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

1. The facility failed to ensure safe care for three (3) of 30 sampled patients (Patients 9, 27 and 28) when there was no documented evidence to ensure 1:1 continuous visual observation/monitoring (one qualified personnel assigned to a patient and is immediately at hand to prevent a patient from engaging in a harmful act) for the patients (Patients 9 and 27) who were at risk for suicide (the act or an instance of taking one's own life voluntarily) and Patient 28 who was at risk for fall (an unintentional event that results in the person coming to rest on the ground or another lower level), in accordance with the facility's policy and procedure regarding suicide precautions (a set of interventions for suicidal assessment, monitoring and treatment of patients at risk for suicide) and the use of a sitter (a staff member who provides continuous observation of a patient in a hospital to prevent patient harm by alerting nurses or other healthcare personnel when needed), respectively. This deficient practice had the potential for Patients 9, 27 and 28 who were placed on 1:1 continuous visual observation to inflict self-harm or suffer from injury. (Refer to A-0144)

2. The facility failed to obtain a physician's order for the use of restraints (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) for one of 30 sampled patients (Patient 12) when all four side-rails of Patient 12's bed were raised, in accordance with the facility's policy and procedure regarding restraints use. This deficient practice resulted in Patient 12 being restrained without a physician's order and had the potential to compromise patient safety with complications such as strangulation (obstruction of blood vessels and/or airflow in the neck resulting in asphyxia [lack of oxygen]), skin tear, etc. (Refer to A-0168)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments.

Based on observation, interview, and record review, the facility failed to ensure safe care for three (3) of 30 sampled patients (Patients 9, 27 and 28) when there was no documented evidence to ensure 1:1 continuous visual observation/monitoring (one qualified personnel assigned to a patient and is immediately at hand to prevent a patient from engaging in a harmful act) for the patients (Patients 9 and 27) who were at risk for suicide (the act or an instance of taking one's own life voluntarily) and Patient 28 who was at risk for fall (an unintentional event that results in the person coming to rest on the ground or another lower level), in accordance with the facility's policy and procedure regarding suicide precautions (a set of interventions for suicidal assessment, monitoring and treatment of patients at risk for suicide) and the use of a sitter (a staff member who provides continuous observation of a patient in a hospital to prevent patient harm by alerting nurses or other healthcare personnel when needed), respectively.

This deficient practice had the potential for Patients 9, 27 and 28 who were placed on 1:1 continuous visual observation to inflict self-harm or suffer from injury.

Findings:

1. During a review of Patient 9's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 5/9/2024, the H&P indicated, Patient 9 was admitted to the facility for management of warfarin (a medicine that prevents formation of blood clots and can cause serious side effects, such as heavy bleeding) poisoning after Patient 9 attempted a suicide (the act or an instance of taking one's own life voluntarily) by ingesting 25 of 2.5 milligrams (mg, a unit of measurement) of warfarin tablets at home.

During a review of Patient 9's medical record (MR) titled, "Hospitalist Team Progress Note," dated 5/14/2024, the MR indicated, Patient 9 was treated for warfarin overdose and was being closely monitored for signs of bleeding. The MR further indicated, Patient 9 was evaluated by inpatient psychiatry (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders), and was recommended psychiatric hospitalization due to danger to self and gravely disabled (a term that refers to a person who is unable to provide for their basic needs due to a mental health disorder). The MR indicated, on 5/13/2024, Patient 9 developed hyponatremia (low blood sodium [salt] levels, can be dangerous if left untreated or treated improperly and may cause seizures [a burst of uncontrolled activity between the brain cells that can cause abnormalities in movements, behaviors, etc.], coma [a state of unconsciousness where a person is unresponsive and cannot be woken], and death) and continued to be admitted to the facility's medical floor, pending discharge to a psychiatric facility once medically stable.

During a review of Patient 9's Medical Record titled, "Psychiatry Consultation Note," dated 5/9/2024, the MR indicated, the psychiatrist recommended to continue treatment plan including a sitter (a staff member who provides continuous observation of a patient in a hospital to prevent patient harm by alerting nurses or other healthcare personnel when needed) and suicide precautions (a set of interventions for suicidal assessment, monitoring and treatment of patients at risk for suicide).

During a review of Patient 9's Medical Record titled, "Psychiatry Progress Note," dated 5/14/2024, the MR indicated, on 5/14/2024, Patient 9 stated to psychiatrist that Patient 9 still wanted to die.

During a review of Patient 9's Medical Record titled, "Nursing Flowsheet- Columbia Suicide Severity Rating Scale (C-SSRS- a suicidal ideation and behavior rating scale and scoring)," dated 5/10/2024, the MR indicated, Patient 9's last recorded C-SSRS score on 5/10/2024 at 8:40 p.m., was 6 (High Suicide Risk, patient identified as increased risk for suicide including but not limited to, those with active suicidal ideation with method and intent, with or without a plan).

During an interview on 5/15/2024, 10:50 a.m., with registered nurse/stroke coordinator (SC), SC stated, when a patient is identified as "at risk for suicide," medical provider is notified, and safety precautions to prevent harm to patient are implemented by the facility. SC further stated a sitter for 1:1 observation (a staff member who provides continuous observation of a patient in a hospital to prevent patient self-harm) should also be provided for patient's safety. SC stated, sitter shall always stay with the patient, and documentation is done every one hour in a flowsheet, called, "Sitter Documentation-Interventions Tracking" which includes documentation of the behavioral and mental status of the patient, as well as continuous observation.

