessed when the acetaminophen was administered at 12:16 p.m. and there was no documented pain reassessment score documented at 3:13 p.m. RN 3 stated the MR indicated on 11/22/24 at 9:02 a.m. Patient 9 was administered acetaminophen with no documented pain score and there was no reassessment of Patient 9's pain after the acetaminophen was administered. RN 3 stated Patient 9's pain should have been reassessed within an hour of the pain medication administration. RN 3 stated the importance of pain assessments and reassessments was to ensure the medication was effective to treat the patient's pain. RN 3 stated if the pain medication was not effective to treat the patient's pain, the nurse should have notified the physician.

During a concurrent interview and record review on 12/12/24 at 3:54 p.m. with RN 3, Patient 10's "ED Nursing Triage (ENT)," dated 9/23/24 was reviewed. RN 3 stated the ENT indicated, "Triage Date/Time: 09/23/2024 [1:45 p.m.] Triage Location: Bedside- treatment area ...Chief Complaint Pt has [history] of pancreatic cancer [times] 5 years with a new mass [a lump in the body] diagnosed [patient] has had chills and fatigue [extreme feeling of tiredness] [times] 2 days [patient] has [nausea/vomiting] [times] 3 today [patient] with [temperature] 100.6 ..."

During a concurrent interview and record review on 12/12/24 at 4:05 p.m. with RN 3, Patient 10's "Vital Signs (VS)," Patient 10's "Medication Administration (MA)," and Patient 10's "ED Nursing Documentation (END)," dated 9/23/24 were reviewed. RN 3 stated the VS indicated at 2:30 p.m. temperature 100.6 oral, respiration 17, Pulse 93, pulse oximetry 98% on room air, blood pressure 113/62 and at 3:57 p.m. temperature 100.6 oral, respiration 17, pulse 88, pulse oximetry 95% on room air, and blood pressure 133/69. RN 3 stated there were no pain assessments documented with the two vital signs while Patient 10 was in the emergency department. RN 3 stated there should be a pain assessment with each vital sign. RN 3 stated the END indicated Patient 10 was discharged at 5:42 p.m. RN 3 stated the second set of vital signs documented were the last set of vital signs documented and when Patient 10 was discharged at 5:42 p.m. there should have been another set of vital signs assessed and documented 15 to 30 minutes prior to Patient 10's discharge.

During a review of the hospital's P&P titled, "Documentation Requirements-Minimum," dated 11/15/12, the P&P indicated, " ...Vital signs include pain scale ..."

During a review of the hospital's P&P titled, "EMTALA Guidelines for ED Services," dated 1/26/24, the P&P indicated, " ...Medical Screening Exam: The process required to reach, with reasonable clinical confidence, the point at which it can determined whether the individual has an emergency medical condition or not ...Medical Screening Exams (MSEs) shall include at a minimum the following ...Vital signs ...Vital signs upon discharge ..."

During a record review of Patient 10's "Medication Administration (MA)," dated 9/23/24 and the hospital's P&P titled, "Pain Assessment, Reassessment and Management," dated 2/23/24, the MA indicated cyclobenzaprine (drug used to relax muscles) 10 mg by mouth times one stat (immediately) was administered at 4:36 p.m. and ketorolac (medication used to treat moderate to severe pain) 30 mg intravenous (in the vein) push times one stat was administered at 4:36 p.m. The MA indicated there was no pain assessment documented at 4:36 p.m. The MA indicated at 5:43 p.m. a pain reassessment for cyclobenzaprine was documented with "pain reduced" and at 5:42 p.m. a pain reassessment for ketorolac was documented with "pain reduced." The MA indicated the pain reassessment for cyclobenzaprine was assessed one hour and seven minutes after the medication was administered. The MA indicated the pain reassessment for ketorolac was assessed one hour and six minutes after the medication was administered. The P&P indicated, " ...The patient shall undergo reassessment of pain 30 minutes after every pain control mechanism employed by patient care providers to ensure effectiveness of intervention ..." The P&P was not followed when Patient 10's pain was not reassessed 30 minutes after a pain control intervention was implemented.

