HospitalInspections.org

Based on observation and interview, the facility failed to provide a safe patient environment when there was not a functional nurse call light system in the following units:

1. In the Emergency Department (ED) there were no call light cords on all 12-patient care bays and no call light panel in the nurse's station (Refer to A 0144);

2. In the Post Anesthesia Care Unit (PACU- a healthcare unit dedicated to the care of patients before, during, and after a surgical or medical procedure involving anesthesia) there were no call light cords on all 7-patient care bays and no call light panel in the nurse's station (Refer to A 0144); and

3. In the Pre-Operative Unit (a designated area within a hospital or surgical center where patients are prepared for surgery) there were no call light cords available on three of four pre-op patient care bays (Refer to A 0144).

The cumulative effect of this systemic failure resulted in the facility's inability to ensure the provision of quality health care, in compliance with the Condition of Participation for Patient's Rights was met.

On April 29, 2025, at 3:25 p.m., the survey team identified significant concerns with the facility's Nurse Call Light System. Due to the seriousness of the situation, an immediate jeopardy (IJ, a situation with the potential to cause harm to the health and safety of the patients) was called in the presence of the Interim Chief Operating Officer (ICNO), Accreditation Regulatory Manager (ARM), Director Clinical Quality Improvement (DCQI), Emergency Department Director (EDD), Interim Director Medical Surgical Telemetry (IDMST), and the Operating Room Charge Nurse (ORCN). The facility's ICNO, ARM, DCQI, EDD, IDMST and the ORCN were verbally notified regarding the concerns of the facility's failure to ensure a safe patient environment when there was no call light system in the Emergency Department (ED), Post Anesthesia Care Unit (PACU), and Pre-Op Unit.

On April 29, 2025, at 7:04 p.m., the DCQI provided a Corrective Action Plan (CAP).

On April 30, 2025, at 3:01 p.m., the Chief Executive Officer (CEO) provided a revised CAP. The CAP indicated the following:

- All Emergency Department (ED) beds and all Recovery Room bays have been equipped with handheld service bells as of April 29, 2025. All staff in the Emergency Department and Recovery Room areas will be trained by the unit supervisor on how to use the handheld service bells prior to providing care for any patients and instructed to teach patients and family members how to use the bells. Staff signed attestations that they received training and understood. All staff on leave of absence, vacation, and new hires will receive education/training upon return to work, and prior to providing patient care.

- A temporary wireless patient call light system will be installed in ED and Recovery Room by end of business April 30, 2025, by the vendor [Name of Vendor]. All staff in the Emergency Department and Recovery Room areas were trained in-person by the unit supervisor on how to use the temporary wireless patient call light system prior to seeing any patients and instructed to teach patients and family members how to use the bells. Staff have signed attestations that they received training and understand.

- The permanent patient call light system in the Preoperative area had patient cords installed at each of the bays on April 30, 2025. The call light system was tested and deemed functional. All staff in the Preop area were trained in-person by the unit supervisor on how to use the handheld service bells prior to seeing any patients and instructed to teach patients and family members how to use the bells. Staff signed attestations that they received training and understood.

On April 30, 2025, at 3:57 p.m., the CAP for the immediate jeopardy was reviewed and accepted.

On April 30, 2025, at 4:45 p.m., the CAP was verified while onsite, through observations, interviews, and record reviews, to have been fully implemented.

On April 30, 2025, at 4:50 p.m., the IJ was removed in the presence of the CEO, ARM, DCQI, and the EDD.

Based on interview and record review, the facility failed to implement their policies and procedures, and failed to ensure a Post Anesthesia Care Unit (PACU, critical care unit where patients recover after surgery and anesthesia) Registered Nurse (RN), was qualified and annual competencies were completed, for six of 11 patients (Patient 1, 2, 8, 10, 11,and 12) when:

1. For Patients 1, 2, and 10, a fall care plan was not initiated despite being a fall risk according to Morse Fall Score (A tool used to determine a patients risk of falling, low risk score between 0-24, scores between 25-50 suggest low risk, a score of 51 and higher indicates a high risk of falling) (Refer to A-0398);

2. For Patient 1, pain was not reassessed within a clinically appropriate time frame after administration of pain medication (Refer to A-0398);

3. For Patients 2, and 11, the nurse did not administer the correct medication order for indicated pain level (Refer to A-0398);

4. For Patient 10, the nurse did not notify the physician of Patient 10's critical lab value (Refer to A-0398);

5. For Patient 8, a fall risk assessment was not completed on admission (Refer A-0398);

6. For Patient 12, family was not notified of a fall (Refer A-0398); and

7. A PACU RN qualifications were not met when critical care courses 2023, and 2024, annual competencies were not completed (Refer A-0398).

