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Based on observation interview and record review the facility failed to protect and promote each patient's rights when:


1. The hospital failed to inform one of nine patients (Pt 31) in advance of care decisions when interpreter services were not used to communicate, from 10/15/24 to 10/20/24 in a language Pt 31 could understand according to the hospital's policy and procedure (P&P) titled, "Limited English-Proficiency (LEP): Language Access for Patient and Companions" (Refer to A-117).

2. Discharge instructions were not in a language the patient (Pt 24) could understand and an interpreter was not used to review the discharge instructions according to the hospital's P&P titled, "Limited English-Proficiency (LEP): Language Access for Patient and Companions" (Refer to A-131).

3. The hospital failed to ensure one of 25 patients (Patient 1) was provided information about advance directives according to the hospital's P&P, "Advance Directives / Patient Self-Determination" (Advance Directives -Legal document that states a person's wishes for medical care if they are unable to communicate their preferences) (Refer to A-132).

4. The hospital failed to ensure patients were free from restraints (chemical, physical, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely), and to ensure restraints were discontinued at the earliest possible time. Licensed Nurses (LNs) did not complete restraint assessment monitoring every two-hours, for one of three patients (Pt 31) to ensure Pt 31 remained free from injury, and to determine if the restraints could be released in accordance with hospital policy and procedure (P&P) (Refer to A-154).

The cumulative effect of these systemic problems resulted in failure to ensure patients were cared for in a safe and effective manner, and their rights were protected and promoted at all times.

Based on observation, interview and record review, the hospital failed to inform one of nine patients (Pt 31) in advance of care decisions when interpreter services were not used to communicate, from 10/15/24 to 10/20/24 in a language Pt 31 could understand according to the hospitals policy and procedure (P&P) titled, "Limited English-Proficiency (LEP): Language Access for Patient and Companions."

This failure denied Pt 31 their right to make informed decisions about, participate in their daily care and had the potentially to affect all non-English speaking patients treated at the hospital.

Findings:

During a concurrent interview and record review on 11/12/24 at 3:23 p.m. with Registered Nurse (RN) 7 and the Director of Nursing (DON) Pt 31's "History & Physical [H&P- an assessment from physician including medical history and exam]," and "Face Sheet [FS- a document that contains a summary of a patients' personal information]," dated 10/11/24, were reviewed. The "H&P" indicated, Pt 31 was admitted to the hospital on 10/11/24 at 4:42 p.m. for sepsis (a life-threatening blood infection), and acute kidney injury (AKI- A sudden and often reversible decline in kidney function) after a laminectomy (a surgical cut into the backbone to get access to the structures in the spinal cord). RN 7 stated the "FS" indicated, Pt 31's preferred language was Spanish.

During a concurrent interview and record review on 11/13/24 at 11:03 a.m. with Shift Manager (SM) 3, Pt 31's "Interpreter Services Flowsheet (ISF)," dated 10/11/24 to 11/13/24, were reviewed. SM 3 stated no Licensed Nursing (LN) documentation was present on the "ISF" to indicate a Spanish medical interpreter was used during Pt 31's admission to the Medical Surgical (MS) Unit. SM 3 stated a Spanish medical interpreter should have been used for Pt 31's admission questions. SM 3 stated Pt 31's "ISF" indicated, no Spanish medical interpreter was used to communicate with Pt 31 or his family on 10/15/24 through 10/20/24. SM 3 stated medical interpreters (CMI) should be used to communicate patient education, medications, plan of care, procedures, treatments, and care options. SM 3 stated LNs could access a medical interpreter via computer tablet, telephone, or use an in-person interpreter. SM 3 stated LNs should use medical interpreters for non-English speaking patients and their caregivers/families to ensure the plan of care was understood. SM 3 stated Pt 31's wife also was non-English speaking. SM 3 stated Pt 31 was "often confused" and did not always have family at bedside so, speaking in a language he understood was important. SM 3 stated speaking to Pt 31 in his preferred language could help to prevent Pt 31 from being scared and give him a sense of what was happening to him. SM 3 stated her expectation was for LNs to document use of medical interpreters in the "ISF" according to P&P.

During a concurrent observation and interview on 11/14/24 at 3:45 p.m. with the In-house Spanish Interpreter (ISI), Family Member (FM) 2 and Registered Nurse (RN) 8, in Pt 31's hospital room, Pt 31 was observed lying in his hospital bed at a 90-degree angle with his eyes open. Pt 31's right and left wrist were in soft restraints (padding attached around a limb attached to bedframe that limits a person's movement). Pt 31 had a foley catheter (a flexible tube that drains urine from the bladder into a collection bag). Pt 31's primary RN (RN 8) was in the room at bedside attempting to get a finger-stick blood sugar (poking finger with needle to test blood sugar levels) and vital signs (VS) from Pt 31. RN 8 was speaking to Pt 31 in English. Pt 31's wife (FM 2) was at bedside. FM 2 stated through the ISI that neither Pt 31 nor FM 2 spoke English. Pt 31 stated they only spoke Spanish. FM 2 stated her husband was often confused, because of his illness. FM 2 stated she was not always updated of Pt 31's change in status. FM 2 stated medical interpreters were used sometimes to communicate with her. FM 2 stated she appreciated when medical interpreters were used because she felt better informed in Pt 31's care and treatment.

During an interview on 11/14/24 at 3:53 p.m. with RN 8, RN 8 stated using medical interpreters for non-English speaking patients and their families was important to help them understand the plan of care. RN 8 stated he should have used a medical interpreter to inform FM 2 about Pt 31's change of condition and any new treatment plans.

During an interview on 11/15/24 at 10:12 a.m. with Clinical Manager (CM) 6, CM 6 stated her expectation was, if patients were non-English speaking LNs should use a medical interpreter. CM 6 stated Pt 31's LNs should use a medical interpreter to communicate with him and his family to explain any new plans of care or treatments. CM 6 stated her expectation was for LNs to document when a medical interpreter was used, what was communicated to the patient, and the interpreter's name and/or ID number.

During an interview on 11/15/24 at 3:25 p.m. with the Chief Nursing Officer (CNO), the CNO stated, Medical Interpreter Services should be used when LNs were communicating with patients about plans of care, changes in or new medications, instructions, and treatments. The CNO stated employees who were native speakers of the patient's preferred language could be used as interpreters when asking patients about toileting, fluids, bathing, or nutrition. The CNO stated her expectation was for LNs to follow the P&P and document what was information was interpreted, the interpreter's name, and ID number information. The CNO stated LNs need to use a medical interpreter in the patient's preferred language so patients could understand and ask questions if clarification was needed. The CNO stated interpretation was important so patients could understand their plan of care.

During a review of the hospital's P&P titled, "Limited English Proficiency (LEP): Language Access for Patients and Companions," dated 4/2/23, indicated, " ... utilization of interpreter services. ... Considerations for determining the appropriate model for the delivery of interpreter services will include the patient's preferences, the nature of the clinical interaction, the availability of qualified in-person medical interpreters and the availability of the technology to allow for telephonic or video-conference interpreters ... Providing Interpreter Services for Meaningful Access ... Interpreter services will be provided for any patient who has Limited English Proficiency. ... Interpreter services, including a Qualified Medical interpreter when needed to provide meaningful, equitable access to the Facility's services, are required for patient assessment, consent, education and discharge ... Determining a patient's history or description of ailment [illness] or injury ... Obtaining informed consent or permission for treatment ... Explaining diagnosis or prognosis [likely course of disease or illness] of ailments or injuries ... Explaining procedures, tests, treatment, treatment options or surgery ... Explaining the administration and side effects of medications, including side effects and food or drug interactions [a change in the way a drug acts in the body when taken with other drugs] ... Explaining follow-up treatment, test results, or recovery ... The documentation of the provision [supplying for use] of interpreter services shall be recorded in the patient medical record and shall include ... Name of requestor ... Date and time of interpretation ... Name of [hospital Name] Qualified Medical interpreter or vendor company name and interpreter name, or telephonic interpreter ID number, as applicable; and a ... Brief description of content interpreted ... For limited communications about basic activities of daily living (ADL), such as a request for water or to use the bathroom, employees who are native speakers of the patient's preferred language may communicate with an LEP patient without the use of a Qualified Medical interpreter, but it is recommended that tools such as picture communication boards be available to allow patients to express their needs ...".


During a review of professional reference titled, "Clinicians' Obligations to Use Qualified Medical interpreters When Caring for Patients with Limited English Proficiency," dated 3/2017, (retrieved from https://journalofethics.ama-assn.org/article/clinicians-obligations-use-qualified-medical-interpreters-when-caring-patients-limited-english/2017-03) indicated, " ... Access to language services is a required and foundational component of care for patients with limited English proficiency (LEP) ... In the United States, patients with LEP have a legal right to access health care in their preferred language ...".

Based on interview and record review the hospital failed to ensure patient's right to make informed decisions about care for one of two patients (Pt 24) when discharge instructions were not in a language the patient (Pt 24) could understand and an interpreter was not used to review the discharge instructions according to the facility's policy and procedure (P&P) titled, "Limited English-Proficiency (LEP): Language Access for Patient and Companions."

This failure denied Pt 24 their right to make informed decisions about, participate in their discharge care and had the potentially to affect all non-English speaking patients discharge at the hospital.

Findings:

During a review of Pt 24's "Face Sheet (FS-a list of a patient's information that provides quick access for healthcare providers)," undated, the FS indicated Pt 24's preferred language was Spanish.