During an interview on 12/13/24 at 2:18 p.m. with the Chief Nursing Officer/Chief Administrative Officer (CNO/CAO), the CNO/CAO stated, "The purpose of pain assessments and reassessments were to ensure the interventions implemented worked or didn't work." The CNO/CAO stated the reassessments determined if the interventions were effective and if the interventions were not effective to meet the patient's tolerable pain level, the nurses should have tried other interventions or notified the physician about their patient's pain. The CNO/CAO stated if there were any questionable orders, it was the responsibility of the nurses to notify the physician.

During a review of the hospital's P&P titled, "Pain Assessment, Reassessment and Management," dated 2/23/24, the P&P indicated, "Purpose: Effective pain assessment and management can remove the adverse psychological [relating to the mind, mental, and emotional] and physiological [relating to the body and its systems] effects of unrelieved pain. Optimal management of the patient experiencing pain enhances healing and promotes both physical and psychological wellness ...Policy ...shall respect and support the patient's right to optimal pain assessment and management. Pain shall be assessed in all patients in the organization ...Procedure: It shall be the responsibility of all clinical staff to screen all patients expeditiously for the presence or absence of pain, and avoid delays related to testing, diagnostics or consultations. If the screening assessment reveals pain is present in the patient, it shall be the responsibility of clinical staff to conduct an in-depth clinical assessment of the pain, and periodic reassessments of the patient for determination of pain and relief from pain, including the intensity and quality ...and responses to treatment. At time of admission to the facility, the patient shall be questioned regarding pain during the initial nursing assessment (pain screening) ...if the screening assessment identifies pain is present, the admitting nurse performs the initial patient assessment shall document the assessment in the [electronic health record (EHR-a digital version of a patient's medical history)] ... The reassessed pain level will be documented in the EHR...Patients shall be taught that pain management is part of their treatment ...Ongoing Reassessment: As part of the reassessment, the [Emergency Department] team shall assess and document the pain in terms of its duration, characteristics and intensity as well as the time of the pain, the pain rating and any use of analgesics. Include other pain interventions, vital signs, the effectiveness of all interventions and any side effects or adverse reactions. Documentation: Pain assessments and reassessments shall be documented in patient's medical record. Response to pain medications and non-pharmacological interventions, noting any adverse reactions shall be documented in patient's medical record ..."

During a review of the hospital's P&P titled, "Documentation Requirements-Minimum," dated 11/15/12, the P&P indicated, "Purpose: To assure all required documentation is completed on admission to the inpatient unit ...This policy is a guide for staff to use detailing the minimum required documentation needed for inpatients ...While the patient is in the hospital: (Observation, Acute, Swing) ...RN Duties include but not limited to ...Round on your patients at the beginning of the shift ...Verify medication orders are correct and medicate as ordered ...Re assess after [as needed medications] given ...CNA duties ...Vital signs are done per orders or at the least every 4 hours ...Vital signs include pain scale ...Swing patient vital signs are done at minimum every shift ...Documentation minimum requirements: More frequent vital signs and assessments can be done as deemed necessary by the [registered nurse] ..."

2. During a concurrent interview and record review on 12/12/24 at 3:54 p.m. with RN 3, Patient 10's "ED Nursing Triage (ENT)," dated 9/23/24 was reviewed. RN 3 stated the ENT indicated, "Triage Date/Time: 09/23/2024 [1:45 p.m.] Triage Location: Bedside- treatment area ...Chief Complaint Pt has [history] of pancreatic cancer [times] 5 years with a new mass [a lump in the body] diagnosed [patient] has had chills and fatigue [extreme feeling of tiredness] [times] 2 days [patient] has [nausea/vomiting] [times] 3 today [patient] with [temperature] 100.6 ..."

During a concurrent interview and record review on 12/12/24 at 4:05 p.m. with RN 3, Patient 10's "Vital Signs (VS)," and Patient 10's "Medication Order (MO)," dated 9/23/24 were reviewed. RN 3 stated the VS indicated at 2:30 p.m. Patient 10's temperature was 100.6 F. RN 3 stated the VS indicated at 3:57 p.m., Patient 10's temperature was still 100.6 F. RN 3 stated the MO indicated Patient 10 was not ordered any fever reducing medications.