These cumulative failures had the potential to compromise patient safety, and cause possible patient harm or injury.

Based on observation and interview, the facility failed to provide a safe patient environment when there was not a functional nurse call light system in the following units:

1. In the Emergency Department (ED) there were no call light cords on all 12 patient care bays and no call light panel in the nurse's station.

2. In the Post Anesthesia Care Unit (PACU- a healthcare unit dedicated to the care of patients before, during, and after a surgical or medical procedure involving anesthesia) there were no call light cords on all 7-patient care bays and no call light panel in the nurse's station.

3. In the Pre-Operative Unit (a designated area within a hospital or surgical center where patients are prepared for surgery) there were no call light cords available on three of four pre-op patient care bays.

This failure had the potential to put a patient's health and safety at risk when needs are not met in a timely manner.

Findings:

On April 29, 2025, an unannounced visit was conducted at the facility for a Complaint Validation survey.

1. A tour of the ED was conducted on April 29, 2025, at 9:05 a.m., with the Emergency Department Director (EDD) and the Interim Director of Medical-Surgical-Telemetry (IDMST).

On April 29, 2025, at 9:20 a.m., during the tour of the ED, it was observed that there were no call light cords available on all 12 patient care bays for patients to utilize to call for assistance and no call light panel in the nurse's station.

On April 29, 2025, at 9:30 a.m., an interview was conducted with the Emergency Department Registered Nurse (EDRN) 1. The EDRN 1 stated that there has not been a call light system in the ED for years. EDRN 1 further stated a call light system is not necessary because there are staff around to look after the patients.

On April 29, 2025, at 9:36 a.m., an interview was conducted with the EDRN 2. EDRN2 stated there are no call light buttons or cords in each ED patient care bays. EDRN 2 stated she just keeps the door open so she can see the patients.

On April 29, 2025, at 9:46 a.m., an interview was conducted with the EDD. The EDD stated there is not a call light system in the ED because it is a small hospital where RNs are always near their assigned rooms. The EDD further stated the ED will be renovated soon and a call light system will be installed.

2. A tour of the PACU was conducted on April 29, 2025, at 12:42 p.m., with the Operating Room Charge Nurse (ORCN), the Director of Clinical Quality, Director Clinical Quality Improvement (DCQI), and the EDD.

On April 29, 2025, at 12:43 p.m., during the tour of the PACU, it was observed that there were no call light cords available on all seven PACU patient care bays, and no call light panel in the nurse's station.

On April 29, 2025, at 12:44 p.m., an interview was conducted with the ORCN. The ORCN stated, as far as she can remember, there was a call light system used in the PACU when she began working at the facility in 2012, but she was unsure of what happened or why the call light system was removed.

On April 29, 2025, at 12:45 p.m., an interview was conducted with the PACU RN 1. The PACU RN 1 stated a call light system is not needed in the PACU because "we only have two patients at a time, and we are always at the bedside."

3. A tour of the Pre-Operative Unit was conducted on April 29, 2025, at 12:50 p.m., with the ORCN, the DCQI, and the EDD.

On April 29, 2025, at 12:50 p.m., during the tour of the Pre-Operative Unit, there were no call light cords available in three of four Pre-Op patient care bays.

On April 29, 2025, at 12:57 p.m., an interview was conducted with the Pre-Op RN. The Pre-Op RN stated, there is always a nurse in the area to respond to patient needs. When asked how patients call the nurse if they needed help, Pre-Op RN stated, " It's a small unit, and patients just needed to call, "Nurse".

On April 29, 2025, at 1 p.m., the DCQI stated the facility did not have a Call Light policy.