During a concurrent interview and record review on 5/15/2024, with SC, Patient 9's (MR) titled, "Sitter Documentation-Interventions Tracking," dated 5/9/2024 through 5/15/2024 and Patient 9's nursing care plan (a structural framework guided by the nursing process that outlines the health and care needs of patients receiving care at the facility and helps care team members organize aspects of patient care in a way that supports the patient's physical, psychological, social and spiritual care, based on the identified needs), dated 5/9/2024-5/15/2024, were reviewed. The MR indicated:
On 5/9/2024, there was no documentation of sitter continuous observation every hour from 7 p.m. through 9 p.m.
On 5/10/2024, there was no record of sitter continuous observation documented from 4 a.m. through 6 a.m., from 3 p.m. through 9 p.m., and from 9 p.m. through 12 a.m.
On 5/11/2024, there was no sitter continuous observation documentation from 11:00 a.m. through 12 a.m.
On 5/12/2024, there was no sitter continuous observation documentation from 12 a.m. though 7:30 a.m.
On 5/13/2024, there was no sitter continuous observation documentation from 3 a.m. through 7:12 a.m., from 1 p.m. through 4 p.m., from 4 p.m. through 7:45 p.m., from 8 p.m. through 10:30 p.m.
On 5/15/2024, there was no sitter continuous observation documentation from 2:37 a.m. through 4 a.m.

SC stated, the sitter provided to Patient 9 for 1:1 continuous observation did not always document the observation findings in Patient 9's medical record. SC further stated the care plan for "At Risk for Suicide" was not developed by nursing during Patient 9's stay at the facility from 5/9/2024 through 5/15/2024.

During an interview on 5/15/2024 at 11:06 a.m. with manager of medical-surgical floor (Mngr 1), Mngr 1 stated, 1:1 sitter provided for patient safety shall document their observations every one hour in the patient's medical record.

During an interview on 5/15/2024 at 11:15 a.m. with Mngr 1, Mngr 1 stated, safety precautions should be implemented for all patients identified at risk for suicide as per facility's policy. Mngr 1 further stated, nursing shall develop a care of plan for patients identified at risk for suicide as a part of their nursing process (a systematic, five-step method that nurses use to plan and provide patient-focused care, to assess, diagnose, plan, implement and evaluate care provided to patients based on their needs). Mngr 1 stated, "At Risk for Suicide," nursing care plan identifies interventions and education necessary to provide for patients who are at risk for harming themselves.

During a review of the facility's policy and procedure (P&P) titled, "Management of Patients Who are a Danger to Self or Others or Gravely Disabled,) dated 7/2023, the P&P indicated," All patients scored as high risk for suicide will be assigned to 1:1 continuous monitoring by a qualified professional at a range that allows for immediate intervention, when needed. The primary registered nurse shall ensure safety precautions for patients at risk for suicide and strategies for caring for patients at risk for suicide. The observations are documented at a minimum every 30 minutes in the flowsheet. Upon admission to inpatient unit, the primary nurse will ensure the "Suicide Risk" Plan of care is added and appropriate interventions are documented in the patient's medical record."

2. During an observation on 5/13/2024 at 2:07 p.m. with Registered Nurse (RN) 4, Patient 27 was observed alert and awake in bed with a sitter (a staff member who provides continuous observation of a patient in a hospital to prevent patient harm by alerting nurses or other healthcare personnel when needed) at the bedside. RN 4 stated Patient 27 was admitted for alcohol withdrawal (symptoms that occur when someone stops using alcohol after a period of heavy drinking).

During a review of Patient 27's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 5/11/2024, the H&P indicated, Patient 27 was admitted to the facility for acute alcohol intoxication (a clinically harmful condition that usually follows the ingestion of large amounts of alcohol). The H&P further indicated Patient 27 was placed on 5150 (allows an adult individual who is experiencing a mental health crisis to be involuntarily detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders] hospitalization when evaluated to be a danger to others, or to himself or herself [if a person place him or herself or others in a position of danger or is likely to suffer harm], or gravely disabled [a term that refers to a person who is unable to provide for their basic needs due to a mental health disorder]) prior to coming into the facility. In addition, the H&P indicated Patient 27 continued to be on suicidal ideation (presence of suicidal thoughts) risk upon admission and the plan was to include for Patient 27 to have a sitter for 1:1 observation and suicidal precaution (a set of interventions for suicidal assessment, monitoring and treatment of patients at risk for suicide).

During a review of Patient 27's "Columbia Suicide Severity Rating Scale (CSSRS - a suicidal ideation and behavior rating scale and scoring)," dated 5/12/24 at 12:40 a.m., Patient 27's CSSRS risk level was "High Suicide Risk."

During a review of Patient 27's "Sitter Documentation Flowsheet," the flowsheet indicated the following:

- From 5/11/2024 at 11:30 p.m. through 5/12/2024 at 6:38 a.m., Patient 27's 1:1 observation for safety monitoring were documented every hour;

- From 5/12/2024 at 3:15 p.m. through 5/12/2024 at 11 p.m., Patient 27's 1:1 observation for safety monitoring were documented every hour; and,

- From 5/13/2024 at 7 a.m. through 5/13/2024 at 7 p.m., Patient 27's 1:1 observation for safety monitoring were documented every hour;

In addition, the "Sitter Documentation Flowsheet," had no documentation of Patient 27's 1:1 observation for safety monitoring after 5/12/24 at 6:38 a.m. through 5/12/2024 at 2 p.m. This lack of documentation was verified by the Patient Safety Officer.

During an interview on 5/16/2024 at 11:15 a.m. with the Patient Safety Officer (PSO), the PSO stated Patient 27's record review was accurate. The PSO verified the following Certified Nursing Attendant (CNA) were assigned sitter for Patient 27 on 5/12/24:

- CNA 2 was the sitter from 7 a.m. to 11 a.m., and,
- CNA 3 was the sitter from 11 a.m. to 7 p.m.

The PSO stated the assigned sitters for Patient 27 did not document the 1:1 observation as indicated in the facility's P&P.

During an interview on 5/14/24 at 3:40 p.m., with Accreditation Regulatory Licensing Regional Director (ARLRD), the ARLRD stated when a patient was determined at risk for suicide, the safety measures would be implemented at all times which included environmental safety check and 1:1 sitter. The ARLRD stated the facility's P&P indicated 1:1 sitter monitoring should be documented every 30 minutes.

During a review of the facility's policy and procedure titled, "Management of patients Who Are a Danger to Self or Others or Are Gravely Disabled," revised on 7/26/2023, the P&P indicated, " ...The observations are documented at a minimum every 30 minutes ...by the qualified professional ..."