During a concurrent interview and record review on 12/12/24 at 4:26 p.m. with RN 3, Patient 10's "Electronic Health Record (EHR-a digital version of a patient's medical records)," dated 9/23/24 was reviewed. RN 3 stated the EHR indicated there was no documentation a physician was notified of Patient 10's fever. RN 3 stated the physician should have been notified about the fever. RN 3 stated the importance of notifying the physician was to ensure patient safety and care by reporting any abnormal signs and symptoms and labs.

During a concurrent interview and record review on 12/13/24 at 2:18 p.m. with the Chief Nursing Officer/Chief Administrative Officer (CNO/CAO), the CNO/CAO stated, "If a patient had a fever, the nurse should report it to the physician and document the physician was notified of the fever." The CNO/CAO stated when the nurse notified the physician about their patient's fever, this gave the physician an opportunity to address the fever.

During a review of the hospital's P&P titled, "EMTALA Guidelines for ED Services," dated 1/26/24, the P&P indicated, "Medical Screening Exam: The process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition or not ...Stabilize: No material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility, or with respect to an emergency medical condition ...All patients shall receive a medical screening exam (MSE) that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. Federal law requires that all necessary definitive treatment shall be given to the patient and only maintenance care can be referred to a physician office or clinic ...The physician shall order appropriate medical staff to attend the patient, maintain and/or initiate treatment or medications and manage known potential adverse effects ...All patients shall receive a Medical Screening Exam (MSE) that includes providing all necessary testing and on-call services within the capability of the hospital to reach diagnosis. Federal law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician office or clinic ...Medical Screening Exams (MSEs) shall include at a minimum the following ...Patient's triage record ...Vital signs ...Necessary testing to rule out emergency medical conditions ...Vital signs upon discharge or transfer ...Complete documentation of the medical screening exam ...Upon completion of the MSE: Provide any necessary stabilizing treatment for EMCs and labor within the hospital's capability and capacity ..."

Based on interview and record review the hospital failed to ensure a medication was administered in accordance with physician orders, facility policy, and accepted standards of practice for one of four sampled patients (Patient 13) when a licensed nurse administered diltiazem (drug used to treat high blood pressure [a condition where the force of blood pushing against the walls of your blood vessels are consistently high] and to control chest pain) and Patient 13 was not monitored according to the hospital's protocol titled, "Diltiazem Infusion," the hospital's policy and procedure (P&P) titled, "Telemetry Box Placement," and P&P titled, "Telemetry Protocol."

This failure had the potential for Patient 13 to have undetected adverse reactions and/or negative outcomes which could contribute to clinical decline of the patient.

Findings:

During a concurrent interview and record review on 12/13/24 at 10:45 a.m. with Registered Nurse (RN) 3, Patient 13's "History and Physical (H&P)," dated 12/8/24 was reviewed. RN 3 stated the H&P indicated, "Patient is a pleasant 69-year-old male with a past medical history of [chronic obstructive pulmonary disease (COPD-a lung disease that damages the airway or other parts of the lungs, making it hard to breathe)] on baseline 4 [liter-a metric unit of measurement for the volume of a liquid or gas] nasal cannula [a small, flexible tube with two prongs that are inserted into the nostrils to deliver supplemental oxygen] oxygen [a colorless, odorless gas that is essential for life] ...atrial fibrillation [a type of irregular heartbeat] reportedly on anticoagulation [prevents or treats blood clots] with [apixaban-drug used to prevent and treat blood clots] ...current smoker presented to the ER with complaints of worsening shortness of breath [the feeling of being unable to breathe deeply or normally] that started 2 to 3 days ago progressively worsening also patient is on oxygen but his oxygen concentrator [a medical device that provides a continuous supply of oxygen-enriched air] was not functioning very well so he has been without oxygen for the last few days denies any current chest pain, obvious fever, productive cough. Patient is a current smoker. Denies any obvious significant weight loss, denies any blood in sputum [mucus and other matter that comes up from the lungs when you cough] ...Plan ...[atrial fibrillation] ...current medications: [diltiazem] bolus [a single large dose of a drug given over a short period of time] continue with [diltiazem] drip [a method of delivering fluids and medications directly into a patient's blood stream] ..."