On April 29, 2025, at 3:25 p.m., the survey team identified significant concerns with the facility's Nurse Call Light System. Due to the seriousness of the situation, an immediate jeopardy (IJ, a situation with the potential to cause harm to the health and safety of the patients) was called in the presence of the Interim Chief Operating Officer (ICNO), Accreditation Regulatory Manager (ARM), Director Clinical Quality Improvement (DCQI), Emergency Department Director (EDD), Interim Director Medical Surgical Telemetry (IDMST), and the Operating Room Charge Nurse (ORCN). The facility's ICNO, ARM, DCQI, EDD, IDMST and the ORCN were verbally notified regarding the concerns of the facility's failure to ensure a safe patient environment when there was no call light system in the Emergency Department (ED), Post Anesthesia Care Unit (PACU), and Pre-Op Unit.

On April 29, 2025, at 7:04 p.m., the DCQI provided a Corrective Action Plan (CAP).

On April 30, 2025, at 3:01 p.m., the Chief Executive Officer (CEO) provided a revised CAP. The CAP indicated the following:

- All Emergency Department (ED) beds and all Recovery Room bays have been equipped with handheld service bells as of April 29, 2025. All staff in the Emergency Department and Recovery Room areas were and will be trained by the unit supervisor on how to use the handheld service bells prior to providing care to any patients, and instructed to teach patients and family members how to use the bells. Staff signed attestations that they received training and understood. All staff on leave of absence, vacation, and new hires will receive education/training upon return to work, and prior to providing patient care.

- A temporary wireless patient call light system will be installed in ED and Recovery Room by end of business April 30, 2025, by the vendor [Name of Vendor]. All staff in the Emergency Department and Recovery Room areas were trained in-person by the unit supervisor on how to use the temporary wireless patient call light system prior to seeing any patients and instructed to teach patients and family members on how to use the bells. Staff have signed attestations that they received training and understand.

- The permanent patient call light system in the Preoperative area had patient cords installed at each of the bays on April 30, 2025. The call light system was tested and deemed functional. All staff in the Preop area were trained in-person by the unit supervisor on how to use the handheld service bells prior to seeing any patients and instructed to teach patients and family members on how to use the bells. Staff signed attestations that they received training and understand.

On April 30, 2025, at 3:57 p.m., the CAP for the immediate jeopardy was reviewed and accepted.

On April 30, 2025, at 4:45 p.m., the CAP was verified while onsite, through observations, interviews, and record reviews, to have been fully implemented.

On April 30, 2025, at 4:50 p.m., the IJ was removed in the presence of the CEO, ARM, DCQI, and the EDD.

Based on interview and record review, the facility failed to ensure the Post Anesthesia Care Unit Registered Nurse (PACU RN) was qualified and competent to care for post-surgery patients.

This failure had the potential for unsafe patient care of surgical patients.

Findings:

On May 1, 2025, at 9:51 a.m., a record review was conducted with the Human Resources Manager (HRM).The employee file of PACU RN was reviewed and indicated the PACU RN was initially hired on October 7, 2022.

There was no documented evidence PACU RN completed a critical care course within 1 year of employment as required by the job description.

There was no documented evidence PACU RN completed the 2023, and 2024, competencies as required by the job description.

On May 1, 2024, at 10:50 a.m., a concurrent interview and record review were conducted with ORCN. The PACU RN job description was reviewed. The ORCN stated PACU RN has not met the requirements indicated in the job description.

A facility document titled,"[Name of Hospital] 7027- Registered Nurse (RN II) Job Description," dated October 7, 2022, indicated,"...Requirements...Current Competencies...Completion of a critical care course within 1 year of employment...Competency...Attach competency list to this position description. Competency list is a living document with current monitoring throughout the evaluation year. Competency list to be finalized at the end of the current evaluation year..."

A facility document titled,"[Name of Hospital] 7027- Registered Nurse (RN II) Job Description," dated August 24, 2023, indicated,"...Requirements...Current Competencies...Completion of a critical care course within 1 year of employment...Competency...Attach competency list to this position description. Competency list is a living document with current monitoring throughout the evaluation year. Competency list to be finalized at the end of the current evaluation year..."

A facility document titled,"[Name of Hospital] 7027- Registered Nurse (RN II) Job Description," dated December 12, 2024, indicated,"...Requirements...Current Competencies...Completion of a critical care course within 1 year of employment...Competency...Attach competency list to this position description. Competency list is a living document with current monitoring throughout the evaluation year. Competency list to be finalized at the end of the current evaluation year..."

