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Based on the review of hospital policies and documents, review of medical records (MR), review of nationally recognized standards of practice, and staff (EMP) interviews, it was determined that the facility failed to supervise and evaluate the nursing care for 1 of 10 admitted patients (Patient #7) sampled. This is evidenced by failure to turn a patient every 2 hours. Findings include:

Hospital policy "Standards of Care and Professional Nursing Practice" dated 12/20/1996 and last reviewed 8/15/2024 revealed "...Formats for Nursing Practice Standards...Standards of clinical practice are comprised of...Lippincott Procedures, Lippincott Advisor...These standards describe a level of patient care or professional practice as cited in evidence-based and other best practice references..."

Lippincott nursing resource titled "Pressure Injury Assessment and Management" dated February 2024, revealed "...General recommendation is to reposition at least every two hours..."

Hospital job descriptions for the Registered Nurse I, II, III, and IV, all undated, revealed, "...registered nurse...assumes responsibility and accountability for patient care activities..."

Hospital policy "Documentation in the Medical Record" dated 4/30/1996 and last reviewed 1/3/2023 revealed, "...The medical record...is used to...Document patient care activities...the medical record should...Reflect when care was provided..."

Hospital policy "Skin Integrity Care Management Guideline" dated 1/6/2003 and last reviewed 2/1/2024 revealed "...Key Patient and Family Educational Topics...Rationale for pressure redistribution therapy/importance of repositioning every 2 hours..."

Review of MR7 revealed Patient #7 was admitted on 1/29/2024, status post hip fracture on prolonged bed rest.
- There was no evidence the patient was turned every 2 hours on the following dates:
13 hours between documented turns on 1/30/24
6 hours between documented turns on 1/31/24
19 hours between documented turns on 2/1/24
10 hours between documented turns on 2/2/24

During an interview on 11/7/2024 at 11:43 AM, EMP3 confirmed this finding.

Based on the review of medical records (MR), review of facility policies and documents, and staff (EMP) interviews, it was determined that for 3 of 10 admitted patients (Patient #7, #10, and #17) sampled, the Hospital failed to ensure nursing staff adhered to policies and procedures of the Hospital. This was evidenced by patient care not being provided as ordered. Findings include:

Hospital policy "Standards of Care and Professional Nursing Practice", dated 12/30/1996 and last reviewed 8/15/2024, revealed "...The RN [Registered Nurse] manages and oversees the delivery of nursing care to patients in compliance with applicable hospital and nursing policies, procedures, and practice guidelines..."

Hospital job descriptions for the Registered Nurse I, II, III, and IV, all undated, revealed, "...registered nurse...assumes responsibility and accountability for patient care activities..."

Hospital policy "Documentation in the Medical Record" dated 4/30/1996 and last reviewed 1/3/2023 revealed, "...The medical record...is used to...Document patient care activities...the medical record should...Reflect when care was provided..."

1. Bladder Scans
Review of MR17 revealed:
- Patient was admitted on 10/31/2024 and was an active patient during Medical Record review on 11/12/2024.
- Physician orders dated 10/31/2024 at 11:27 AM documented, "Bladder scan post void x 3..."
- There was no evidence of any bladder scans completed for this admission.

This finding was confirmed with EMP3 on 11/12/2024 at 12:09 PM.

2. Oral Intake
A. Review of MR7 revealed:
- Physician order dated 1/30/2024 at 7:32 AM documented, "I&O [Intake and Output] Q8H"
- Physician order dated 2/1/2024 at 10:47 AM documented "Diet...Carbohydrate Controlled"
- There was no evidence of oral intake documented on 2/3/2024 and 2/6/2024 and no evidence of liquid oral intake documented on 2/1/2024, 2/2/2024, 2/4/2024, and 2/7/2024.

This finding was confirmed with EMP3 on 11/7/2024 at 12:11 PM.

B. Review of MR10 revealed:
- Physician order dated 8/15/2024 at 2:54 AM documented "I&O Q4H". Patient was ordered a regular diet after procedure was completed on 8/15/2024 at 3:00 PM.
- There was no evidence of PO (by mouth) intake documented from 8/16/2024 to 8/19/2024 (3 days) before patient was discharged 8/20/2024.

This finding was confirmed with EMP28 on 11/7/2024 between 1:45 and 2:35 PM.

Based on the review of medical records (MR), review of hospital policies, and staff (EMP) interviews it was determined that medications were not given per practitioner's orders for 1 of 10 admitted patients (Patient #16) sampled. Findings include:

Hospital policy "Medication Administration" dated 8/26/2019 and last reviewed 1/3/2023 revealed, "...Medications administered shall be documented in the patient's medical record..."