During a concurrent interview and record review on 12/13/24 at 11:30 a.m. with RN 3, Patient 13's "Physician Orders (PO)," Patient 13's "Vital Signs (VS)," dated 12/8/24 and the hospital's protocol titled, "Diltiazem Infusion," dated 8/2/23 were reviewed. RN 3 stated the PO indicated, Diltiazem 5 milligrams (mg-a unit of mass)/milliliter (mL-a metric unit of measurement for volume or capacity) per 25 mL vial 20 mg IVP times 1 dose stat (immediately) was ordered at 11:25 a.m. RN 3 stated the PO indicated, Patient 13 was administered diltiazem at 2:04 p.m. RN 3 stated the VS indicated Patient 13's vital signs were documented at 2:43 p.m., 3:41 p.m., and 7:33 p.m. RN 3 stated the Protocol indicated, "[Blood pressure (BP)] should be monitored every 15 minutes for the first two (2) hours and then every two (2) hours for the next six (6) hours." RN 3 stated Patient 13's vital signs were not monitored according to the Protocol. RN 3 stated the importance of following the hospital's protocol was to ensure patient safety. RN 3 stated not following the protocol could cause harm to the patient.

During a concurrent interview and record review on 12/13/24 at 11:45 a.m. with RN 3, Patient 13's "Electronic Health Record (EHR-an electronic version of a patient's medical history)," dated 12/8/24 and the hospital's protocol titled, "Diltiazem Infusion," dated 8/2/23 were reviewed. RN 3 stated when a patient was placed on telemetry monitoring, the nurse documented if the patient was telemetry monitored in the Nurses Notes or Cardiac Section of the EHR. RN 3 stated at 2:04 p.m. there was no documentation Patient 13 was on cardiac monitoring. RN 3 stated the Protocol indicated, "Patients should be on telemetry for heart rate and rhythm for the duration of infusion and conversion therapy." RN 3 stated the protocol was not followed when there was no documentation Patient 13 was telemetry monitored.

During a record review of Patient 13's "Telemetry Monitoring Strips (TMS-a visual representation of a patient's heart's electrical activity)," dated 12/10/24 and the hospital's P&P titled, "Telemetry Box Placement," dated 1/1/20, the TMS indicated there were no initial TMS documented on 12/8/24. The P&P indicated, "An initial strip is to be printed from the monitor to initiate telemetry monitoring and must have dual signature of CNA and Ward Clerk verifying that name, room number and box number are accurate. RN signing first reading is to confirm both signatures are present ..."

During a record review of Patient 13's "TMS," dated 12/10/24 and the hospital's P&P titled, "Telemetry Protocol," dated 3/13/13, the P&P indicated, "A rhythm strip will be documented every four hours and for any complaint of chest pain or any change in rhythm ...A rhythm strip will also be documented when giving IV push cardiac medications ..." The TMS indicated there were no documented TMS on 12/8/24.

During an interview on 12/13/24 at 2:18 p.m. with the Chief Nursing Officer (CNO), the CNO stated the risks of not following the hospital's Diltiazem Protocol could cause harm to patients. The CNO stated protocols were evidence based and nurses should follow the hospital's protocols. The CNO stated if a nurse had an issue with the protocol, the nurse should talk to the physician.