Based on interview and record review, the facility failed to implement their policies and procedures (P&P) for six of 11 sampled patients (Patient 1, 2, 8, 10, 11, and 12 ) when:

1. For Patients 1, 2, and 10, a fall care plan was not initiated despite being a fall risk according to Morse Fall Score (A tool used to determine a patients risk of falling, low risk score between 0-24, scores between 25-50 suggest low risk, a score of 51 and higher indicates a high risk of falling);

2. For Patient 1, pain was not reassessed within a clinically appropriate time frame after administration of pain medication;

3. For Patients 2, and 11, the nurse did not administer the correct medication order for indicated pain level;

4. For Patient 10, the nurse did not notify the physician when Patient 10 had a critical lab value;

5. For Patient 8, a fall risk assessment was not completed on admission; and

6. For Patient 12, family was not notified of a fall.

These failures had the potential to compromise patient safety, resulting in poor pain management, unqualified staff, and delays in medical care and/or death.

Findings:

1a. A review of Patient 1's record was conducted on April 30, 2024, at 9:17 a.m., with the Accreditation Regulatory Manager (ARM). A facility document titled, "History and Physical," dated April 30, 2025, at 11:28 a.m., was reviewed and indicated Patient 1 was admitted to the facility on April 28, 2025, for an ankle fracture.

A facility document titled, "MORSE FALL RISK," dated April 28, 2025, through April 29, 2025, was reviewed. The document indicated, "...April 28, 2025, at 9 a.m...MORSE FALL SCORE...15, April 28, 2025, at 9 p.m...MORSE FALL SCORE...35...April 29, 2025, at 9 a.m...MORSE SCORE...60...April 29, 2025, at 9 p.m...MORSE SCORE...80..."

A facility document titled,"Operative Note," dated April 29, 2025, at 7:07 p.m., was reviewed. The document indicated, "...PROCEDURE PERFORMED...Open reduction internal fixation left trimalleolar [a serious ankle fracture that includes all three malleoli bones in the ankle]..."

There was no documented evidence in the Patient 1's electronic medical record (EMR), that a fall care plan was implemented for Patient 1.

On April 30, 2025, at 10:30 a.m., a concurrent interview and record review were conducted with the ARM. The ARM stated the patient was a fall risk on admission and a fall care plan was not implemented per facility policy.

1b. A review of Patient 2's record was conducted on April 30, 2024, at 10 a.m., with the ARM. A facility document titled, "History and Physical," dated April 28, 2025, at 12:45 p.m., was reviewed and indicated Patient 2 was admitted to the facility on April 28, 2025, for pneumonia (an infection of the lungs).

A facility document titled, "MORSE FALL RISK," dated April 28, 2025, through April 29, 2025, was reviewed the document indicated, "...April 28, 2025, at 10 a.m...MORSE FALL SCORE...35, April 28, 2025, at 10 p.m...MORSE FALL SCORE...60...April 29, 2025, at 10 a.m...MORSE SCORE...35...April 29, 2025, at 10 p.m...MORSE SCORE...30..."

There was no documented evidence in Patient 2's EMR, that a fall care plan was implemented for Patient 2.

On April 30, 2025, at 10:56 a.m., a concurrent interview and record review were conducted with the ARM. The ARM stated the patient was a fall risk and a fall care plan was not implemented for this patient. The ARM further stated the policy was not followed; a care plan should have implemented.

1c. A review of Patient 10's record was conducted on April 30, 2025, at 10:42 a.m., with the Operating Room Charge Nurse (ORCN). A facility document titled, "History and Physical," dated April 28, 2025, was reviewed and indicated Patient 10 was admitted to the facility on April 28, 2025, for DKA (diabetic ketoacidosis - a serious complication of diabetes [diabetes, high blood sugar in the body]), altered mental status and urinary retention (inability to empty bladder completely).

A facility document titled, "MORSE FALL RISK," dated April 28, 2025, was reviewed and the document indicated, Patient 10's Morse Fall Risk score on admission was 60.

According to the MORSE FALL RISK SCORE the patient was a "high fall risk."

There was no documented evidence that a fall risk care plan was implemented for Patient 10.

On April 30, 2025, at 10:55 a.m., an interview was conducted with the ORCN. The ORCN stated the policy was not followed when the fall risk care plan was not initiated on admission.