3. During an observation on 5/13/2024 at 2:20 p.m. with Registered Nurse (RN) 7, Patient 28 was observed lying in bed with eyes closed, with a sitter (a staff member who provides continuous observation of a patient in a hospital to prevent patient harm by alerting nurses or other healthcare personnel when needed) at the bedside. RN 7 stated Patient 28 was admitted today (5/13/2024) for uncontrolled behavior and agitation (a state or feeling of being restless). RN 4 stated Patient 28 was on 1:1 sitter (a staff member who provides continuous observation of a patient in a hospital to prevent patient harm by alerting nurses or other healthcare personnel when needed) for safety and risk for fall (an unintentional event that results in the person coming to rest on the ground or another lower level).

During a review of Patient 28's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 5/13/2024, the H&P indicated Patient 28 was admitted with a chief complaint of agitation (a feeling of irritability) and restlessness.

During a review of Patient 28's "Sitter Documentation Flowsheet," the flowsheet indicated from 5/13/2024 at 6 a.m. to 2 p.m., Patient 28's 1:1 observation for safety monitoring were documented every hour.

During an interview on 5/16/2024 at 10:32 a.m. with the Patient Safety Officer (PSO), the PSO stated Patient 28's record review was accurate. The PSO stated the documentation for the 1:1 observation should be every 30 minutes as indicated in the facility's policy and procedure.

During a review of the facility's policy and procedure (P&P) titled, "Use of Sitter/Care Companion," revised in 11/2022, the P&P indicated, " ...The CNA will document whether the patient is asleep or awake and the patient's behavior every 30 minutes utilizing the Sitter Documentation ..."

Based on observation, interview, and record review, the facility failed to obtain a physician's order for the use of restraints (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) for one of 30 sampled patients (Patient 12) when all four side-rails of Patient 12's bed were raised, in accordance with the facility's policy and procedure regarding restraints use.

This deficient practice resulted in Patient 12 being restrained without a physician's order and had the potential to compromise patient safety with complications such as strangulation (obstruction of blood vessels and/or airflow in the neck resulting in asphyxia [lack of oxygen]), skin tear, etc.

Findings:

During a concurrent observation and interview on 5/13/2024 at 3:52 p.m., inside Patient 12's room, with Charge Nurse (CN) 3, Patient 12 was observed awake with all 4 side rails of his (Patient 12) bed up. CN 3 stated the following: Patient 12 should not be put in bed with all 4 side rails up. It was considered a restraint (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) when 4 side rails are up. I did not know why Patient 12 had all 4 side rails up. It was a safety concern for Patient 12 and he (Patient 12) may fall out of the bed when trying to get out. I (CN 3) would tell staff to put down the side rails. There was no order from physician to place Patient 12 in a restraint.

During a review of Patient 12's "Face Sheet (a document that gives a patient's information at a quick glance and includes the patient's name, date of birth, address, etc.,)" dated 5/2024, the Face Sheet indicated Patient 12 was admitted to the facility unit on 5/13/2024 for Congestive Heart Failure (a condition that happens when the heart cannot pump blood well enough to give the body normal supply).

During a review of Patient 12's "Registered Nurse Admission Note," dated 5/2024, the registered Nurse Admission Note indicated Patient 12 had a history of dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life) who is only alert and oriented to himself, and place.

During a review of Patient 12's "History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 5/2024, the H&P indicated Patient 12 was unable to provide reliable history due to underlying dementia and Patient 12 sustained a fall (an unintentional event that results in the person coming to rest on the ground or another lower level) prior to admission to the facility.

During a concurrent interview and record review on 5/14/2024 at 2:09 p.m. with the Department Administrator Medical Surgical (DPMS) 1, Patient 30's "RN Shift Summary (RSS)," dated 5/2024 was reviewed. The RSS indicated, on 5/13/2024 at 5 a.m. there was no assessment documented for restraints use on Patient 12, and on 05/13/2024 for 5 p.m. there was no assessment documented for restraints use on Patient 12. DPMS 1 stated the following: Confirmed no physician order for restraint use in Patient 12's medical record. If patients were on any restraint use, then there should be a physician's order for it and the nurse assigned to the patient will document the assessment of the restraint.

During an interview on 5/16/2024 at 2:57 p.m. with the Department Administrator East Oncology (DAEO) 1 stated the following: DAEO 1 confirmed the restraint situation with all 4 side rails up when Patient 12 was in bed on 5/13/2024 was on her (DAEO 1) unit. It was a safety issue for Patient 12. The staff will be educated on the inappropriate use of restraint on Patient 12.

During a review of the facility's policy and procedure (P&P) titled "Restraint Use," dated 2022, the "P&P" indicated "All patients have the right to be free from restraint or seclusion, of any form ... A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. Under this definition, commonly used devices and other practices could meet the definition of a restraint, such as: Using four side rails to prevent a patient from voluntarily getting out of bed. The responsible physician must be notified as soon as possible from the initiation of the restraint, and the physician will provide a telephone or written order for the restraint."

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

1. The facility failed to ensure ongoing assessment for one of 30 sampled patient's (Patient 1) pain level immediately before and after physical therapy (interventions to help manage movement, increase strength and flexibility of patients with various conditions) in accordance with accepted standards of nursing practice and the facility's policy and procedure regarding pain assessment and management. This deficient practice had the potential to result in a delay in providing necessary treatment to address Patient 1's pain thus worsening Patient 1's pain. (Refer to A-0395)

2. The facility failed to implement pain intervention based on gathered pain assessment to manage one of 30 sampled patient's (Patient 28) pain, in accordance with the facility's policy and procedure regarding pain assessment and management. This deficient practice resulted in delay of treatment and uncontrolled pain for Patient 28. (Refer to A-0395)

3. The facility failed to document a complete set of vital signs to include pain assessment (Vital signs include measurements of a person's essential bodily functions, including body temperature, heart rate, rate of breathing, blood pressure, and level of pain), document physician notification regarding abnormal vital signs, and document assessed responses to care interventions for one of 30 sampled patients (Patient 24), in accordance with the facility's policy and procedure regarding Standard of Care. This deficient practice had the potential for Patient 24's care needs not to be addressed in a timely manner, which may result in Patient 24's pain level to worsen or blood pressure to increase and lead to patient harm such as a heart attack (when the flow of blood to the heart is severely reduced) due to uncontrolled blood pressure. (Refer to A-0395)