During a concurrent interview and record review on 11/13/24 at 1:49 p.m. with Registered Nurse (RN) 7 and Nurse Educator (NE) 3, Pt 24's "Discharge Instructions (DI)," dated 11/13/24 was reviewed. RN 7 stated the DI was written in English.

During a concurrent interview and record review on 11/13/24 at 1:55 p.m. with RN 7 and NE 3, Pt 24's "Interpreter Flowsheet (IF)," dated 11/13/24 and "Nursing Discharge Summary (NDS)," dated 11/13/24 were reviewed. RN 7 stated the "IF" indicated no interpreter was used to give discharge instructions to Pt 24. RN 7 stated the "NDS" indicated no interpreter was used to give discharge instructions to Pt 24. RN 7 stated it was important to provide discharge instructions and education in Pt 24's primary language to ensure Pt 24 understood the information and Pt 24's questions were answered at the time of discharge.

During an interview on 11/14/24 at 3:25 p.m. with Clinical Manager (CM) 5, CM 5 stated Licensed Nurses (LN) are expected to provide discharge instructions in Spanish when the patient's preferred language is Spanish. CM 5 stated LNs are expected to use a qualified translator to provide discharge instructions to patients who have a different preferred language. CM 5 stated LNs are expected to document the use of a translator in the patient's electronic medical record (EMR- a digital version of a patient's medical history).

During an interview on 11/15/24 at 3:13 p.m. with the Chief Nursing Officer (CNO), the CNO stated LNs are expected to use a certified interpreter in the patient's primary language to ensure the patient understands the education and to ask questions if needed.

During a review of the facility's P&P titled, "Limited English-Proficiency (LEP): Language Access for Patient and Companions," revised 3/2023, the P&P indicated, " ...It is the policy of [Name of Hospital] that patients or surrogate decisionmakers (hereafter patients) who are Limited English Proficient (LEP), will have services provided to them in their primary language during the delivery of all significant healthcare services. Interpreter services will be available within a reasonable time during all hours of operation, at no cost to patients ... Patients and companions who are Limited English Proficient (LEP) shall have information and services provided to them in their primary language while receiving healthcare services at all [Name of Hospital] ... Interpreter services, including a Qualified Medical Interpreter when needed to provide meaningful, equitable access to the Facility's services, are required for patient assessment, consent, education and discharge, including but not limited to the following topics ... Providing discharge instructions or discussing plans ... Language Accessible Vital Documents ... a. All Vital Documents shall be printed in the Threshold Languages. Only a qualified translation company that certifies the accuracy of its documents shall be used for written translation for any document that affects a patient's health care. b. Vital Documents that are not produced in a written translation shall be verbally translated to the patient by a Qualified Medical Interpreter. The provision of oral translation of all Vital Documents to patients shall be documented in the medical record ..."

During a review of the facility's P&P titled, "Discharge of the Adult Inpatient," reviewed 6/2022, the P&P indicated, " ...Discharge Packets (Plans and Written Instructions) ... Will be in a form the patient, family and/or caregiver(s) can understand ... The nurse will review the Discharge Instruction Packet with the patient, family and/or appropriate caregivers in order to educate them regarding the anticipated needs for continued care, treatment, and services following discharge ..."

Based on interview, and record review, the hospital failed to ensure one of 25 patients (Patient 1) was provided information about advance directives in accordance with the Policy and Procedure, "Advance Directives / Patient Self-Determination" (Advance Directives -Legal document that states a person's wishes for medical care if they are unable to communicate their preferences.)

This failure resulted in Patient (Pt) 1's rights and wishes to go unidentified in the event of an emergency.

Findings:

During a concurrent interview and record review on 11/13/24 at 3:13 p.m. with Shift Manager (SM) 3, Pt 1's "History and Physical [H&P- an assessment from physician including medical history and exam]" dated 9/4/24, were reviewed. The "H&P" indicated, Pt 1 was admitted as an inpatient on 9/4/24 at 5:47 p.m.

During a concurrent interview and record review on 11/13/24 at 3:17 p.m. with SM 3, Pt 1's "Condition of Admission and Treatment (COA), and "Advance Directive and POLST [physician order for life sustaining treatment] Tracking [ADPT]" dated 9/4/24, were reviewed. SM 3 stated page 5 of the "COA" asked patients questions about Advance Directives. SM 3 stated the "COA" page five was completed by registration staff when patients were admitted. SM 3 stated page five of Pt 1's "COA" did not have any of the advanced directive questions completed by hospital staff. The "COA" indicated, hospital staff must check a box on the form to indicate if the patient had an advanced directive or did not have an advanced directive. The "COA" had additional boxes for hospital staff to check if patients indicated they did or did not want information about advanced directives. The "COA" had a line for hospital staff to sign and date when the form was completed and was signed and dated. SM 3 stated Pt 1's "COA" should have had the boxes checked if Pt 1 received information or declined information about advanced directives. SM 3 stated Pt 1 should have been asked the questions on the "COA" and the "COA" should have been completed. SM 3 stated Pt 1 should have been given information about advanced directives for her to decide if she wanted one. SM 3 stated Pt 1's "ADPT" form was completed by a nurse. SM 3 stated Pt 1's "ADPT" indicated Pt 1 answered no to having an advanced directive. SM 3 stated the "ADPT" had a question on the form to prompt nurses to ask patients if they wanted a visit to complete, change or discuss an Advance Directive. SM 3 stated the area in Pt 1's form was blank. SM 3 stated her expectation was for nurses to complete all admission questions on the "ADPT" form.

During an interview on 11/15/24 at 2:52 p.m. with the Director of Patient Access (DPA), the DPA stated the Patient Access Registration (PAR) staff ask patients about Advanced Directives after admission. The DPA stated if patient's say they have an Advanced Directive the PAR staff request a copy from the patient. The DPA stated when patients do not have an Advanced Directive the PAR staff asked patients if they wanted information.

During a record review of the hospital's policy and procedure titled, "Advance Directives / Patient Self-Determination RI-51), dated 2/23, indicated, " ... The front page of the Advance Directive Statement will be completed ... to document each patient's Advance Directive status by the staff member who initiates the admission process ... Planned admission via Registration Department: Done by the Registration Clerk during the hours the Department is open and by the ER Registration Clerk after hours. ... Direct admission to a patient care unit: Done by the Registration Clerk at the bedside during the hours that the Registration Department is open and by the Nursing staff on the inpatient unit after hours ... Pre-registration of a surgical patient: Done by the Registration Clerk. ... Emergency Department (ED) patient who is admitted: Done by the ED Registration staff when the decision to admit an ED patient is made ...The form is reviewed with the patient and/or his/her legal representative. The appropriate box (es) and space(s) are completed to indicate the current Advance Directive status ... Patients requesting an advance directive document to read and/or prepare are given a blank copy of this document ... Nursing Assessment/Healthcare Team Follow-Up Process ... The nurse who admits the patient will ... Review the front page of the Advance Directive Statement to ascertain the Advance Directive status of the patient ... Completes the Advance Directive section of the Nursing Admission Assessment ... Follow up appropriately ...".

Based on observation, interview and record review, the hospital failed to ensure patients were free from restraints (chemical, physical, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely) and to ensure restraints were discontinued at the earliest possible time, when nurses did not complete restraint assessment monitoring every two-hours for one of three patients (Pt 31) to ensure Pt 31 remained free from injury and to determine if the restraints could be released , in accordance with hospital policy and procedure (P&P).

These failures resulted in Pt 31 to go without restraint monitoring, violated Pt 31's right to be released from restraints at the earliest possible time, and had the potential to cause injury from restraints.


Findings:

During a concurrent interview and record review on 11/12/24 at 3:23 p.m. with Registered Nurse (RN) 7 and the Director of Nursing (DON) Pt 31's "History & Physical [H&P- an assessment from physician including medical history and exam]," dated 10/11/24, was reviewed. The "H&P" indicated, Pt 31 was admitted to the hospital on 10/11/24 at 4:42 p.m. for sepsis (a life-threatening blood infection), and acute kidney injury (AKI- A sudden and often reversible decline in kidney function) after a laminectomy (a surgical cut into the backbone to get access to the structures in the spinal cord).

During a concurrent interview and record review on 11/13/24 at 11:30 a.m. with Shift Manager (SM) 3, Pt 31's "Restraint Monitoring Flowsheet (RMF)," dated 10/16/24 to 11/13/24 were reviewed. The "RMF" indicated Pt 31 was on two-point (a mechanical restraint that restricts a patient's wrist movement) soft limb (soft materials for arm or leg) restraints on 10/25/24. SM 3 stated Pt 31's LN was supposed to document monitoring assessments for Pt 31 every two hours. SM 3 stated Pt 31's "RMF" had no restraint monitoring documentation on 10/25/24 at 6 a.m., and on 10/30/24 at 4 a.m. SM 3 stated Pt 31's "RMF" indicated on 10/28/24 at 6 a.m. and on 10/30/24 at 6 a.m. LNs did not document a complete restraint monitoring assessment. SM 3 stated LNs were supposed to document in the "RMF" a complete restraint monitoring assessment every two hours. SM 3 stated, restraint monitoring assessments included, visual or safety observation, skin, circulation, level of consciousness, toileting, flids or nourishment offered, and response to interventions. SM 3 stated monitoring documentation was absent from Pt 31's "RMF". SM 3 stated monitoring patients in restraints was important to ensure patient's safety and patients were not being injured while in restraints.