A facility P&P titled, "STANDARD OF CARE: ASSESSMENT, REASSESSMENT, AND CARE PLANS," dated July 18, 2024, indicated, "...All patients will receive nursing care based on principles of patient centered care and utilization of assessment and reassessments of the patient's needs, by the registered nurse...The plan of care that is mutually set with the patient is culturally and age specific to the individual patient/family. The complete patient assessment establish the foundation for the diagnosing/analyzing of patient problems, formulating a plan of care and determining appropriate referrals and reassessments...Focused...A partial review of physical, psychological, spiritual/cultural, social, and educational needs based on...Patient's needs and patient's response to interventions...physician orders...Patient's diagnosis...Care setting and unit specific guidelines...The patient's plan of care is initiated on admission and reviewed on admission and reviewed a minimum of every shift based on patient's response to their specific assessed need for care and treatment...The electronic medical record suggested care plans based on the patient's problem list and are to be customized to the patient's specific needs...Patient care goals, needs, interventions, and response to care are reviewed (and updated as needed) and documented every shift...The patient's goal and needs guide the consultation and collaboration relative to planning, implementing, and formulating the patient's plan of care...Consultation and collaboration, as appropriate to patient's needs..."

2. A review of Patient 1's record was conducted on April 30, 2024, at 9:17 a.m., with the ARM. A facility document titled, "History and Physical," dated April 30, 2025, at 11:28 a.m., was reviewed and indicated Patient 1 was admitted to the facility on April 28, 2025, for an ankle fracture.

A facility document titled, "Operative Note," dated April 29, 2025, at 7:07 p.m., was reviewed and the document indicated, "...PROCEDURE PERFORMED...Open reduction internal fixation left trimalleolar..."

A facility document titled, "IVIEW/I&O (Input and output)," dated April 29, 2025, at 10:10 a.m., was reviewed and the document indicated, "...Numeric Rating Pain Scale...8/10 [a tool used to measure the intensity of pain, with 1 representing very mild pain and 10 representing the worst pain]..."

A facility document titled, "MAR [Medication Administration Record] Summary," dated April 29, 2025, at 10:12 a.m., indicated, "...morphine...2 mg [milligram, unit of measurement] = [equals] 1 ml [milliliter, unit of measurement]...injection, IV [Intravenous] Push...Q4H [every four hour], PRN [as needed]...For: Pain Severe..."

There was no documentation in Patient 1's electronic medical record (EMR) that Patient 1's pain was reassessed in a clinically appropriate time frame after administration of pain medication.

On April 30, 2025, at 9:56 a.m., a concurrent interview and record review were conducted with the ARM. The ARM stated the task comes up in the computer as an overdue task and this is red, it does not look like pain was reassessed after pain medication was administered. The ARM further stated the policy was not followed.

A facility P&P titled, "PAIN MANAGEMENT," dated July 18, 2024, indicated, "...A reassessment for the presence and intensity of pain shall be performed as a component of the shift assessment for inpatients and following any intervention intended to lessen the patient's pain (e.g. administration of pain medication...)...This reassessment is a dynamic and ongoing process which shall take place within a clinically appropriate time frame...Documentation of pain assessment and reassessment must occur by the end of the shift..."

3a. A review of Patient 2's record was conducted on April 30, 2024, at 10 a.m., with the ARM. A facility document titled, "History and Physical," dated April 28, 2025, at 12:45 p.m., was reviewed and indicated Patient 2 was admitted to the facility on April 28, 2025, for pneumonia.

A facility document titled, "Pain Assessment," dated April 28, 2025, at 10:37 a.m., was reviewed and indicated, "...Numeric Rating Pain Scale...6/10..."

A facility document titled, "Order," dated April 28, 2025, at 11:20 a.m., was reviewed and indicated, "...acetaminophen-HYDROcodone [medication to manage severe pain] (Norco 325 mg [milligram, unit of measurements]- 5 mg [milligram, a unit of measurement] oral tablet)...2 [two...tab [tablet]...oral...Q6hr [every six hours]...PRN reason...Pain Severe..."

A facility document titled, "MAR [Medication Administration Record] Summary," dated April 28, 2025, at 11:51 a.m., indicated,"...acetaminophen-HYDROcodone...(Norco 325 mg - 5 mg oral tablet)...2...tab...oral...Q6hr...PRN reason...Pain Severe..."

There was no order found in the EMR for pain medication indicated for pain level 5-7/10, moderate pain.

There was no documentation found in the EMR that the nurse called the physician requesting medication for a moderate pain level medication.