4. The facility failed to initiate, develop, implement and update an individualized nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for three (3) of 30 sampled patients (Patient 2, Patient 9, and Patient 20) in accordance with the facility's policy and procedure regarding care planning as evidenced by:

4.a. Failure to initiate, update, and implement a care plan for infection prevention and control for Patient 2 who tested positive for Clostridium Difficile (C. Difficile.- is a bacterium that can infect the colon [large bowel or large intestines] and cause diarrhea [loose stools] and colitis, an inflammation of the colon). This deficient practice had the potential to result in the spread of infectious agents among other patients and the staff when appropriate infection control and prevention interventions are not implemented such as the use of gowns, gloves, etc. (Refer to A-0396)

4.b. Failure to initiate and update a suicide risk care plan for Patient 9 who was at high risk for suicide (the act or an instance of taking one's own life voluntarily). This deficient practice had the potential to place Patient 9 at an increased risk of harm when safety planning interventions to reduce the risk for suicide were not initiated, implemented and maintained. (Refer to A-0396)

4.c. Failure to initiate and implement a respiratory (the process that brings oxygen in the air into the lungs and moves oxygen through the body) care plan for Patient 20 who was diagnosed with Pneumonia (an infection in the lung tissues causing swelling, fluid, or pus in the lung). This deficient practice had the potential to result in nursing staff not properly assessing and evaluating Patient 20's respiratory needs and risks which may result in patient harm or death. (Refer to A-0396)

5. The facility failed to conduct pain assessment after pain medication (Morphine, administered intravenously [through the vein] to relieve pain) administration for one of 30 sampled patients (Patient 1) in accordance with the facility's policy and procedure regarding pain assessment and management. This deficient practice had the potential for the patient's (Patient 1) response to the pain medication intervention not being assessed and identified in a timely manner and might result in delay of additional treatment thus worsening Patient 1's pain. (Refer to A-0398)

6. The facility failed to assess the pain level of one of 30 sampled patients (Patient 28) before and after administering the pain medication (Dilaudid, narcotic pain medication), in accordance with the facility's policy and procedure regarding pain assessment and management. This deficient practice resulted in delay of treatment and had the potential to cause adverse health outcomes which could negatively affect Patient 28's health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death. (Refer to A-0398)

7. The facility failed to notify the primary care provider and document physician notification when one of 30 sampled patients (Patient 8) refused a scheduled administration of blood pressure medication (Amlodipine [a class of medications that lower blood pressure by relaxing the blood vessels of the heart] 5 milligrams [mg, a unit of measurement] taken by mouth), in accordance with the facility's policy and procedure regarding physician notification and documentation. Patient 8 had a blood pressure of 146/96 (high; normal is 120/90) millimeters of Mercury (mmHg, a unit of measurement) and 160/70 (high; normal is 120/90) mmHg, respectively. This deficient practice had the potential for Patient 8's high blood pressure to not be promptly addressed which may result to adverse outcomes such as uncontrolled blood pressure, patient harm or death. (Refer to A-0398)

8. The facility failed to document the revised expiration date (28 days once the vial is opened or punctured) on three of three sampled multi-dose vials (multi-dose vial is a bottle of liquid medication [injectable] that contains more than one dose of medication for use on multiple persons) of insulin (2 vials of Humulin R [a short-acting insulin-starts to work in 30 minutes], a type insulin to lower blood glucose [sugar] and 1 vial of Humulin N [an intermediate acting insulin-a type insulin that lowers blood glucose (sugar) in two to four hours and lasts for 18 hours) after these three multi-dose vials were opened, in accordance with the facility's policy and procedure regarding safe medication labeling. This deficient practice had the potential to negatively affect the health of patients in the facility if expired insulin was used to control blood sugar levels in people with diabetes (high blood sugar) (Expired or spoiled insulin begins to break down and does not work as well to lower the blood glucose levels), which may lead to uncontrolled blood sugar level including diabetic coma (a life threatening disorder that causes unconsciousness which can happen when blood sugar is very high) or death. (Refer to A-0398)

9. The facility failed to implement the Clinical Institute Withdrawal Assessment of Alcohol (CIWA-A, a tool which provides detailed and evidence-based measures for alcohol withdrawal status) for one of 30 sampled patients (Patient 27) as ordered by the physician and in accordance with the facility's policy and procedure regarding Clinical Institute Withdrawal Assessment of Alcohol (CIWA-A). This deficient practice had the potential to result in the delay of treatment/interventions for a patient having alcohol withdrawal symptoms (a range of symptoms that occur when a person stops or significantly reduce alcohol intake after long-term use. Examples: increased blood pressure, confusion, hallucinations [a false perception of events or events], etc.) thus resulting in the worsening of Patient 27's condition, harm or death. (Refer to A-0398)

10. The facility failed to verify the Peripheral Inserted Central Catheter (PICC, intravenously placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is positioned in a location at the superior vena cava [a large significant vein responsible for returning blood from the body to the heart], and used for intravenous [through the vein] treatment that is required over a long period) placement prior to use for one of 30 sampled patients (Patient 14), in accordance with the facility's policy and procedure regarding intravenous access device placement verification. This deficient practice had the potential to result in complications such as venous thrombosis (when a blood clot forms in one of the body's deep veins), arrythmia (irregular heartbeat), etc., which may cause patient harm or death. (Refer to A-0398)

11. The facility failed to ensure one of 30 sampled patient's (Patient 27) Lorazepam (also known as Ativan, a sedative that can be used for seizure disorders [a burst of uncontrolled activity between the brain cells that can cause abnormalities in movements, behaviors, etc.] and/or to relieve anxiety) was administered as ordered by the physician and in accordance with the Clinical Institute Withdrawal Assessment of Alcohol (CIWA-A, a tool which provides detailed and evidence-based measures for alcohol withdrawal status) protocol. This deficient practice resulted in delay of treatment and had the potential to worsen for Patient 27's alcohol withdrawal symptoms to worsen, which may cause prolonged hospitalization or death. (Refer to A-405)