During a concurrent interview and record review on 11/13/24 at 11:40 a.m. with SM 3, Pt 31's "Physician Orders (PO)" dated 10/25/24, was reviewed. The "PO" indicated, " ... Restraints-Non Violent/Non Destructive ... 10/25/24 10:00:00 [10 a.m.] ... [every two hours] (interval) ... Soft Limb, Bilateral Wrists, Climbing out of bed/chair risking safety: Pulling at lines, Tubes or Dressings ...Order Comments: RENEW RESTRAINTS DAILY ...". SM 3 stated, every two hours on the "PO" meant to monitor the patient every two hours.

During a concurrent observation and interview on 11/14/24 at 3:45 p.m. with the Spanish Interpreter (SI), and Family Member (FM) 2 in Pt 31's hospital room, Pt 31 was observed lying in his hospital bed at a 90-degree angle with his eyes open. Pt 31's right and left wrist were in soft restraints (padding attached around a limb [wrist] attached to bedframe, that limits a person's movement).

During an interview on 11/15/24 at 10:05 a.m. with Clinical Manager (CM) 6, CM 6 stated LNs should monitor and document restraint assessments every two hours and once per shift to determine if patients needed to remain on restraints. CM 6 stated, at least every two hours LNs should, reposition the patient, offer food or drinks and check circulation (flow of blood) to limbs (arm or leg). CM 6 stated when LNs assess restraints it should be documented.

During an interview on 11/15/24 at 3:43 p.m. with the Chief Nursing Officer (CNO), the CNO stated, her expectation was for LNs to monitor and document non-violent restraints every two hours according to hospital P&P. The CNO stated LNs should, assess for skin breakdown (skin damage), offer food, water, and toileting, and determine if patients could be released from restraints. The CNO stated an assessment of a patient in restraints should happen at least every two hours, to determine if a patient has a compromised (impaired or unable to function) limb, skin breakdown, agitation (tense, irritable, or confused), or a decline in mental status. The CNO stated LNs should assess patients in restraints to determine the earliest time the restraints can be removed.

During a review of the hospital's P&P titled, "Restraint Seclusion (PC-37)", dated 1/24/19, indicated, " ... PATIENT ASSESSMENT AND DOCUMENTATION OF THE NEED FOR NONVIOLENT/NON-SELF-DESTRUCTIVE RESTRAINTS: ... The RN must document the assessment in the EHR at the initiation of restraints ... Patient evaluation will be completed every TWO (2) hours on the even hour throughout the shift and will include but is not limited to ... Perform and Provide ... Vital signs with emphasis on cardiac and respiratory status ... Skin integrity ... Signs of any injury associated with restraint application ... CSM - circulation, sensation, range of motion ... LOC - level of consciousness ... Comfort (response to restraints - restless, calm, agitation) ... Provide nutrition and hydration ... Provide hygiene ... Provide for elimination ... Maintain safe environmental, dignity and safety ... Assess for readiness for discontinuation of restraint or behavior necessitating the continuation of restrains ... Non Violent/Non Self Destructive Restraint orders will not exceed one (1) calendar day ...".

During a review of professional reference titled, Patient Restraint and Seclusion," dated 11/14/22, (retrieved from https://www.ncbi.nlm.nih.gov/books/NBK565873/ f (nih.gov) indicated, " ... Healthcare workers should know that restraint and seclusion can have significant adverse implications on patients and should be deemed a last resort. Healthcare professionals must follow the 4 basic ethical healthcare principles: autonomy [make decisions and act independently without interference from others], justice, beneficence [the doing of good, promoting the well-being of others], and non-maleficence [doing no harm]. Per beneficence - the act of doing good - and non-maleficence - do no harm; healthcare providers must ensure the administration of restraint is implemented as a last resort ... Healthcare workers must also be sure to appropriately monitor the patient following restraint and seclusion to avoid deleterious [causing harm] effects such as pressure ulcers [localized area of damaged skin or tissue that occurs when pressure is applied to skin for a long time], skin breakdown, abrasions [scraping or wearing away] , asphyxia [body deprived of oxygen, suffocation], strangulation, incontinence [involuntary loss of bladder control], depression, social isolation, and drug overdose or interaction ...Document appropriate clinical indications and prepare a standardized checklist for staff to monitor and supply patient needs effectively. Numerous deaths and adverse patient outcomes have been reported due to inappropriate restraint placement and negligent [failing to take proper care] monitoring. After restraint placement, patients should be reevaluated every hour and moved regularly ... Once it is safe, the patient should also be evaluated for medical causes of agitation ...".

Based on observation, interview and record review, the facility failed to have a well-organized and effective nursing service when:

1. The hospital failed to develop and keep a current nursing care plan for three of 34 patients, Patient (Pt) 9, Pt 22 and Pt 23, when Licensed Nurses (LN) did not assess and develop an individualized care plan for pain and post-operative surgery in accordance with hospital policy and procedure (P&P), "Core Nursing Standards of Practice" (Refer to A-396).

2. A cardiopulmonary resuscitation (CPR, a lifesaving procedure performed when the heart stops beating) backboard (a flat, rigid board used to support the patient during CPR) was missing from Crash Cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations) #2 on the seventh floor and Crash Cart #2 was not maintained and checked in accordance with hospital P&P (Refer to A-398 Finding 1).

3. Licensed Nurses (LN) in the Emergency Department (ED) did not assess temperatures with every vital sign assessment for two of three sampled patients (Pt 25 and Pt 26), in accordance with hospital P&P, "Core Standards of Practice" (Refer to A-398 Finding 2).

4. Medication reconciliation (the process of comparing a patient's medication orders to all of the medications that the patient has been taking) was not completed for three of eight patients (Pt 22, Pt 24 and Pt 29) in accordance with hospital P&P, "Medication Reconciliation" (Refer to A-398 Finding 3).

5. Licensed Nurses (LN) for two of six patients (Pt 1 and Pt 31), did not assess pain or reassess pain after administration of pain medications in accordance with hospital P&P, "Pain, Assessment and Management of" (Refer to A-398 Finding 4).

6. Licensed Nurses (LN) did not document a chest pain assessment and/or notification to the physician of a change in condition related to chest pain or abdominal pain for one of 10 patients (Pt 1), in accordance with hospital P&P "Core Nursing Standards of Practice" (Refer to A-398 Finding 5).

7. Nursing staff administered blood products not in accordance with the hospitals policy and procedures (P&P) titled "Blood Products Transfusion", for one of one patient (Patient 9). (Refer to A-410).

The cumulative effect of these system problems resulted in the hospital's inability to provide nursing services in a safe setting.

Based on interview and record review, the hospital failed to develop and keep current a nursing care plan for three of 34, Patient (Pt) 9, Pt 22 and Pt 23, when Licensed Nurses (LN) did not assess and develop an individualized care plan for pain and post-operative surgery in accordance with their policy and procedure titled "Core Nursing Standards of Practice".

This failure had the potential to result in Patients' care needs going unmet and could possibly lead to a decline in health status.

Findings:

During a concurrent interview and record review on 11/13/24, at 11:06 a.m., with Registered Nurse (RN) 1 and Educator Manager (EM), Pt 9's electronic health record (EHR- digital collection of medical information) was reviewed. Pt 9's "History and Physical (H&P -- the formal document that physicians produce through interview with the patient, physical exam, and summary of laboratory testing)", dated 11/2/2024 at 3:20 a.m. and "Document in Plan [Nursing Care Plan]", dated 11/2/2024, were reviewed. Pt 9's H&P indicated Pt 9 was brought to the hospital for lethargy (general state of fatigue) and pain with a history of congestive heart failure (a chronic condition that occurs when the heart can not pump enough blood to the body), chronic obstructive pulmonary disorder (a common lung disease that makes it hard to breath), and chronic alcohol use. Pt 9 had been admitted to primarily treat hepatic encephalopathy (a serious but potentially reversible brain disorder that occurs when the liver is unable to filter toxins from the blood), pain, urinary tract infection and sepsis (a serious condition in which the body responds to a blood infection). Pt 9's "Nursing Care Plan" indicated, "...Confusion...Impaired Mobility...Nutrition...Risk for Falls... Fluid Volume Excess...Infection...Risk for Impaired Skin Integrity...[Alcohol] Abuse ... " as the focused care problems for nursing interventions. RN 1 stated, the care plan did not address one of the main reasons for the admission, pain. RN 1 stated, there should be a focus in the nursing care plan that addresses the patient's pain. RN 1 stated nurses are expected to develop a care plan to align with the needs of the patient.

During a review of Pt 22's "History and Physical (H&P-an assessment from physician including medical history and exam)," dated 10/21/24, the H&P indicated Pt 22 was a 24-year-old male who came to the facility for an outpatient procedure for excision (a medical procedure involving the removal of tissue through a surgical incision) of a right neck mass.

During a concurrent interview and record review on 11/13/24 at 9:41 a.m. with the post-anesthesia care unit (PACU-a specialized unit for the care of patients after surgery and the patient's vital signs are closely observed, pain management begins, and fluids are given) Clinical Manager (CM) 3, Pt 22's "Orders/Plans," dated 11/12/24 was reviewed. CM 3 stated Pt 22's care plan in the PACU addressed issues of anxiety. CM 3 stated a care plan for pain management was not initiated in the PACU and should have been. CM 3 stated care plans were initiated for patients to help guide Licensed Nurses (LN) on an individualized plan for patient care.