On April 30, 2025, at 11:26 a.m. a concurrent interview and record review were conducted with the ARM. The ARM stated the nurse gave a medication intended for severe pain and did not call the physician for clarification. The ARM further stated the policy was not followed.

3b. A review of Patient 11's record was conducted on April 30, 2025, at 1:12 p.m., with the ORCN. A facility document titled, "History and Physical," dated April 24, 2025, was reviewed and indicated Patient 11 was admitted to the facility on April 24, 2025, for a left hip fracture.

A facility document titled, "Pain Assessment Detail," dated April 24, 2025, indicated,"...Numeric Pain Acceptable Intensity Score...0 - no pain..."

A facility document titled, "Order," dated April 24, 2025, indicated,"...Morphine [medication for severe pain]...2 mg = 1ml...injection, IV, Push...Q4hrs, PRN...For Severe Pain..."

A facility document titled, "Order Activity Flowsheet," dated April 24, 2025, through April 28, 2025, indicated Morphine was given to Patient 11 for pain levels 5 through 7 (moderate pain) on the following dates:

- April 25, 2025, at 5:33 a.m., with a numeric rating pain scale of 7;

- April 25, 2025, at 1:33 p.m., with a numeric rating pain scale of 7;

- April 26, 2025, at 1:17 a.m., with numeric rating pain scale of 6;

- April 26, 2025, at 1:17 a.m., with numeric rating pain scale of 6;

- April 26, 2025, at 5:51 p.m., with numeric rating pain scale of 7;

- April 27, 2025, at 3:34 a.m., with numeric rating pain scale of 6;

- April 27, 2025, at 10:12 a.m., with numeric rating pain scale of 7; and

- April 27, 2025, at 6:29 p.m., with numeric rating pain scale of 7.

A facility document titled, "MAR Summary," dated April 24, 2025, through April 26, 2025, indicated, "...Dilaudid [medication for severe pain]...1 mg = 1ml injection...IV, Push...Q 6hrs...PRN...For: Pain Severe..."

A facility document titled, "Order Activity Flowsheet," dated April 25, 2025, through April 28, 2025, indicated Dilaudid was given to Patient 11 for pain levels 5 through 7 (moderate pain) on the following dates:

- April 25, 2025, at 8:54 p.m., with numeric rating pain scale of 7;

- April 26, 2025, at 4:37 a.m., with numeric rating pain scale of 6;

- April 26, 2025, at 3:28 p.m., with numeric rating pain scale of 6;

- April 26, 2025, at 10:43 p.m., with numeric rating pain scale of 6; and

- April 27, 2025, at 6:47 a.m., with numeric rating pain scale of 6.

There was no order found in the EMR for pain medication indicated for pain level 5-7/10, moderate pain.

There was no documentation found in the EMR that the nurse called the physician requesting medication for a moderate pain level medication.

On April 30, 2025, at 3:44 p.m., an interview was conducted with the ORCN. The ORCN stated the pain medication order was not followed and the nurse should have called the physician for clarification. ORCN further stated the facility policy was not followed.

A facility P&P titled, "MEDICATION ORDERS: REQUIREMENTS FOR SAFE ORDER WRITING," dated May 24, 2020, indicated, "...Orders written for "PRN pain" must be accompanied by specific information indicating the level of pain the medication ordered is intended to treat. The hospital uses a 0-10 scale to rate the severity of pain...If orders are written using the pain rating of mild, moderate and severe, the following conversions apply...pain scale...mild...1-4...moderate...5-7...severe...8-10...physician orders without an assigned pain scale for multiple "PRN" pain medication orders will be clarified with the prescribing physician and the order placed in the patients chart..."

4. A review of Patient 10's record was conducted on April 30, 2025, at 10:42 a.m., with the ORCN. A facility document titled, "History and Physical," dated April 28, 2025, was reviewed and indicated Patient 10 was admitted to the facility on April 28, 2025, for DKA, altered mental status and urinary retention.

A facility document titled, "Results Details," dated April 30, 2025, was reviewed. The document indicated, "...WBC (white blood cells-type of blood cell made in your bone marrow and found in the blood) 28 10e9/L (10 raised to the power of 9/ Liter - unit of measurement) (CRIT) [critical]...Normal low: 4.2...Normal high 10.8...Result Comment...April 30, 2025...05:56 US (United States)/Central...CRITICAL RESULTS have been phoned with read back to PREV CRITICAL NOT CALLED..."