12. The facility failed to administer one of 30 sampled patient's (Patient 29) Flagyl (antibiotic medication for treatment of infection) as ordered by the physician and in accordance with the facility's policy and procedure regarding Medication administration. This deficient practice resulted in delay of treatment and had the potential to prolong Patient 29's hospitalization due to untreated infection. (Refer to A-405)

13. The facility failed to follow one of 30 sampled patient's (Patient 29) fentanyl (narcotic pain medication) titration (is the process of adjusting the dose of a medication for the maximum benefit without adverse effects) dose as ordered by the physician and in accordance with the facility's policy and procedure regarding Medication administration. This deficient practice had the potential to cause adverse health outcomes which could negatively affect Patient 29's health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death. (Refer to A-0405)

14. The facility failed to administer one of 30 sampled patient's (Patient 30) Norco (narcotic pain medication) as ordered by the physician and in accordance with the facility's policy and procedure regarding Medication administration. This deficient practice had the potential for Patient 30's pain to remain unrelieved and may worsen thus resulting in physical and psychological harm. (Refer to A-0405)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care in a safe environment.

Based on interview and record review, the facility failed to ensure appropriate nursing care was provided for three (3) of 30 sampled patients when:

1. The facility failed to ensure ongoing assessment of Patient 1's pain level immediately before and after physical therapy (interventions to help manage movement, increase strength and flexibility of patients with various conditions) in accordance with accepted standards of nursing practice and the facility's policy and procedure regarding pain assessment and management. This deficient practice had the potential to result in a delay in providing necessary treatment to address Patient 1's pain thus worsening Patient 1's pain.

2. The facility failed to implement pain intervention based on gathered pain assessment to manage Patient 28's pain, in accordance with the facility's policy and procedure regarding pain assessment and management. This deficient practice resulted in delay of treatment and uncontrolled pain for Patient 28.

3. The facility failed to document a complete set of vital signs to include pain assessment (Vital signs include measurements of a person's essential bodily functions, including body temperature, heart rate, rate of breathing, blood pressure, and level of pain), document physician notification regarding abnormal vital signs (high blood pressure), and document assessed responses to care interventions for Patient 24 in accordance with the facility's policy and procedure regarding Standard of Care. This deficient practice had the potential for Patient 24's care needs not to be addressed in a timely manner, which may result in Patient 24's pain level to worsen or blood pressure to increase and lead to patient harm such as a heart attack (when the flow of blood to the heart is severely reduced) due to uncontrolled blood pressure.

Findings:

1. During a review of Patient 1's medical record (MR) titled, "Emergency Department (ED) Progress Note," dated 9/17/2023 at 1:40 p.m., the MR indicated, Patient 1 returned to the ED after being discharged on 9/16/2023 at 3:30 p.m. complaining of severe thoracic pain (pain that occurs in the thoracic spine, which is located in the upper and middle back, between the shoulder blades, and extends from the bottom of the neck to the waist) and diffuse lethargy (a symptom that involves an unusual decrease in consciousness) and weakness.

During a review of Patient 1's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 9/17/2023, the H&P indicated, Patient 1 was admitted to telemetry observation unit (a hospital floor where patients are continuously monitored for their heart, breathing, and blood pressure through electronic signals) with a diagnosis of leukocytosis (an increase in the number of white cells [fights infection] in the blood, especially during an infection), back pain, fatigue (a feeling of constant tiredness), metabolic encephalopathy (a group of neurological disorders that impair brain function due to a chemical imbalance in the blood) and lactic acidosis (a medical condition that occurs when the body produces too much lactic acid [a chemical produced from the breakdown of sugar in the body]).

During a review of Patient 1's medical record (MR) titled, "Physical Therapy Consultation," dated 9/18/2023, the MR indicated, Patient 1 was evaluated by a physical therapist (PT) on 9/18/2023 at 8 a.m. The MR indicated, during the physical therapy Patient 1 complained of pain in the back and shoulder and described pain as constant and aching. The MR further indicated, Patient 1's pain level was moderate at rest and with activity and that Patient 1 was not performing at baseline due to back pain, weakness, and coordination deficits (neurological findings). The MR further indicated, primary nurse and physician were updated on Patient 1's status and neurological findings after the PT completed the assessment at 8:35 a.m.

During a concurrent interview and record review on 5/14/2024 at 9:12 a.m. with quality coordinator (QC), Patient 1's medical record (MR) titled, "Nursing Flowsheet-Pain Assessment," dated 9/18/2023 was reviewed. The MR indicated, on 9/18/2023, Patient 1 was assessed for pain at 7 a.m., indicating, Patient 1's pain level was 0 out of 10 (a pain scale uses numbers from 0 to 10, with 0 representing no pain and 10 representing the worst pain possible), and another at 12:25 p.m., wherein Patient 1's pain was recorded to be 7 out of 10 (a score of 7 indicates severe pain). QC verified, on 9/18/2023, from 8 a.m. to 12 p.m., no other pain assessment was recorded in Patient 1's medical record including the pain verbalized by Patient 1 to the physical therapist on 9/18/2023 at 8 a.m. There was also no record that Patient 1 was administered pain medication between 8 to 9 a.m. on 9/18/2023 when Patient 1 verbalized to the physical therapist about having moderate pain at rest and with activity. In addition, there was no record of pain medication administered to Patient 1 between 8:35 a.m. and 12 p.m. when the physical therapy session ended.

During an interview on 5/14/2024 at 9:45 a.m. with the Physical Medicine and Rehab Assistant Director (APTD), APTD stated, typically before beginning a physical therapy treatment with a patient, a physical therapist (PT) shall assess patients for the presence of pain, and if needed, pain medicine can be administered by the primary nurse. APTD further stated, after the treatment session is completed, all assessment findings (a summary of the patient's ability or inability to perform certain tasks) are discussed with the primary nurse, including the treatment goals and progress and the expectation is for the nurse to follow up with the patient and address any issues, such as pain, if necessary.