During a review of Pt 23's "H&P," dated 10/31/24, the H&P indicated "...71 year old male with a [past medical history] of chronic HFrEF (heart failure with reduced ejection fraction-the amount of blood, as a percentage, that is pumped out of a filled ventricle with each heartbeat), chronic atrial fibrillation (irregular and often very rapid heart rhythm) with RVR (rapid ventricular response-when the rapid contractions of the atria make the ventricles beat too quickly), hypertension (high blood pressure) ..." .

During a review of Pt 23's "Progress Note (PN)," dated 11/12/24, the PN indicated, "...patient to undergo cardiac catheterization (a long, thin, flexible tube called a catheter is put into a blood vessel in the arm, groin or upper thigh, or neck. The catheter is then threaded through the blood vessels to the heart) ..."

During a concurrent interview and record review on 11/13/24 at 11:13 a.m. with CM 3 and Nurse Educator (NE) 3, Pt 23's "Orders/Plans," dated 11/12/24 was reviewed. CM 3 stated Pt 23's care plan in the PACU addressed issues for fall. CM 3 stated a care plan for pain management was not initiated in the PACU and should have been initiated. NE 3 stated a care plan to address discharge plan should have also been initiated for Pt 23.

During an interview on 11/14/24 at 3:32 p.m. with CM 3, CM 3 stated LNs are expected to initiate care plans for patients in PACU. CM 3 stated LNs should follow the policy.

During a concurrent interview and record review with the Chief Nursing Officer (CNO), on 11/15/24, at 3:15 p.m., the CNO stated the nursing care plan should have addressed Pt 9's primary needs for the admission, and it was not. The CNO stated a nursing care plan for Pt 9's pain was not developed and implemented. The CNO stated LNs are expected to initiate a care plan addressing pain for patients in the PACU. The CNO stated, nurses are expected to follow the policy to develop, document and update the care plan to meet the patient's care needs.

During a review of the facility P&P titled, "Core Nursing Standards of Practice", dated 6/2022, the P&P indicated, " 2. Nursing Diagnosis - The registered nurse analyzes assessment data to determine actual or potential nursing diagnoses, patient problems and issues. The registered nurse: ... a. Identifies actual or potential risks to the patient's health and safety or barriers to health, which may include but are not limited to interpersonal, systematic, cultural or environmental circumstances. ... b. Uses assessment data, standardized classification systems, technology, and clinical decision support tools to articulate actual or potential nursing diagnoses, patient problems, and issues. ... c. Verifies the nursing diagnoses, patient problems and issues with the patient, family, and interprofessional colleagues. ... d. Prioritizes nursing diagnoses, patient problems, and issues based on mutually established goals to meet the needs of the patients across the health-illness continuum. ... e. Documents nursing diagnoses, patient problems, and issues in a manner that facilitates the determination of the expected outcomes and plan (ANA [American Nurses Association], 2015). ... 4. Plan of Care - The registered nurse develops a plan that prescribes strategies to attain expected, measurable outcomes. The registered nurse: ... a. Partners with the patient to implement the plan in a safe, effective, efficient, timely, patient-centered, and equitable manner. ... "

The "Lippincott Manual of Nursing Practice 10th Edition," dated 2014, page 16-17 indicated, " Standards of practice General Principles... 1. The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable ...b. These standards provide patients with a means of measuring the quality of care they receive ...5. A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation ... Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record ... Failure to formulate or follow the nursing care plan ..."

Based on observation, interview, and record review, the facility failed to follow their policies and procedures when:

1. A cardiopulmonary resuscitation (CPR, a lifesaving procedure performed when the heart stops beating) backboard (a flat, rigid board used to support the patient during CPR) was missing from Crash Cart (a wheeled container carrying medicine and equipment for use in emergency resuscitations) #2 on the seventh floor and Crash Cart #2 was not maintained and checked in accordance with hospital policies and procedures.

This failure had the potential to put patients at risk of not having their needs met if the crash cart was needed in an emergent situation.

2. Nursing Staff in the Emergency Department (ED) did not assess temperatures with every vital sign assessment for two of three sampled patients (Pt 25 and Pt 26), in accordance with hospital policy and procedure titled, "Core Standards of Practice".
These failures had the potential to result in missing a change in condition in patients and a possible delay in implementing interventions to address the clinical needs of patients.

3. Medication reconciliation (the process of comparing a patient's medication orders to all the medications that the patient has been taking) was not completed for three of eight patients (Pt 22, Pt 24 and Pt 29) according to the hospital policy and procedure titled, "Medication Reconciliation."

This failure resulted medication reconciliation not being performed and had the potential to cause harm to Pt 22, Pt, 24 and Pt 29.

4. For two of six patients (Pt 1 and Pt 31) Licensed Nurses (LN) did not complete a pain assessment, did not reassess pain after administration of pain medications and did not complete a level of sedation assessment after opioid (a class of drug used to treat moderate to severe pain) administration in accordance with hospital policy and procedure (P&P), "Pain, Assessment and Management of (PC-56 B)".

These failures had the potential to for Pt 1 and Pt 31 to receive inadequate pain management, or oversedation (greater than the desired therapeutic level of a relaxed, calm, sleepy state caused by medication) , and had the potential for LNs to miss change in conditions of Pt 1 and Pt 31.

5. LNs did not document chest pain assessment and notification to the physician of a change in condition related to chest pain and abdominal pain for one of ten patients (Pt 1) in accordance with hospital policy and procedure, titled, "Core Nursing Standards of Practice".

This failure resulted in no documentation of coordinating care for Pt 1 and had the potential to result in a possible delay of needed treatment and services for Pt 1.

Findings:

1. During a concurrent observation and interview on 11/12/24 at 10:34 a.m. on the seventh floor medical/surgical (M/S) unit with Registered Nurse (RN) 2, Crash Cart #2 did not have a backboard on the cart. RN 2 stated the backboard should have been hanging on the back of the Crash Cart but it was not there.

During a review of the facility's policy and procedure titled, "Crash Cart Management (CCM)", dated 6/2023, the "CCM" indicated, " ... All Crash Carts will be maintained with age appropriate emergency equipment, supplies, and medications for the patient population being served. Crash Carts ... are located throughout the patient care areas to provide timely .... response to code [the heart stops beating] situations ... The Crash Cart 'Content List', which is laminated and available on the cart, describes the exact location (e.g. drawers or top of the cart) of all items (supplies and medications) contained on the Crash Cart. This list is standardized in all nursing units ... the content list serves as a guide and verification tool for the daily and monthly cart checks ... Guidelines ... Crash Cart Check Process ... Designated Registered Nurses will check the Crash Cart each shift and document their findings on the Crash Cart Checklist ... Replacement of missing equipment and other content will be immediately handled by the designee ... Crash Cart Contents ... The code Blue Committee is responsible for reviewing and updating the Crash Cart Contents List per American Heart Association Guidelines ... References ... American Heart Association ...".

During a review of the facility's "Adult Crash Cart Content List (CL)", dated 3/29/22, the "CL" indicated, " ... Top of Cart Contents ... 1 EA [each] ... Adult Backboard ...".

During a concurrent interview and record review on 11/15/24 at 3:15 p.m. with the Chief Nursing Officer (CNO), the facility's "7th Floor Crash Cart Checklist #2 (CCC)", dated 11/2024, was reviewed. The "CCC" indicated, the crash cart had been checked each shift from 11/1/24 to 11/15/24. The CNO stated the crash cart should be checked each shift for all the supplies and items located on the cart.

During the review of a professional reference titled, "Unleashing the potential of CPR boards: Enhance life-saving techniques and ensure workplace safety (UP)", dated 2024, "UP" indicated, " ... CPR boards play a vital role in providing stability, proper positioning, and support during resuscitation procedures ... One of the essential CPR boards is the standard adult CPR board, which offers a sturdy surface for performing CPR on adult patients. It ensures proper alignment of the head, neck, and torso, facilitating effective compressions [pushing of the chest bone to pump the heart] and ventilations [providing respirations] ... CPR boards are an essential piece of equipment for emergency response situations ... By having CPR boards readily available in emergency response kits or medical facilities, responders can quickly access the necessary equipment to initiate life-saving interventions. These boards contribute to improving the quality of CPR and increasing the chances of a successful resuscitation outcome during critical moments ...".

2. During a review of Pt 25's "Emergency Department Physician Note (EDPN)," dated 11/10/24, the EDPN indicated, " ...85 year old female, with a [past medical history] of HTN [hypertension- high blood pressure], Alzheimer disease [a brain disorder that gradually destroys memory and thinking skills], and dementia [a condition that causes loss of memory and the ability to think clearly] ... BIBA [brought in by ambulance] from ... retirement homes after experiencing an unwitnessed fall from her wheelchair ..."
During a concurrent interview and record review on 11/14/24 at 11:04 a.m. with Registered Nurse (RN) 5, Pt 25's "Vital Signs Summary (VSS)" dated 11/10/24 was reviewed. RN 5 stated the VSS indicated Pt 25 had a temperature assessed at 8 p.m. and no other temperature was assessed with a vital sign assessment during Pt 25's visit to the ED. RN 5 stated a temperature assessment should be completed with every vital sign assessment.

During a review of Pt 26's "EDPN," dated 11/1/24, the EDPN indicated, " ...73 year old female with [past medical history] of DM [diabetes mellitus- a condition that happens when your blood sugar (glucose) is too high] ... kidney disease [a condition where the kidneys are damaged and cannot filter blood properly], ... GERD [gastroesophageal reflux disease-a chronic condition that occurs when stomach contents leak back into the esophagus], HTN ... BIBA ... for altered mental status [a change in how well your brain is working] ..."