A facility document titled, "Results Review," dated April 30, 2025, was reviewed. The document indicated, "...Physician Notification..." There was no documented evidence that the critical lab result was reported to the physician.

On April 30, 2025, at 11:14 a.m., an interview was conducted with the ORCN. The ORCN stated the policy was not followed when the WBC critical lab value was not reported to the physician within an hour.

A review of the facility's P&P titled, "CRITICAL TESTS AND CRITICAL VALUES AND RESULTS," revised date April 18, 2024, indicated, "...At [Name of Hospital] a one-hour time frame is established for reporting the results, when available, of critical tests and routine tests with critical abnormal findings..."

5. On April 29, 2025, at 9:42 a.m., a tour of the Intensive Care Unit (ICU, a special department of the hospital that provides intensive care) was conducted with the Interim Director Medical-Surgical-Telemetry (IDMST) and the Director for Clinical Quality and Improvement (DCQI).

On April 29, 2025, at 9:57 a.m., an interview was conducted in Patient 8's room. Patient 8 was observed in bed awake, and stated he was in the Emergency Department on April 28, 2025, at 6 p.m. and stayed there while waiting for an available bed in ICU.

On April 30, 2025, at 10 a.m., Patient 8's medical record was reviewed with the ORCN. A facility document titled, "[Name of Hospital] ADMISSION FACESHEET," dated April 28, 2025, was reviewed and indicated, Patient 8 was admitted on April 28, 2025, at 6:35 p.m.

A facility document titled, "History and Physical," dated April 29, 2025, was reviewed. The document indicated, "...CHIEF COMPLAINT...snake bite to right index finger...Assessment/Plan...Toxic effect of rattlesnake venom..."

A facility document titled, "Orders," undated, was reviewed. The document indicated, "...Plan Information...Admission order...Initiated and Signed by [Name of Physician]...04/28/2025 [April 28, 2025]...21:59 [9:59 p.m.]..."

A facility document titled, "Results Review," undated, was reviewed. There was no documented evidence that the initial fall risk assessment was completed on admission.

An interview was conducted on April 30, 2025, at 10:02 a.m., with the ORCN. The ORCN stated the admitting orders should be initiated within 60 minutes including the fall risk assessment.

An interview was conducted on April 30, 2025, at 10:25 a.m., with the ORCN. The ORCN stated the policies were not followed when the fall risk assessment was not completed on admission.

A review of the facility's P&P titled, " FALLS PREVENTION AND RESOURCES," revised dated July 18, 2024, indicated, "... Initial Fall Risk Assessment...Upon entry into the hospital system or through emergency services, a registered nurse will complete the Morse Fall Risk Screening tool in electronic documentation as part of the initial assessment per facility policy..."

A review of the facility's P&P titled, "STANDARD OF CARE: ASSESSMENT, REASSESSMENT, AND CARE PLANS," dated July 18, 2024, indicated, "...Initial Assessment...Level of Care...Intensive Care Unit...Physical Assessment Initiated within...1 hour...Assessment comprise three elements...Data collection includes, but not limited to...Fall Risk score..."

6.On May 1, 2025, at 9 a.m., Patient 12's medical record was reviewed with the ORCN. A facility document titled, "History and Physical," dated November 30, 2024, was reviewed and indicated Patient 12 was and admitted to the facility on November 30, 2024, with a diagnosis of left Pleural Effusion (buildup of excess fluid in the space between the lungs and the chest wall).

A facility document titled, "Results Review," dated November 30, 2024, was reviewed. The document indicated, "...Morse Fall Risk Score...15..."

A facility document titled,"Nursing Note," dated December 4, 2024, was reviewed. The document indicated, "...Rapid response paged at 0802 [8:02 a.m.] for patient fall..."

A facility document titled, "Rapid Assessment Team Record," dated December 4, 2024, was reviewed. The document indicated,"...RAT [Rapid Assessment Team] Team Activated Time 12/04/2024 [December 4, 2024] 08:02 [a.m.]...RAT Staff Concern...Other...Fall..."

A facility document titled, "Results Review," dated December 4, 2024, was reviewed. The document indicated, "Physician Communication...Name of Physician Contacted...[Name of Physician]..."

There was no documented evidence that the emergency contact was notified of the fall.

On May 1, 2025, at 9:12 a.m., an interview was conducted with the ORCN. The ORCN stated the facility policy was not followed when Patient 12's family was not notified of the fall.