During a review of the facility's policy and procedure (P&P) titled, "Plan of Care, Assessment, and Reassessment of Patients," dated 1/2022, the P&P indicated, "Patient need for care related to their admission is implemented via nursing process for nursing and clinical assessment by other disciplines as appropriate. The scope and basis of any other assessment is based on the patient's diagnosis. Patients are reassessed by nursing every shift and as needed. The hospital provides care, treatment, and services for each patient according to the plan of care, including but not limited to, providing supportive care, treating a disease or condition and or treating symptoms such as pain, using accepted professional standards of nursing practice."

During a review of the facility's policy and procedure (P&P) titled, "Pain Assessment and Management," dated 8/2021, the P&P indicated, "If patient has pain, comprehensive pain assessment must be provided based on patient needs, age, and abilities. Assessing and reassessing pain should be done as needed based on the treatment plan, and responses to interventions throughout their hospitalization, including, but not limited to operative and other procedures and prior to discharge."

During a review of the facility's policy and procedure (P&P) titled, "Pain Assessment and Management," revised in 8/2021, the P&P indicated, "Patients have the right to ...Have pain prevented or controlled when possible ...Receive pain medication in a timely manner ..."

2. During a review of Patient 28's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 5/13/2024, the H&P indicated, Patient 28 was admitted with a chief complaint of agitation (a feeling of irritability) and restlessness. Patient 28's medical history included opiate (narcotic medication) dependence, drug diversion (abuse of prescription drugs), and lumbar (refers to the five bones in the lower back) back pain.

The H&P further indicated the physician from Addiction Medicine was consulted and had recommended for Patient 28 to have Dilaudid (narcotic medication) 1 milligram (mg, a unit of measurement) every 4 hours as needed (PRN) for pain.

During a review of Patient 28's "Medication Administration Record (MAR)," the MAR included a physician's order of Dilaudid 1 mg intravenous (IV, through the veins) one time, to start on 5/13/2024 at 10:30 a.m.

During a review of Patient 28's "Vitals (Vital signs- include temperature, respiratory rate, heart rate, blood pressure and pain level) - Pain Documentation Flowsheet," the flowsheet (contains important data regarding a patient's condition) indicated the following pain assessment of Patient 28:

- On 5/15/2024 at 10:37 a.m., Patient 28 had a sharp pain on the back, the pain assessment score was 6 (pain score of 4-6 is moderate pain).

The MAR did not indicate Patient 28 was administered Dilaudid 1 mg IV for Patient 28's pain on 5/15/2024 at 10:37 a.m.; and,

- On 5/16/2024 at 6:36 a.m., Patient 28's pain assessment score was 7 (pain score of 7-10 is severe pain).

The MAR did not indicate Patient 28 was administered Dilaudid 1 mg IV for Patient 28's pain on 5/16/2024 at 6:36 a.m.

The lack of documented evidence for pain intervention was verified by the Patient Safety Officer (PSO).

During an interview on 5/16/2024 at 10:32 a.m., with the PSO, the PSO stated that Patient 28's pain should have been addressed and pain medication should have been given as ordered by the physician to manage Patient 28's pain.

During a review of the facility's policy and procedure (P&P) titled, "Pain Assessment and Management," revised in 8/2021, the P&P indicated, "Patients have the right to ...Have pain prevented or controlled when possible ...Receive pain medication in a timely manner ..."

3. During a review of Patient 24's electronic health record (EHR - a digital health record accessed through a facility's computer system), dated 5/13/2024, the EHR indicated Patient 24 presented to the facility's emergency room on 5/13/2024 at 9:17 a.m., with diagnoses including shortness of breath SOB - difficulty with breathing) and chest pain (a sensation of pain or discomfort over a person's chest may be an urgent indication of a sudden change in a person's heart health).

During a concurrent interview and record review on 5/14/2024 at 1:15 p.m. with the Chief Nurse Executive (CNE) and the Magnet Program Manager (MPM), Patient 24's "Ambulatory Extended Vital Flowsheet," dated 5/13/2024, was reviewed within the patient's EHR. The "Ambulatory Extended Vital Flowsheet" indicated:
-5/13/2024 at 9:44 a.m.: vital signs documentation incomplete, no pain assessment documented.
-5/13/2024 at 10:37 a.m.: vital signs documentation incomplete, no pain assessment documented.
-5/13/2024 at 1:26 p.m.: vital signs documentation incomplete, no pain assessment documented.
-5/13/2024 at 2:01 p.m.: vital signs documentation incomplete, no pain assessment documented.
-5/13/2024 at 3:00 p.m.: vital signs documentation incomplete, no pain assessment documented with a blood pressure (BP) measurement of 181/78 (A normal blood pressure measurement is 120/90, indicating this patient's BP was abnormally high).

During a concurrent interview and record review on 5/14/2024 at 1:15 p.m. with the CNE, the facility's policy and procedure (P&P) titled, "Standard of Practice-Triage," revised 8/2023 was reviewed. The P&P indicated, "Vital signs including pain scale will be completed and documented based on patient acuity (minimally every 2 hours), unless ordered more frequently by provider or clinically indicated." The CNE stated patient vital signs include their pain assessment, and should be taken at minimum every two hours, per the facility's P&P.

During an interview on 5/15/2024, between 11:16 a.m. and 11:36 a.m., with the Director of Emergency Services (DES), the CNE, the Quality Coordinator (QC2), the Director of Nursing Services (DNS), and the Assistant Director of Education (ADER), the DES was asked about nursing and vital signs and stated, "Expectation is vitals sign are taken upon triage, once roomed and 30 minutes before discharge, every two hours and anytime there is an intervention that would alter heart rate, blood pressure."

During an interview on 5/15/2024, between 11:16 a.m. and 11:36 a.m., with the DES, the CNE, the QC2, the DNS, and the ADER, the DES stated, "vital signs include pain assessment" and are taken every two hours at minimum.