During a concurrent interview and record review on 11/14/24 at 11:41 a.m. with RN 5, Pt 26's VSS, dated 11/1/24 and 11/2/24 were reviewed. The VSS indicated Pt 26 had a temperature assessed at 5:06 p.m. and no other temperature was assessed with a vital sign assessment during Pt 26's visit to the ED.

During an interview on 11/14/24 at 3:41 p.m. with the Emergency Department Clinical Manager (CM) 4, CM 4 stated LNs are expected to assess and document a temperature with every vital sign assessment.

During an interview on 11/15/24 at 3:13 p.m. with the Chief Nursing Officer (CNO), the CNO stated a temperature should be taken with every vital sign to recognize changes in a patient's condition.

During a review of the facility's P&P titled, "Core Standards of Practice," reviewed 6/2020, the Policy and procedure (P&P) indicated, " ...Vital signs include temperature, heart rate, respiratory rate, blood pressure, and pulse oximetry ..."

3. During a review of Pt 22's "History and Physical (H&P-an assessment from physician including medical history and exam)," dated 10/21/24, the H&P indicated Pt 22 was a 24-year-old male who came to the facility for an outpatient procedure for excision (a medical procedure involving the removal of tissue through a surgical incision) of a right neck mass.

During a concurrent interview and record review on 11/13/24 at 9:25 a.m. with Clinical Manager (CM) 3, Pt 22's "Medication Reconciliation (MR)" tab, undated, was reviewed. CM 3 stated the "MR" indicated the last documented date was on 11/5/24. CM 3 stated Pt 22's medication history was not completed when Pt 22 arrived in the preoperative (before a surgical operation) area of the Post-Anesthesia Care Unit (PACU- a specialized unit where the patient's vital signs are closely observed, pain management begins, and fluids are given). CM 3 stated LNs are expected to complete the patient's medication history to ensure the medication list is the most current. CM 3 stated it was important to know the patient's medication history because it could cause interactions with anesthesia (a medical intervention that uses drugs to temporarily induce a state of controlled loss of awareness or sensation), and it was to prevent an adverse effect from occurring.

During an interview on 11/14/24 at 3:32 p.m. with CM 3, CM 3 stated pre-admission completes a medication history when the patient registered for the procedure. CM 3 stated LNs in the preoperative area are expected to review the patient's medication history on the day of the procedure. CM 3 stated it was important for LNs to review the patient's medication history on the day of the procedure to make sure a medication was not missed or changed since the last review.

During a review of Pt 24's "H&P," dated 11/4/24, the H&P indicated Pt 24 was a 69-year-old male with benign prostatic hyperplasia (BPH-a condition in which the prostate gland grows larger than normal) who came to the facility for a transurethral resection of the prostate (TURP-a surgery to remove the inside part of the prostate gland) procedure.

During a concurrent interview and record review on 11/13/24 at 1:49 p.m. with Registered Nurse (RN) 7 and Nurse Educator (NE) 3, Pt 24's "MR" tab, undated, was reviewed. RN 7 stated the "MR" indicated a medication reconciliation was not completed at discharge for Pt 24. RN 7 stated the medication reconciliation should have been completed before discharge to determine new medication and medications to continue at home and how often to take them.

During a review of Pt 29's "H&P," dated 11/7/24, the H&P indicated Pt 29 was an 81-year-old male with a past medical history of Chronic Obstructive Pulmonary Disease [COPD-a common lung disease that makes it difficult to breathe], Congestive Heart Failure [CHF-a chronic condition that occurs when the heart can't pump enough blood to meet the body's needs], and atrial fibrillation [an abnormal heartbeat] who came to the Emergency Department (ED) for shortness of breath and dry cough for a couple of days.

During a concurrent interview and record review on 11/14/24 at 9:43 a.m. with Registered Nurse (RN) 1, Pt 29's "MR" tab, undated, was reviewed. RN 1 stated the "MR" indicated a medication reconciliation was not completed at admission for Pt 29. RN 1 stated it should have been completed when Pt 29 was admitted to determine if there were medication changes at discharge. RN 1 stated an adverse effect could cause harm to the patient when medication reconciliation was not completed.

During an interview on 11/14/24 at 3:25 p.m. with CM 5, CM 5 stated Licensed Nurses (LN) are expected to complete a medication reconciliation when a patient is admitted to the unit. CM 5 stated LNs are expected to complete a medication reconciliation when a patient is discharged. CM 5 stated LNs are responsible to review the patient's medication history and the physician would then review and sign the medication reconciliation.

During an interview on 11/15/24 at 3:13 p.m. with the Chief Nursing Officer (CNO), the CNO stated LNs are expected to make every effort to have an accurate medication list collected so the physician can finalize and reconcile the patient's medications. The CNO stated it was important to make sure patients are receiving the appropriate medications.

During a review of the facility's P&P titled, "Medication Reconciliation," reviewed 6/2023, the P&P indicated, " ...POLICY: [Name of Hospital] nursing and medical staff ensures that each patient's medication profile is reconciled on admission to the hospital, at the time of transfer to a different level of care, and on discharge from the hospital and its various outpatient locations ... GUIDELINES: ... Inpatient ... Upon Admission: a. Registered nurse staff is responsible for obtaining an accurate and complete medication history including prescription medications, over the counter medications as well as herbal therapies. b. Included in the history is the medication name, dosage, frequency of administration, and the date and time of last dosage taken. c. The medication history is to be documented on the admission assessment database in the electronic health record (EHR). d. LIP [Licensed Independent Practitioner] will review the medications on the Admission Medication History and reconcile the list through the EHR ... Upon discharge from the hospital: a. LIP will review the Discharge Medication Reconciliation Section in the EHR and identify the medications they want the patient to: 1) Continue taking at home. 2) Discontinue on discharge 3) Change the dosage, route, or frequency of the medications before they go home ... Outpatient ... All Outpatient locations administering medication will: a. Obtain a current medication list from the patient, family member(s) and/or LIP. b. Upon discharge from the outpatient location the current medication list will be reconciled and any changes to the patient's current medications will be noted ..."

4. During a concurrent interview and record review on 11/12/24 at 3:23 p.m. with Registered Nurse (RN) 7 and the Director of Nursing (DON) Pt 31's "History & Physical [H&P- an assessment from physician including medical history and exam]," dated 10/11/24, was reviewed. The "H&P" indicated, Pt 31 was admitted to the hospital on 10/11/24 at 4:42 p.m. for sepsis (a life-threatening blood infection), and acute kidney injury (AKI- A sudden and often reversible decline in kidney function) after a laminectomy (a surgical cut into the backbone to get access to the structures in the spinal cord).

During a review of Pt 31's "Medication Order (MO)", dated 11/6/24 at 11:13 a.m., the "MO" indicated, " ... morphine (medication used to treat moderate to severe pain) ... 4 [milligrams] (a unit of measurement), IV (intravenous, into vein) Push (medication pushed into vein by syringe through IV line), [injection]- (use of a syringe to push medication into body)], [every 4 hours] ... [as needed] Reason: Pain Severe (7-10) ...".

During a concurrent interview and record review on 11/13/24 at 2:30 p.m. with Shift Manager (SM) 3, Pt 31's "Pain Monitoring Flowsheet (PMF)," and "Medication Administration Record (MAR- a record of drugs administered to a patient)," dated 11/8/24, were reviewed. Pt 31's "PMF" indicated, on 11/8/24 at 12:23 p.m. a numeric pain scale with a pain intensity of 10 (10/10 pain indicating worst possible pain). SM 3 stated no additional pain assessment information was documented. SM 3 stated a pain score of seven to 10 was severe pain. Pt 31's "MAR" indicated, on 11/8/24 at 12:25 p.m. LNs administered 4 milligrams morphine IV. SM 3 stated Pt 31's "PMF" indicated, on 11/8/24 at 12:40 p.m. a continued pain intensity of 10, with an acceptable pain (level of pain considered tolerable enough to allow someone to carry out their normal daily activities) intensity score of 4. SM 3 stated Pt 31's "PAF" indicated LNs did not document a sedation scale after administration of morphine. SM 3 stated LNs should have documented a sedation scale. SM 3 stated LNs documented, "Effective-Pain Goal Met". SM 3 stated LNs only documented the pain intensity and the pain scale prior to administration of medication. SM 3 stated LNs should have contacted the physician when Pt 31 continued to have a pain intensity of 10. SM 3 stated Pt 31's "PMF" indicated a numeric score of four was an acceptable level of pain, and LNs documented pain medication was effective when Pt 31 continued to report a pain level of 10. SM 3 stated a score of 10 was not Pt 31's reported acceptable level of pain. SM 3 stated if pain medication was not effective and patients continued to complain of pain, the patient should be assessed, and the physician should be contacted. SM 3 stated each time Pt 31 was assessed for pain LNs should have documented the location of pain, pain intensity, the pain scale used, and patient's acceptable level of pain.

During an interview on 11/15/24 at 10:05 with Clinical Manager (CM) 6, CM 6 stated pain assessments should be done once per shift, with vital signs and whenever patients complain of pain. CM 6 stated LNs should reassess patients after pain medications were administered to ensure (make certain) pain was well controlled or if there was anything else LNs could do for the patient to help alleviate pain.