A review of the facility's P&P titled, "Fall Prevention and Resources," revised date July 18, 2024, indicated, "...Notification of fall...physician...emergency contact..."

Based on observation, interview, and record review the facility failed to ensure all available supplies and equipment were ready for use when:

1.15 expired silk suture kits were found in a medication/storage room in the Intensive Care Unit (ICU, a specialized department of the hospital that provides intensive care) ready for use; and

2. Two Stryker Chairs (used for evacuating non ambulatory patients during an emergency) were hung in a locked patio without quick accessibility and staff were not trained on how to use the equipment.

These failures had the potential to delay patient care and services or cause patient harm/death.

Findings:

1. A tour of the Intensive Care Unit (ICU) was conducted on April 29, 2025, at 9:46 a.m., with the Patient Care Coordinator (PCC), and the Operating Room Charge Nurse (ORCN). During the tour of the ICU, in the ICU medication/supply room, 15 expired silk suture kits ready for use, were observed with the following expiration dates:

-ETHICON PERMA-HAND SILK 2-0 - expiration date January 31, 2025, (8 total);

-ETHICON PERMA-HAND SILK 3-0 - expiration date December 31, 2024;

-ETHICON PERMA-HAND SILK 4-0 - expiration date November 30, 2020, (2 total) and expiration date July 31, 2024, (2 total); and

-ETHICON PERMA-HAND SILK 6-0 - expiration date May 31, 2022, (2 total).

On April 29, 2025, at 9:59 a.m., an interview with the ORCN was conducted. The ORCN stated the above mentioned suture kits were expired and should not be in there.

On April 29, 2025, at 10:01 a.m., an interview was conducted with the PCC. The PCC stated the suture kits are expired and should not be in there. The PCC further stated the nurses should be checking for expired items, and removing them from the area.

A review of the facility's policy and procedure (P&P) titled, "Procurement and Supply Chain," dated June 21, 2023, indicated, "...All supply items should be reviewed weekly and upon issuance in respect to expiration dates. All expired items will be immediately removed from the storage location and placed in a holding area until proper disposition can be made..."

2. A tour of the facility's Surgical Tower (a second-floor unit), was conducted on April 29, 2025, at 12 p.m., with the Director of Clinical Quality and Improvement (DCQI), the Emergency Department Director (EDD), and Interim Director of Medical/Surgical/Telemetry (IDMST). During the tour of the Surgical Tower, to the left of the elevators was a locked door leading to a patio. On the patio were two Stryker Chairs hanging on the patio wall. The key was requested to open the patio door and the IDMST stated security has the key. After waiting approximately five minutes the tour was continued. At 12:17 p.m., a staff member (security guard), was observed opening the locked door. It took approximately 17 minutes for the locked door to be opened to have access to the emergency evacuation equipment. The unit did not have a key to open the locked door.

Upon completion of the unit tour, there were no other emergency evacuation equipment observed.

An interview was conducted on April 29, 2025, at 12:25 p.m., with the DCQI. The DCQI stated there was no documented evidence of staff training, in-services, or education, on how to use the emergency equipment. The DCQI further stated there was not a policy and procedure for the use of the Stryker Chairs available to staff on the unit.

On April 29, 2025, at 12:24 p.m., an interview was conducted with the IDMST. The IDMST stated, "my staff, and I have not been trained on how to use the Stryker Chair, the security has to open the door, we do not have a key on the unit." The IDMST further stated, "I have been here since 2018, and I have never seen that door opened".

A review of the facility P&P titled, "Safe Patient Handling," dated September 1, 2020, indicated, "...The Safe Patient Handling policy is applicable to all employees working at [Name of facility] whose job tasks require direct hands-on patient care...Provide training to healthcare workers that perform direct hands-on patient care which includes...The use of lifting devices to handle patients safely...Employees participate actively in training and demonstrate competency in the safe and appropriate use of assistive and mechanical lifting devices..."

A facility Operational Manual titled, "Evacuation Chair, Stryker," dated August 8, 2023, indicated, "...Always read and strictly follow the warnings and cautions listed on this page. Service only by qualified personnel...Do not allow untrained helpers to assist in the operation of the product. Untrained helpers may cause injury to the occupant or themselves. Always transport an occupant....with a minimum of two trained operators...Set methods and procedures to educate and train your staff on the safe operation or maintenance of this product..."