During a concurrent interview and record review on 5/15/2024, between 11:16 a.m. and 11:36 a.m., with the DES, the CNE, the QC2, the DNS, and the ADER, the DES was asked to review Patient 24's EHR to show where their pain assessments were documented. The DES stated, "I am unable to show you," and further stated, he (the DES) reviewed the patient's vital signs and medical chart, and the expectations of care were not met. The DES stated, "Nursing care was not appropriate and below standard" for Patient 24.

During an interview on 5/15/2024, between 11:16 a.m. and 11:36 a.m., with the DES, the CNE, the QC2, the DNS, and the ADER, the DES was asked about expectations from nurses when there was a change in a patient's condition. The DES stated, nurses are required to assess the patient, and notify the physician of any changes of patient conditions, including vital signs. The DES confirmed Patient 24's high blood pressure was not reassessed or treated, and the patient's health record did not reflect notification of the physician by the responsible registered nurse.

During a review of the facility's policy and procedure (P&P) titled, "Standard of Practice-Triage," revised 8/2023, the P&P indicated, "Vital signs including pain scale will be completed and documented based on patient acuity (minimally every 2 hours), unless ordered more frequently by provider or clinically indicated."

During a review of the facility's policy and procedure (P&P) titled, "Standard of Care," revised 8/2023, the P&P indicated, "The patient's response to therapy, medications, treatments, diagnostic procedures must be documented. Prior to the administration of medications assessment of need and vital signs with pain scale are to be documented [ ...] 60 minutes for oral or intramuscular assessment and documentation, effectiveness, response and post administration vital signs are to be completed and documented."

Based on interview and record review, the facility failed to initiate, develop, implement and update an individualized nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for three (3) of 30 sampled patients (Patient 2, Patient 9, and Patient 20) in accordance with the facility's policy and procedure regarding care planning as evidenced by:

1. Failure to initiate, update, and implement a care plan for infection prevention and control for Patient 2 who tested positive for Clostridium Difficile (C. Difficile- is a bacterium that can infect the colon [large bowel or large intestines] and cause diarrhea [loose stools] and colitis, an inflammation of the colon). This deficient practice had the potential to result in the spread of infectious agents among other patients and the staff when appropriate infection control and prevention interventions are not implemented such as the use of gowns, gloves, etc.

2. Failure to initiate and update a suicide risk care plan for Patient 9 who was at high risk for suicide (the act or an instance of taking one's own life voluntarily). This deficient practice had the potential to place Patient 9 at an increased risk of harm when safety planning interventions to reduce the risk for suicide were not initiated, implemented and maintained.

3. Failure to initiate and implement a respiratory (the process that brings oxygen in the air into the lungs and moves oxygen through the body) care plan for Patient 20 who was diagnosed with Pneumonia (an infection in the lung tissues causing swelling, fluid, or pus in the lung). This deficient practice had the potential to result in nursing staff not properly assessing and evaluating Patient 20's respiratory needs and risks which may result in patient harm or death.

Findings:

1. During a review of Patient 2's "History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 5/10/2024, the H&P indicated, Patient 2 was admitted to the facility with a diagnosis of proctocolitis (inflammation of the colon [the large bowel or large intestine] and rectum [the last several inches of the large intestine]) and diarrhea (loose stools), and had past medical history (PMH, the total sum of a patient's health status prior to the presenting problem) of hypertension (high blood pressure), history (Hx) of breast cancer, cervical disc degeneration (a natural process that occurs when the discs in the upper neck region of the spine break down).

During a review of Patient 2's medical record (MR) titled, "Orders," dated 5/12/2024, the MR indicated, an order to collect stool specimen (a sample of feces that is analyzed in a laboratory to check for evidence of a medical condition) to test for C. difficile (Clostridioides difficile, is a bacterium that can infect the colon and cause diarrhea and colitis, an inflammation of the colon) was placed on 5/12/2024.

During a review of Patient 2's medical record (MR) titled, "Orders," dated 5/12/2024, the MR indicated, Patient 2 was placed in Contact Plus isolation precautions (a method used to protect people from spores that can spread through contact with a patient or objects in their room. Contact precautions are used to prevent the spread of germs that can be transmitted by touch, such as C. difficile) pending test results for C. difficile.

During a record review on 5/14/2024 at 1:35 p.m. with quality coordinator (QC), Patient 2's MR titled, "Clostridiodes difficile Checklist," dated 5/12/2024, was reviewed. The MR indicated, on 5/12/2024, primary nurse documented necessary steps taken following the specimen collection were as follows:
a. Isolation documented in flowsheet.
b. Infection was added to Care Plan (provides a framework for evaluating and providing patient care needs related to the nursing process)
c. Education of patient and family was documented in flowsheet.
d. Replaced disinfectant wipes with bleach containing wipes.

During a concurrent interview and record review on 5/14/2024 at 1:35 p.m., with quality coordinator (QC) and the manager of medical/surgical floor (Mngr 1), Patient 2's medical record, dated 5/12/2024, was reviewed. The MR indicated, Patient 2 tested positive for C. Difficile on 5/12/2024. The MR further indicated, Patient 2 had no care plan developed for "Infection," on 5/12/2024 and no education to patient and family was documented by primary nurse on 5/12/2024.

This lack of documented evidence was verified by the QC and the Mngr 1. Mngr 1 stated, nursing shall develop, implement, and update a care plan for "Infection" because the care plan is developed to remind the nurses of necessary interventions that should be taken when patients have an infection. Mngr 1 further stated, education should be provided and documented, so patients and family understand the medical condition.

During an interview on 5/17/2024 at 9:24 a.m., with patient safety officer (PSO), PSO stated, when patients are admitted with specific problems, nurses shall identify the problems and initiate care plans specific to a patient condition. PSO further stated, nursing care plans are developed to address specific needs of patients and to track patients' progress toward addressing those needs.

During a review of the facility's policy and procedure (P&P) titled, "Plan of Care/Assessment/Reassessment of Patients," dated 1/2022, the P&P indicated, " 4.11. Planning Care, Treatment and Services: Each patient's plan for care, treatment and services is individualized and appropriate to the patient's needs, strengths, limitations, and goals. Planning involves integration of assessment findings in the care-planning process, documenting the plan, monitoring for its effectiveness, and involving patients in care planning."