During a concurrent interview and record review on 11/13/24 at 3:12 p.m. with SM 3, Pt 1's "H&P," dated 9/4/24, were reviewed. The "H&P" indicated, Pt 1 was brought in by ambulance to the Emergency Department (ED) on 9/4/24 at 1:25 p.m. with moderate-to severe widespread abdominal pain radiating (spread from one area of body to another) to the left lower quadrant (LLQ- left lower section of abdomen) pain, nausea, and vomiting. Pt 1 had a past medical history (PMH) of hypertension (HTN-high blood pressure) and colitis (swelling of the large intestine). The "H&P" indicated, Pt 1 was admitted for abdominal pain, and acute renal failure (when the kidneys suddenly can't filter waste products from the blood). Pt 1 was admitted as an inpatient on 9/4/24 at 5:47 p.m.

During a concurrent interview and record review on 11/13/24 at 3:18 p.m. with SM 3 Pt 1's "Medication Order (MO)", dated 9/7/24 at 3:39 p.m., was reviewed. The "MO" indicated, ...Order: morphine ... 4 milligrams [mg-a unit of measurement], IV Push (pushed into IV line) ... [injection] ... [one time dose] Priority: STAT (immediately) ....

During a concurrent interview and record review on 11/13/24 at 3:22 p.m. with SM 3, Pt 1's "PMF," and "MAR," dated 9/4/24 to 9/7/24, were reviewed. The "Pain Monitoring Flowsheet" indicated on 9/4/2024 at 1:25 p.m. a reported numeric pain intensity score of 8. SM 3 stated Pt 1's "PMF" indicated no additional LN pain assessment information was documented. SM 3 stated Pt 1's "MAR" indicated no medications were administered. SM 3 stated LNs should have documented the location, duration, type, and acceptable level of pain. The "PMF" indicated on 9/4/2024 at 3:47 p.m. a numeric pain intensity score of 2 (mild pain). SM 3 stated no additional pain assessment information was documented. SM 3 stated Pt 1's "MAR" indicated no pain medications were administered. Pt 1's "PMF" indicated on 9/4/24 at 4:46 p.m. a numeric pain intensity score of seven (severe pain), and the Pasero Opioid (class of drug used to treat moderate to severe pain) Sedation Scale (POSS - a valid reliable tool used to assess sedation when administering opioids) were completed. SM 3 stated no additional pain assessment information was documented. SM 3 stated Pt 1's "MAR" indicated on 9/4/2024 4:46 p.m. LNs administered 4 mg morphine IV. SM 3 stated a pain reassessment should have been completed by 5:16 p.m. The "PMF" indicated Pt 1's pain was not reassessed until 7:40 p.m. SM 3 stated Pt 1's pain should have been reassessed to determine if medication was effective. SM 3 stated Pt 1's "PMF" indicated, LNs did not document Pt 1's location of pain during any pain assessment. SM 3 stated LNs should have completed pain assessments according to hospitals P&P. SM 3 stated LNs needed to determine where Pt 1's pain was originating from. SM 3 stated LNs needed to ensure pain was being treated, and following up with patients to ensure pain wasn't worsening or changing. SM 3 stated "assessments drive our care (information collected from assessments determine patient care)". SM 3 stated LNs need to determine where pain is located to determine what information to give the physician about what could be causing the pain.

During an interview on 11/15/24 at 10:17 a.m. with CM 5, CM 5 stated LNs were expected to assess and document pain location, pain intensity, number, what was being done about the pain, and what pain medication was being administered. CM 5 stated, LNs should contact the physician if pain medications were not effective.

During an interview on 11/15/24 at 3:40 p.m. with the Chief Nursing Officer (CNO), the CNO stated pain assessments should include, numerical value, duration (how long pain), intensity (how strong), and location (where pain was located) of the pain. The CNO stated when LNs do not complete a pain assessment a patient's pain may go untreated. The CNO stated when LNs do not complete a full pain assessment LNs could miss a change in condition (a significant worsening in health). The CNO stated incomplete pain assessments could be detrimental (causing harm) in a patient's healing. The CNO stated anytime a pain medication was given LNs were expected to reassess and document pain according to hospital P&P.

During a review of the hospital's P&P titled, "Pain, Assessment and Management of (PC-56-B)", dated 2/23, indicated, " ... Assessment parameters include, but are not limited to: ... Nature of pain, location, duration, type, intensity, factors that exacerbate pain, any pain relief methods that have proven effective or ineffective, and the patient's desire for pain control (i.e. complete pain relief, etc.) ... Age, developmental status, physical condition, cultural, spiritual, ethnic and personal belief systems ... Information will be obtained from family, significant others and/or non-verbal ... cues for those patients who are unable to communicate verbally ... Numeric Rating Scale: (zero to ten with zero being pain free and ten (10) the worst pain imaginable) verbally communicated - older children and adults ... Pasero Opioid Sedation Scale (POSS) is a validated, standardized scale used in multiple populations for assessment of opioid sedation ... Use POSS to monitor sedation in patients receiving any form of opioids (oral, topical, IV, rectal) ... Notify MD for patients that are having levels in three to four (3-4) range and review medications ... The patient's self-report of pain is obtained and recorded on the Vital Sign Flow Sheet ... Using the appropriate tool ... Each and every time Vital Signs are taken ... Or at least once per shift ... At a reasonable interval, after every pain intervention to determine effectiveness ... No more than thirty (30) minutes after IV analgesic ... No more than sixty (60) minutes after PO analgesic ... If the patient is sleeping, "S" is documented ... A pain rating of three (3) or more, or greater than the patient's goal, will be reported and assessed by a Registered Nurse ... Additional pain management interventions will be performed, as needed, to obtain an acceptable outcome ... Care providers will communicate and collaborate regarding effective pain management for an individual patient, when appropriate ... All assessments, reassessments and interventions for pain management are to be documented appropriately in electronic medical record ...".

During a review of the hospital's P&P titled, "Core Nursing Standards of Practice (PC-460)," dated 6/9/22, indicated, " ... Assessment ... The registered nurse performs and/or oversees the collection of pertinent data and information relative to the patient's health or the situation. Data will be obtained by interview, observation, physical exam and review of the patient record. Priority of data collection is determined by the patient's immediate health care needs ... Care Delivery - The registered nurse performs and/or oversees delivers care according to the patient's need, LP [licensed provider] orders, and the plan of care to achieve identified outcomes ... Comfort and Sedation ... Pain is assessed by location, intensity and exacerbating and relieving characteristics using the appropriate pain scale on admission, a minimum of every shift, and PRN ... A pain assessment and reassessment is performed and documented before and after each intervention for pain ...

During a professional reference review titled, "Acute Pain Management Pearls: A Focused Review for the Hospital Clinician [health care professional]," dated 12/22/22, (found at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9818465/) indicated, " ... Uncontrolled pain worsens patient outcomes ... Uncontrolled acute pain triggers a complex neurohormonal cascade [a series of coordinated responses where hormones produced by neurons [make up brain and nervous system] that are released in succession to body responses] that is toxic to nearly every organ system, as evidenced by increased rates of renal [kidney] and gastrointestinal [stomach and intestine] dysfunction, infection, cardiopulmonary [heart and lungs] and thrombotic [blood clot] complications, impaired wound healing, adverse psychological effects, and poorer functional recovery and quality of life ... Acute pain management in hospitalized patients should therefore be a clinician and institutional [facility] priority as a key driver of patient outcomes ...".

5. During a concurrent interview and record review on 11/13/24 at 3:12 p.m. with SM 3, Pt 1's "H&P," dated 9/4/24, were reviewed. The "H&P" indicated, Pt 1 was brought in by ambulance to the ED on 9/4/24 at 1:25 p.m. with moderate-to severe abdominal pain radiating to the left lower quadrant (LLQ- left lower section of abdomen) pain, nausea, and vomiting. Pt 1 had a past medical history (PMH - a record of a patient's health before the current problem) hypertension (HTN- high blood pressure), and colitis (swelling of the large intestine [long tube inside abdomen that turns food waste into stool]) The "H&P" indicated, Pt 1 was admitted for abdominal pain, and acute renal failure (when the kidneys suddenly can't filter waste products from the blood). Pt 1 was admitted as an inpatient on 9/4/24 at 5:47 p.m.

During a concurrent interview and record review on 11/14/24 at 9:40 a.m. with SM 3, Pt 1's "PMF" dated 9/7/24 was reviewed. The "PMF" indicated on 9/7/24 at 8 a.m. Pt 1 reported pain intensity as zero. SM 3 stated Pt 1's next pain score was documented until 2:59 p.m. SM 3 stated Pt 1's "PMF" indicated on 9/7/24 at 2:59 p.m. a pain intensity score of 7. SM 3 stated Pt 1's "PMF" had no documentation of a pain assessment associated with chest pain on 9/7/24.

During an interview on 11/14/24 at 2:05 p.m. with Shift Manager (SM) 4, SM 4 stated on 9/7/24 she was the Charge Nurse (Shift Manager) on the Pt 1's unit from 6:30 a.m. to 7 p.m. SM 4 stated her role as a Charge Nurse was a resource (answer questions, help with care) for the LNs on the unit. SM 4 stated she recalled in the morning of 9/7/24 around 8:30 a.m. Pt 1 reported chest pain to one of the LNs. SM 4 stated she thought Pt 1's primary nurse (RN 14) called Pt 1's physician. SM 4 stated she later found out that RN 14 did not document the call to physician. SM 4 stated LNs should document communication with physicians, so the care team has a record of when the physicians were contacted.