During a review of the hospital's protocol titled, "Diltiazem Infusion," dated 8/2/23, the Protocol indicated, "Diltiazem ...infusions are indicated for control of rapid ventricular response to atrial fibrillation ...Initial Bolus ...Administer 0.25 mg/kg, average of 20 mg, via intravenous push (IVP) over 2 minutes ...Fifteen (15) minutes after the initial bolus, if the heart rate (HR) is still greater than 120 [beats per minute (bpm)] and systolic blood pressure (SBP) is greater than 100, repeat the bolus 0.35mg/kg, (average dose of 20 mg), IVP over 2 minutes ...If HR remains greater than 120 bpm after second bolus, notify the physician ...Continuous Infusion Rate ...Begin the drip rate at 5-10 mg/hour immediately after the initial bolus. The infusion rate may be adjusted in increments of 5 mg per hour up to 15 mg/hr MAX to maintain HR 70-110 bpm. If the patient converts to sinus rhythm, notify the physician to potentially discontinue the infusion or to titrate the infusion to maintain a HR of 70-110 ...Maximum duration of infusion is 24 hours. The physician should reevaluate and reassess the risks and benefits of continued infusion ...Monitoring Parameters ...Patients should be on telemetry for heart rate and rhythm for the duration of infusion and conversion therapy ...BP should be monitored every 15 minutes for the first two (2) hours and then every two (2) hours for the next six (6) hours ..."

During a review of the hospital's P&P titled, "Telemetry Box Placement," dated 1/1/20, the P&P indicated, "Procedure: CNA and Ward Clerk are to place telemetry box on patient together and confirm number and patient name and room number. Ward Clerk is to enter patient into monitoring system and Ward Clerk and CNA staff are to double confirm box number and patient name and room number ..."

During a review of the hospital's P&P titled, "Telemetry Protocol," dated 3/13/13, the P&P indicated, "Patients on telemetry will be covered by the accepted telemetry protocol ...This is to ensure rapid treatment of any potential harmful arrhythmias ..."

Based on interview and record review, the hospital failed to ensure nursing staff updated and developed individualized care plans (required documents to help guide care for patients) for 6 of 13 patients (Pt) related to infection (Pt 2, Pt 5, Pt 7, and Pt 8), heart failure (Pt 4) or shortness of breath (Pt 3).

1. Nurses did not develop an individualized care plan for Pt 2's infection when his admitting diagnosis (the reason he was admitted to the hospital) was for an infected aortic endograph (a device used to treat an abdominal aortic aneurysm (AAA) (a bulge in the wall of the aorta, the body's main artery, that occurs in the abdominal region without open surgery.

2. Nurses did not develop an individualized care plan for Pt 5's infection when his admitting diagnosis was cellulitis (a bacterial infection that affects the skin and the tissue just beneath it) in his lower left leg.

3. Nurses did not develop an individualized care plan for Pt 7's infection when her admitting diagnosis was colitis (an inflammation of the intestinal tract) and she was diagnosed with Clostridioides difficile (C. diff) (an infectious bacteria). C. diff can cause mild to severe diarrhea and can be life-threatening.

4. Nurses did not develop an individualized care plan for Pt 8's infection when his admitting diagnosis was a septic (sepsis - severely infected) hip.

5. Nurses did not develop an individualized care plan for Pt 4's heart failure when his admitting diagnosis was congestive heart failure (a condition that occurs when the heart can't pump enough blood to meet the body's needs.

6. Nurses did not develop an individualized care plan for Pt 3's difficulty breathing when his admitting diagnosis was asthma and shortness of breath.

These failures had the potential to cause inconsistent delivery of care, which can result in the decline or lack of improvement for Pt's 2,3,4,5,7, and 8.

Findings:

1. During a concurrent interview and record review on 12/11/24 at 3:12 with Registered Nurse (RN) 1, RN 1 opened the Electronic Medical Record (EMR) for Pt 2. The document titled, "H&P (History and Physical) dated 08/31/2024 indicated, " ... 86-year-old M [male] with past medical history of ... AAA, (status post EVAR (endovascular aneurysm repair - repair of the bulging vein) ... Patient was transferred to [outside hospital] for evaluation of findings related to infected endovascular graft. ID (Infectious Disease specialist - physician who specializes in infections that cause illnesses) at [outside hospital] recommended 6 weeks of IV (intravenous - liquid medication given directly into a vein) ceftriaxone (an antibiotic- a mediation that fights bacterial infections) ...and was transferred back for continuation of IV antibiotic.