Hospital policy "Standards of Care and Professional Nursing Practice", dated 12/30/1996 and last reviewed 8/15/2024, revealed, "...The RN [Registered Nurse] manages and oversees the delivery of nursing care to patients in compliance with applicable hospital and nursing policies, procedures, and practice guidelines..."

Hospital job descriptions for Registered Nurses I, II, III, and IV revealed, "...registered nurse...assumes responsibility and accountability for patient care activities..."

Review of MR16 revealed:
- Physician order dated 11/4/2024 at 6:43 PM documented Lactated Ringers (LR) 100 ML/HR (milliliter per hour) intravenous. The order was discontinued on 11/7/2024 at 9:05 AM.
- "Medication Administration Record" (MAR) documented that the first 1000 ML bag began on 11/4/24 at 6:58 PM and the second 1000 ML bag began on 11/6/2024 at 9:18 PM (26 hours 20 minutes). The patient received 1000 ML over 26 hours which calculates to approximately 38 ML/HR.

During an interview on 11/12/2024 at 2:45 PM, EMP32 confirmed the finding and stated nurses are expected to document when IV bags are started in the MAR.

Based on observation and review of hospital policy, it was determined that for 1 of 4 patient rooms (Room #3C23B) observed, the Hospital failed to maintain the patient care environment safely. This was evidenced by the failure to remove potentially infectious material from a patient bed. Findings include:

Centers for Disease Control and Prevention document "Guidelines for Environmental Infection Control in Health-Care Facilities" dated 2003 and updated 7/2019 revealed, "...The methods...and frequency of cleaning...are determined by the health-care facility policy. However, high-touch housekeeping surfaces in patient-care areas (...bedrails...) should be cleaned...more frequently than surfaces with minimal hand contact..."

Hospital policy "Environmental Services Infection Prevention Policy" dated 6/15/2015 and last reviewed 10/1/2024 revealed, "...Purpose: To define department specific routine and targeted cleaning of environmental surfaces as indicated by the level of of patient contact...Standard 10-Step Cleaning...Sanitize all horizontal surfaces...use approved disinfectant to address high touch areas; bed rails..."

Upon surveyor request on 11/13/24 at 11:45 AM, the Hospital was unable to provide a policy that documented how often housekeeping should clean high-touch surfaced in medical/surgical patient rooms.

During environmental tours of Unit 3C, the following observations were made:

1. Patient room #3C23B on 11/6/2024 between 10:53 and 11:20 AM:
- A brownish-red discoloration, approximately 3 inches long, was seen on the right-side lower bed rail.

2. Patient room #3C23B on 11/7/2024 at 12:15 PM:
- The same brownish-red discoloration, approximately 3 inches long, was still seen on the right-side lower bed rail, 25 hours 22 minutes after the initial observation.
- Upon request by EMP3, housekeeping cleaned the bed rail and removed the discoloration.

This finding was confirmed with EMP3 during observation of finding in patient room #3C23B on 11/7/2024 at 12:15 PM.

Based on observation and review of hospital documents and policies, it was determined that for 2 of 2 clean supply rooms (Units 7E and 3C) and 1 of 1 medication room (Unit 7E) observed, the hospital failed to maintain medical supplies at an acceptable level of safety and quality. This was evidenced by improper storage of clean medical supplies and the presence of expired medical supplies. Findings include:

Hospital policy "Supply Storage Policy" dated 3/1/2013 and last reviewed 7/19/2022 revealed, "Purpose: To provide supplies that are free of contamination and safe for patient use...Patient care supplies will not be stored directly on floor...Stock will be rotated so that the supplies, within their expiration date, are used first...discard outdated disposable items..."

Hospital Standard Operating Sheet for Par Technicians, "Par Replenishment" dated 6/9/2020 revealed, "...Work area: Nursing Unit...clean rooms...During restock, all expectations related to cleanliness, organization...stock rotation...should be met..."

During an environmental tour of Units 7E and 3C on 11/6/2024 between 9:50 and 11:20 AM, the following observations were made:

1. Unit 7E Clean Supply room:
- 2 BD Vacutainer Ref-367986 #3206585, expired 2024-7-31.
- 1 plastic storage container stored on the floor, containing medical supplies.

2. Unit 7E Medication room:
- 5 Smiths Medical jelco 0.5 ml insulin syringe #429950-05, expired 2024-02-20.

3. Unit 3C Clean Supply room:
- 1 BD Universal Viral Transport vial Lot N20440400-179D35, expired 2024-01-31.
- 3 BD Universal Viral Transport vials Lot N20319700-005023, expired 2023-11-30.

These findings were confirmed with EMP5 at the time of the finding.