During an interview on 11/14/24 at 2:40 p.m. with RN 13, RN 13 stated she was working on Pt 1's unit on 9/7/24 from 7 a.m. to 7:30 p.m. and was assigned to a different patient in the same room as Pt 1. RN 13 stated she was caring for her assigned patient and heard Pt 1 moaning and calling out for help, over the curtain in the room. RN 13 stated Pt 1 was complaining of chest pain and was saying "somebody help me". RN 13 stated she informed Pt 1's primary nurse (RN 14), and the Charge Nurse (SM 4) about Pt 1's pain. RN 13 stated she did not contact Pt 1's physician. RN 13 stated she did not document in Pt 1's medical record because she was not Pt 1's primary nurse. RN 13 stated she should have documented any care she provided in Pt 1's medical record.

During an interview on 11/14/24 at 3:17 p.m. with Medical Doctor (MD) 1, MD 1 stated he was Pt 1's primary admitting hospitalist (a dedicated in-patient physician who works exclusively in a hospital). MD 1 stated on 9/7/24 he assessed Pt 1 after LNs contacted him about abdominal pain, and Pt 1 appeared to be in distress. MD 1 stated Pt 1's reported pain was a change in her baseline pain level (initial measurement taken about a patient's health condition). MD 1 stated he ordered a CT scan (computed tomography - medical imaging procedure that uses X-rays to create detailed cross-sectional images of the body, used to diagnose disease, or plan treatment) of Pt 1's abdomen.

During an interview on 11/15/24 at 10:17 p.m. with Clinical Manager (CM) 5, CM 5 stated anytime LNs contacted the physician the information should be documented in the medical record.

During an interview on 11/15/24 at 10:47 a.m. with the Manager of Patient Safety (MPS), the MPS stated Pt 1's daytime primary nurse (RN 14) from 9/7/24 no longer works at the hospital.

During an interview on 11/15/24 at 11:13 a.m. with the MPS, the MPS stated any LNs who provided care to or contacted the physician for Pt 1 should have documented in Pt 1's medical record. The MPS stated Pt 1's medical record was lacking documentation. The MPS stated when Pt 1's medical record was reviewed by the Chief Medical Officer (CMO) he discovered no chest pain assessment was documented. The MPS stated LNs failed to document Pt 1's chest pain assessment, notification to the physician for chest pain or abdominal pain, and what the physician was doing for the chest pain or abdominal pain.

During an interview on 11/15/24 at 10:47 a.m. with the MPS, the MPS stated Pt 1's family requested a meeting with the care team a week after Pt 1's death. The MPS stated in preparation of the meeting Pt 1's medical record was reviewed by the Chief Medical Officer (CMO). The MPS stated a lack of LN documentation for a chest pain assessment was identified. The MPS stated the CMO was reviewing the physician's care of Pt 1 and did not investigate lack of LN documentation in Pt's 1 medical chart.

During an interview on 11/15/24 at 11:24 a.m. with RN 9, RN 9 stated he was working on the Medical Surgical (MS-a hospital unit where patients are treated for a variety of medical conditions) Unit during the dayshift on 9/7/24. RN 9 stated he was not Pt 1's primary nurse. RN 9 stated he answered Pt 1's call light and Pt 1's family were requesting to speak to MD 1. RN 9 stated he then called MD 1 to report Pt 1's family wanted an update. RN 9 stated MD 1 came to the MS unit to assess Pt 1 shortly after. RN 9 stated he did not document contacting MD 1 in Pt 1's medical record. RN 9 stated he "probably should have". RN 9 stated he was not sure if he could access the medical record because Pt 1 was not "his patient (he was not Pt 1's primary nurse)".

During an interview on 11/15/24 at 1:58 p.m. with the Chief Nursing Officer (CNO), the Manager of Patient Services (MPS), and the Accreditation Regulation Manager (ARM), the CNO stated further review of Pt 1's medical record was complete by nursing management. The CNO stated a review of Pt 1's medical record and interviews of Pt 1's LN care team were completed prior to a "CANDOR [Communication and Optimal Resolution- process that healthcare institutions and practitioners can use to respond in a timely, through and just way when an unexpected event occurs]" meeting with Pt 1's family. The CNO stated a lack of LN documentation was identified during nursing management review of Pt 1's medical record. The CNO stated some of the LNs interviewed about failure to document care reported not documenting because, Pt 1 was not "their patient" meaning, LNs were not assigned the patient as the primary nurse. The CNO stated a

Based on interview and record review, the hospital failed to ensure the nursing staff administered blood products according to their policy and procedures (P&P) titled "Blood Products Transfusion", for one of one patient (Patient 9) when documentation was missing for the completion of administration of a blood product, vital signs (measurements of the body's basic functions, such as breathing rate, temperature, pulse, and blood pressure), and a nursing assessment.

This failure had the potential to place Pt 9 at risk for overlooking a possible reaction to the administration of a blood product and negative health outcomes.

Findings:

During a concurrent interview and record review on 11/13/24, at 11:06 a.m., with the Registered Nurse (RN) 1 and Educator Manager (EM), Pt 9's electronic health record (EHR- digital collection of medical information) was reviewed. Pt 9's "History and Physical (H&P -- the formal document that physicians produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending)", dated 11/2/2024 at 3:20 a.m. and "Blood Transfusion [Flowsheet]", dated 11/3/2024 and 11/4/24, were reviewed. Pt 9's H&P indicated Pt 9 was brought to the hospital for lethargy and pain with a history of congestive heart failure (a chronic condition that occurs when the heart cannot pump enough blood to the body), chronic obstructive pulmonary disorder (a common lung disease that makes it hard to breath), and chronic alcohol use. Pt 9 was admitted to primarily treat hepatic encephalopathy (a serious but potentially reversible brain disorder that occurs when the liver is unable to filter toxins from the blood), pain, urinary tract infection and severe sepsis (a serious condition in which the body responds improperly to an infection). RN 1 stated, on 11/3/2024, the provider had ordered a total of three units of fresh frozen plasma (FFP) (blood product that contains clotting factors to help patients with a risk of bleeding) and one unit of packed red blood cells (used for treating patients with a low blood count). RN 1 stated, the last unit of FFP was started on 11/4/2024 at 5:03 a.m. RN 1 stated, the nurse did not document the time the FFP had been completed and it should have been documented. RN 1 stated, the nurse should have documented the time of the completion of the FFP, vital signs and if the patient had any adverse effects from the blood product.

During an interview on 11/15/24 at 3:12 p.m., with the Chief Nursing Officer (CNO), the CNO stated she was aware of the case for Pt 9 and her expectations of nurses were to follow the P&P for blood transfusions. The CNO stated it was important to ensure that nurses document per the hospitals policy for the safety of the patient and not miss a possible adverse reaction.

During a review of the hospital's P&P titled, "Blood and/or Blood Products Transfusion (PC-78)", dated 7/24, the P&P stated, " ... 2. The patient's baseline vital signs are to be taken and recorded on the Blood Transfusion Record ... a. Pre transfusion ...b. Within fifteen (15) minutes of starting transfusion ... c. Thirty (30) minutes of starting transfusion ... d. Once when infusion is complete ... e. One (1) hour after infusion is completed...."

Based on observation, interviews, and record review, the facility failed to maintain secure access to locked medication rooms when Registered Nurse (RN) 1 shouted the medication room door lock code across the hall on the 7th floor medical/surgical (M/S) unit.

This failure had the potential to result in unauthorized patients, staff and visitors access to medications in the locked medication room.

Findings:

During a concurrent observation and interview on 11/12/24 at 10:30 a.m. on the 7th floor at the medication room door with Registered Nurse (RN) 2, RN 2 stated the medication room door code had recently been changed throughout the hospital and she could not remember it. RN 2 called out to RN 1 and asked RN 1 to come to the medication room and give her the code, RN 1, who was not visible, yelled the code number to open the medication room door. RN 1 was observed across the next hallway on the other side of the nursing station. When asked if the method of yelling the code was common practice, RN 2 stated, " ... that's why I asked him to come over here ...".

During an interview on 11/12/24 at 10:40 a.m. with RN 1, RN 1 stated it was wrong to yell the medication room door code and there was a risk of visitors hearing the code. RN 1 stated a visitor could then access the medication room.

During an interview on 11/15/24 at 3:15 p.m. with the Chief Nursing Officer (CNO), the CNO stated yelling the medication code out in the hall could lead to unauthorized individuals' access to medications.

During a review of the facility's policy and procedure titled, "Medication Storage and Security (MSS)", dated 4/20/24, the "MSS" indicated, " ... Medications outside the Pharmacy Department will be handled and stored ... maintaining adequate and appropriate security at all times ... Safety and security ... all medications will be maintained in a secure storage area insuring accessibility by authorized individuals only ... Definitions ... Secure--Medications are considered 'secure' when locked or under constant surveillance ...".

During the review of a professional reference titled, "Hospital Medication Security: A guide to protecting controlled substances (HMS)", dated 9/26/24, the "HMS" indicated, " ... Without medication access control systems and surveillance, medications can be stolen or tampered with, leading to potential overdoses, medication errors, or the use of unsafe drugs ...".

Based on observation, interviews, and record review, the facility failed to ensure unusable medications were not available for patient use when an intravenous (IV, in the vein) fluid bag was out of its protective overwrap against professional standards in the storage room on the 6th floor.

This failure had the potential for patients to receive altered, ineffective, and contaminated medications.