During a review of the hospital document titled, "Discharge Summary" dated, 9/4/24, the document indicated, " ...Discharge Diagnosis: Endovascular graft infection ..."

During a review of the hospital document titled, "Problem Activity," RN 1 stated this is the document usually called a Care Plan in other facilities. RN 1 searched the document for a care plan related to infection and was unable to find one. RN 1 stated Pt 2 was admitted with an infection, and he still has infections, and a Care Plan should have been created for infections.

During an interview and record review on 12/13/24 at 9:08 a.m. with RN 7, RN 7 stated she was the nurse assigned to Pt 2 but she does not remember him. RN 7 stated Care Plans should always include the patient's primary diagnosis, and nurses can customize care plans to include any other items they need to be following, including safety concerns, such as fall risks and skin care. RN 7 stated care plans need to be patient specific.

2. During a concurrent interview and record review on 12/11/24 at 4:04 p.m. with Registered Nurse (RN) 1, RN 1 opened the Electronic Medical Record (EMR) for Pt 5. The document titled, "H&P (History and Physical) dated 08/31/2024 indicated, " ...Chief Complaint: LT (left) Leg Infection ... 73 year old female with past medical history of Prediabetes (a serious health condition that occurs when your blood sugar levels are higher than normal, but not high enough to be diagnosed as type 2 diabetes) prior Pseudomonas (a type of bacteria) infection with history of sepsis 2 times in the past ..."

During a review of hospital document titled "Problem Activity," the document indicated, " ...Nursing Physical Assessment ...Wound noted to LLL (left lower leg) ... wound cleaned and dressed ..." RN 1 stated this is the document that serves as a care plan in this hospital, and there is no other document called a "care plan." RN 1 stated, "our care plan module isn't good. There should definitely be a care plan for infection, that's the main reason she was here. We need to do a lot of education with nurses."


3. During a concurrent interview and record review on 12/12/24 at 10:33 a.m. with Registered Nurse (RN) 1, RN 1 opened the Electronic Medical Record (EMR) for Pt 7. The document titled, "H&P (History and Physical) dated 11/25/24 indicated, "79 year old female with past medical history of chronic A-fib (an irregular heart rhythm), who presented with severe recurrent diarrhea... Patient so far has had 4 watery BMs (bowel movements) while in the ED (Emergency Department) ...CT (computerized tomography) [of her] abdomen [and] pelvis positive for pancolitis (inflammation of the entire colon.)

During a concurrent interview and record review of hospital document titled, "Discharge Summary" dated 11/30/24, the document indicated, " Hospital course: ... During this admission patient was treated for acute (sudden onset) pancolitis and diagnosed with C. difficile colitis Clostridioides difficile (C. diff) (an infectious bacteria). C. diff can cause mild to severe diarrhea and can be life-threatening.) Patient was started on IV Flagyl (an antibiotic) and p.o. vancomycin (an antibiotic), but still patient continued with diarrhea with traces of blood.

During a concurrent interview and record review of hospital document titled, "Problem Activity," the document indicated, " ...Nursing Physical Assessment ...Wound noted to LLL (left lower leg) ... wound cleaned and dressed ..." RN 1 stated this is the document that serves as a care plan in this hospital, and there is no other document called a "care plan." RN 1 stated C. diff is the main reason this patient came to the hospital, it is a serious infection that is very contagious.

4. During an observation and interview on 12/11/24 at 12:30 p.m. with Pt 8, Pt 8 was observed sitting in a wheelchair next to his hospital bed. Pt 8 stated he had an infection in his hip, and they have been giving him medicine for his hip and knee. Pt 8 stated his hip and leg do not hurt much anymore, and he wants to go home.