Findings:

During a concurrent observation and interview on 11/12/24 at 11:00 a.m. in the 6th floor storage room with Registered Nurse (RN) 3, an IV fluid bag missing its protective overwrap was in the stock of IV fluids available for patient use. RN 3 stated an IV fluid bag that did not have a protective overwrap could not be used for a patient. RN 3 stated the IV fluid bag could have been tampered with or fluid could have evaporated for the bag once the overwrap had been removed. RN 3 stated the exposed IV bag needed to be disposed of.

During a review of a professional reference titled, "Working up a sweat (WUS)", dated 10/2002, the "WUS" indicated, " ... The purpose of the overwrap [for IV bags] is to improve shelf life and to stabilize the drug concentration. What happens then if a bag is removed from its overwrap and remains unused for days or weeks? Over time, the fluid volume inside the bag decreases and the drug concentration per milliliter [ml, a unit of measure] increases ... Don't remove the overwrap from any I.V. bag stored in your unit until you're ready to use the solution ...".

During a review of a professional reference titled, "Expiration dates and removal of i.v. bag overwrap (EDR)", dated 9/1/95, the "EDR" indicated, " ... The overwrap protects against evaporation of the solution, desiccation [removal of moisture] of the container, drug oxidation [common way of degrading a drug], and photochemical [with light] inactivation of the drug. Without a barrier, substantial moisture loss may occur, increasing the drug concentration ... Manufacturers of these products recommend ... removing the overwrap just before the drug or solution is administered ...".

Based on observation, interview, and record review, the hospital failed to maintain a clean and sanitary environment when:

1. Two boxes of N-95 masks (a disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) and a spill kit (spill-response tools and equipment worn by an employee for protection against infectious materials) were stored in the soiled utility room (a room designated to store waste products and dirty surgical instrument carts) of the Emergency Department (ED) not in accordance with hospital's policy and professional standards.

2. An intravenous (IV-tube inserted in the vein) filtered extension set (tubing with a small micron solution filter in the drip chamber or attached to the tubing) was observed to be opened and placed back into the clean supplies in the Emergency Department (ED) medication room not in accordance with professional standards.

3. An expired Y-connector (port used to administer secondary and IV push medications) was observed in the clean supplies and stored for use in the ED medication room not in accordance with professional standards.

4. A normal saline fluid (fluid used to replace water and electrolyte) bag was not labeled with the expiration date in the warmer in the Post-Anesthesia Care Unit (PACU-specialized unit where the patient's vital signs are closely observed) clean utility room (a?room used to store clean medical equipment and supplies) not in accordance with the hospital's policy and procedure titled, "Fluid Warming."

These failures had the potential to place patients at risk for cross contamination (process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and the spread of infection.

Findings:

1. During a concurrent observation and interview on 11/12/24 at 10:30 a.m. with the Emergency Department Clinical Manager (CM) 4, in the Emergency Department Soiled Utility room, a cabinet containing two boxes of N-95 masks (a disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) and a spill kit (spill-response tools and equipment worn by an employee for protection against infectious materials) was observed. CM 4 stated clean items should not be stored in the soiled utility room. CM 4 stated all things in the soiled utility room was considered dirty and should not be used. CM 4 stated when clean items stored in a soiled utility room was used, it could be an infection control issue for patients.

During an interview on 11/15/24 at 9:05 a.m. with the Infection Preventionist Manager (IP), the IP stated clean items should not be stored in the soiled utility room. The IP stated it was important not to store clean items in the soiled utility room due to cross-contamination to patients or staff.

During an interview on 11/15/24 at 3:14 p.m. with the Chief Nursing Officer (CNO), the CNO stated soiled utility room were considered dirty. The CNO stated clean supplies should not be stored in the soiled utility room.

During a review of the facility's P&P titled, "Medical Waste Management Plan," revised 3/2024, the P&P indicated, "Waste containing discarded materials contaminated with excretion, exudate, or secretions from patients that are required to be isolated to protect others from highly communicable diseases employee orientation shall include, but not be limited to: 1. Definitions of Medical Wastes 2. Containment, transportation, and storage of medical waste."

During a review of a professional reference titled, "Infection Control and Prevention (ICP)," undated, by the Agency for Healthcare Research and Quality (AHRQ), (found at https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/infectioncontrol.pdf), the "ICP" indicated, " ...There is a clear separation of clean and dirty work areas. Clean areas are used for storage and preparation of medications and unused supplies; dirty work areas are used for contaminated equipment."

2. During a concurrent observation and interview on 11/12/24 at 10:25 a.m., with the Emergency Department Clinical Manager (CM) 4, in the ED Medication Room, an opened filtered extension set package was observed in the clean supply cabinet. CM 4 verified the filtered extension set package was opened. CM 4 stated the opened filtered extension set should have been thrown away and not placed back in the clean supplies. CM 4 stated the seal was broken and should not be used on patients, because it was an infection control concern .

During an interview on 11/15/24 at 9:05 a.m. with the Infection Prevention Manager (IP), the IP stated after a filtered extension package was opened, it should not be placed back into the clean supply. The IP stated the opened filtered extension should have been thrown away. The IP stated infection control was a concern when supplies that had been previously opened were used on different patients.

During an interview on 11/15/24 at 3:14 p.m. with the Chief Nursing Officer (CNO), the CNO stated supplies with packaging that has been breached should be discarded.

During a review of a professional reference titled, "Quick Safety: Managing packaged sterile supplies and devices (QS)," dated June 2022, (found at https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-65/#:~:text=Managing%20commercially%20prepared%20sterile%20supplies,on%20or%20with%20their%20devices.), the QS indicated, " ...In order to protect patients from infection and other potential harm from expired or compromised supplies and devices, organizations must identify the best location to store the supplies so that staff can readily access them, ensure the supplies are being stocked to the most optimal par levels, and that items have not passed their expiration dates. Additionally, the storage area must be maintained so that supplies are stored safely, in a manner where they are kept in good condition while protecting them from contamination. The purpose of this Quick Safety is to provide guidance for managing and storing packaged sterile supplies within your facility with the goal to keep patients safe from infection and other potential harm from expired or compromised supplies and devices ... CMS [Centers for Medicare and Medicaid Services] requires that sterile packages are stored so that sterility is not compromised, and sterile items are inspected for integrity before use ..."

3. During a concurrent observation and interview on 11/12/24 at 10:30 a.m., with Emergency Department Clinical Manager (CM) 4, in the ED medication room, a Y-connector with an expiration date of 7/12/24 was observed. CM 4 verified the expiration date as 7/12/24 on the Y-connector package and stated the package was compromised once expired and should have been thrown away.
During an interview on 11/15/24 at 9:05 a.m. with the Infection Prevention Manager (IP), the IP stated expired supplies should be removed and disposed. The IP stated the integrity of the contents could not be verified if expiration date had passed.
During an interview on 11/15/24 at 3:14 p.m. with the Chief Nursing Officer (CNO), the CNO stated an expired supply should be discarded.

During a review of a professional reference titled, "Quick Safety: Managing packaged sterile supplies and devices (QS)," dated June 2022, (found at https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-65/#:~:text=Managing%20commercially%20prepared%20sterile%20supplies,on%20or%20with%20their%20devices.), the QS indicated, " ...In order to protect patients from infection and other potential harm from expired or compromised supplies and devices, organizations must identify the best location to store the supplies so that staff can readily access them, ensure the supplies are being stocked to the most optimal par levels, and that items have not passed their expiration dates. The purpose of this Quick Safety is to provide guidance for managing and storing packaged sterile supplies within your facility with the goal to keep patients safe from infection and other potential harm from expired or compromised supplies and devices ..."

4. During a concurrent observation and interview on 11/12/24 at 11:43 a.m. with the Director of Surgical Services (DSS) in the Post-Anesthesia Care Unit (PACU -specialized unit where the patient's vital signs are closely observed) clean utility room, a 3000 milliliter (mL-unit of measure) bag of normal saline solution without a label of the expiration date was found in the warmer. The DSS stated the normal saline solution bag should have been labeled with an expiration date when placed in the warmer. The DSS stated fluid bags should not be in the warmer for longer than 14 days. The DSS stated it was important to label the fluid bags with an expiration date. The DSS stated this was based on the manufacturer's recommendation. The DSS stated there could be changes to the chemicals in the solution if the fluid was warmed too long. The DSS stated all staff who place new fluid bags in the warmer should place a label with the expiration date on it.

During an interview on 11/15/24 at 9:05 a.m. with the Infection Prevention Manager (IP), the IP stated the process for labeling the fluid bag should have been followed. The IP stated if the fluid is warmed too long it can become contaminated with the risk of organism (a microbe, like bacteria, virus, fungus, or parasite, that has the potential to cause an infection) build-up within the fluid. The IP stated the integrity of the fluid would be questionable.

During an interview on 11/15/24 at 3:14 p.m. with the Chief Nursing Officer (CNO), the CNO stated fluid bags should be dated to keep from using fluids that are contaminated.

During a review of the facility's P&P titled "Fluid Warming," reviewed 3/2023, the P&P indicated, " ...Each flexible bag (pouch) or semi rigid pour bottle will be labeled with the date that it expires indicating removal from the warmer ... IV and Irrigation Fluids ... Warming recommendations for Large (150 ml or greater) Volume Intravenous (IV) a. Solution in plastic bags: 1) not to exceed 40 °C (104°F) and for a period no longer than fourteen (14) days ..."