During a concurrent interview and record review on 12/12/24 at 11:00 a.m. with Registered Nurse (RN) 1, RN 1 opened the EMR for Pt 8. The document titled, "HOSPITAL H&P" dated 11/20/2024 indicated, " ... patient is an 80-year-old and with PMH (past medical history) of ... bacteremia (an infection in the blood) ... and recurrent (happening over and over) right knee prosthetic (artificial) joint infection who was found to have right hip prosthetic joint staph aureus (a bacteria) infection. He underwent his right hip prosthesis revision (repair of previous hip surgery) ... on 11/12/2024, who has been transferred to [name of hospital] for ... completion of IV antibiotic (2 g (grams - a unit of measure) rocephin (an antibiotic) for total of 6 weeks
(11/12 to 12/20/2024). Patient currently complains of right hip pain and denies any other symptoms ...".

During a concurrent interview and record review of hospital document titled, "Problem Activity," RN 1 was unable to find a care plan for infection. RN 1 stated, "he had a septic him and knee, and came in for antibiotics. The whole reason he was here was for his infection, so she should have had a care plan for infection if nothing else."

5. During a concurrent interview and record review on 12/12/24 at 11:30 a.m. with Registered Nurse (RN) 1, RN 1 opened the EMR for Pt 4. The document titled, "HOSPITAL H&P" dated 12/07/2024 indicated Pt 5 was an 81-year-old man admitted to the hospital on 12/7/24 for shortness of breath and atrial fibrillation (an irregular heart rhythm.) Note indicated ER physician's examination he was found to have wheezing as well as possible evidence of CHF (congestive Heart Failure)and was given IV Lasix (a medication to reduce extra water in the body) ...

During a concurrent interview and record review of hospital document titled, "Problem Activity," RN 1 was unable to find a care plan for cardiac (heart) output. RN 1 stated she did not see any care plan that addressed heart failure or atrial fibrillation at all. RM 1 stated, "there should be a care plan for fluid volume and cardiac output at least."

6. During a concurrent interview and record review on 12/11/24 at 11:30 a.m. with Registered Nurse (RN) 1, RN 1 opened the EMR for Pt 3. The document titled, "HOSPITAL H&P" dated 12/10/2024 indicated Pt 3 was a " ... 50-year-old male with a past medical history of hypertension, asthma ... RESPIRATORY: positive for dyspnea (difficulty breathing).

During a concurrent interview and record review of hospital document titled, "Problem Activity," RN 1 was unable to find a care plan for shortness of breath or any reference to asthma, which was one of the reasons he came to the hospital.. RM 1 stated, "there should be a care plan for shortness of breath, since he has a history of asthma and was having difficulty breathing when he came in."


During an interview on 12/13/24 at 9:08 a.m. with RN 7, RN 7 stated Care Plans should always include the patient's primary diagnosis, and nurses can customize care plans to include any other items they need to be following, including safety concerns, such as fall risks and skin care. RN 7 stated care plans need to be patient specific.

During an interview on 12/13/24 at 10:19 a.m. with RN 4, RN 8 stated the purpose of a Care Plan is to make sure the problem is resolving (the patient is improving). RN 8 stated Care Plans are supposed to be updated every shift, and they should include safety issues such as skin breakdown, and any acute problems the patient is having. RN 8 stated the primary reasons for admission should always be included in the Care Plan.

During a record review of hospital policy titled, "Policy and Procedure," dated 11/24/2012, the document indicated, " ... Subject: Care Plans ... POLICY: Patient care is to be delivered in accordance with a patient-specific care plan that addresses the patient's physical and psychosocial needs. PURPOSE: To ensure appropriate nursing evaluation of and response to each hospitalized patient's physical and psychosocial needs. PROCEDURE: 1. A plan of care, unique to each patient, will be initiated by nursing staff within 24 hours of admission. 2. The initial care plan includes identification and prioritization of patient problems, planned nursing interventions, and patient specific, measurable goals. 3. Care plans for both Inpatient and Swing patients will be re-evaluated every shift and updated as patient condition and/or needs require. 4. Unmet goals and/or new or ongoing problems may indicate a need for post-hospitalization services such as Home Health Care, outpatient services, or referral to community resources. 5. Documentation will reflect communication on plans to meet ongoing needs. 6. The patient care plan is a part of the permanent clinical record.