2. During a review of Patient 9's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 5/9/2024, the H&P indicated, Patient 9 was admitted to the facility for management of warfarin (a medicine that prevents formation of blood clots and can cause serious side effects, such as heavy bleeding) poisoning after Patient 9 attempted a suicide (the act or an instance of taking one's own life voluntarily) by ingesting 25 of 2.5 milligrams (mg, a unit of measurement) of warfarin tablets at home.

During a further review of Patient 9's medical record (MR) titled, "Hospitalist Team Progress Note," dated 5/14/2024, the MR indicated, Patient 9 was treated for warfarin overdose and was being closely monitored for signs of bleeding. The MR further indicated, Patient 9 was evaluated by inpatient psychiatry (a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders), and was recommended psychiatric hospitalization due to danger to self and gravely disabled (a term that refers to a person who is unable to provide for their basic needs due to a mental health disorder).

The MR indicated, on 5/13/2024, Patient 9 developed hyponatremia (low blood sodium [salt] levels, can be dangerous if left untreated or treated improperly and may cause seizures [a burst of uncontrolled activity between the brain cells that can cause abnormalities in movements, behaviors, etc.], coma [a state of unconsciousness where a person is unresponsive and cannot be woken], and death) and continued to be admitted to the facility's medical floor, pending discharge to a psychiatric facility once medically stable.

During a review of Patient 9's Medical Record (MR) titled, "Psychiatry Consultation Note," dated 5/9/2024, the MR indicated, the psychiatrist recommended to continue treatment plan including a sitter (a staff member who provides continuous observation of a patient in a hospital to prevent patient harm by alerting nurses or other healthcare personnel when needed) and suicide precautions (a set of interventions for suicidal assessment, monitoring and treatment of patients at risk for suicide) .

During a review of Patient 9's Medical Record titled, "Psychiatry Progress Note," dated 5/14/2024, the MR indicated, on 5/14/2024, Patient 9 stated to psychiatrist that Patient 9 still wanted to die.

During a review of Patient 9's Medical Record titled, "Nursing Flowsheet- Columbia Suicide Severity Rating Scale," (C-SSRS - a suicidal ideation and behavior rating scale and scoring), dated 5/10/2024, the MR indicated, Patient 9's last recorded C-SSRS score on 5/10/2024 at 8:40 p.m., was 6 (High Suicide Risk, patient identified as increased risk for suicide including but not limited to, those with active suicidal ideation [thoughts of harm] with method and intent, with or without a plan).

During a concurrent interview and record review on 5/15/2024 at 10:50 a.m., with registered nurse/stroke coordinator (SC), Patient 9's medical record (MR) titled, "Care Plan (provides a framework for evaluating and providing patient care needs related to the nursing process)," dated 5/9/2024 through 5/15/2024 was reviewed. SC verified, "Suicide Risk" care plan was not developed and updated by nursing for Patient 9. SC further stated, nursing shall develop a care plan specific to suicidal risk to implement necessary interventions for harm prevention.

During an interview on 5/15/2024 at 11:15 a.m., with the manager of medical surgical (serves general population such as illness and surgery) unit (Mngr 1), Mngr 1 stated, nursing care plans are a part of the nursing process. Mngr 1 further stated, nursing care plans outline patient's healthcare needs, goals, and the nursing interventions required to meet those needs.

During a review of the facility's policy and procedure (P&P) titled, "Management of Patients Who are a Danger to Self or Others or Gravely Disabled,) dated 7/2023, the P&P indicated," Upon admission to inpatient unit, the primary nurse will ensure the "Suicide Risk" Plan of care is added and appropriate interventions are documented in the patient's medical record."

During a review of the facility's policy and procedure (P&P), titled, "Plan of Care/Assessment/Reassessment of Patients," dated 1/2022, the P&P indicated, " 4.11. Planning Care, Treatment and Services: Each patient's plan for care, treatment and services is individualized and appropriate to the patient's needs, strengths, limitations, and goals. Planning involves integration of assessment findings in the care-planning process, documenting the plan, monitoring for its effectiveness, and involving patients in care planning."

3. During a review of Patient 20's "Face Sheet (FS, a document that gives a patient's information at a quick glance and includes the patient's name, date of birth, address, etc.)," dated May 2024, the "FS" indicated Patient 20 was admitted to the facility on 5/13/2024 at 9 a.m. for Pneumonia (an infection in the lung tissues causing swelling, fluid, or pus [thick fluid made up of bacteria] in the lung).

During a review of Patient 20's "History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 5/2024, the "H&P" indicated the following: Patient 20 presented to the facility with cough and weakness. Patient 20 was lying on his (Patient 20) side and coughing. Patient 20 had a chest X-ray (uses radiation to produce images of the heart, lung, etc. for better visualization and diagnosis) reading resulting with right pulmonary infiltrate (a substance in the lung such as blood or pus that can lead to lung damage) to his (Patient 20) right lung.

During a concurrent interview and record review on 5/14/2024 at 3:25 p.m. with Department Administrator Medical Surgical (DPMS) 1, Patient 20's "Nurse Care Planning (NCP, provides a framework for evaluating and providing patient care needs related to the nursing process)," dated May 2024 was reviewed. The NCP indicated, from 5/13/2024 through 5/14/2024, there was no selected care plan to address respiratory condition for Patient 20. The DPMS 1 stated the following: Confirmed no selected care plan to address respiratory condition for Patient 20 in the medical record. The staff nurses had 24 hours to select care plan for patients. There are respiratory care plans to be selected for patients with Pneumonia. The nurse assigned to the patient should have selected a respiratory care plan for the Patient 20. Not selecting the right care plan does not ensure patient getting the right care provided. Will educate and follow up with the staff nurse.

During a review of the facility's policy and procedure (P&P) titled, "Plan of Care," dated 2022, the "P&P" indicated "Planning Care, Treatment and Services: Each patient's plan for care, treatment and services is individualized and appropriate to the patient's needs, strengths, limitations, and goals. Planning for care, treatment, and services includes developing a plan that includes patient care goals that are reasonable and measurable, and documenting the plan."

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

1.a. Conduct pain assessment after pain medication (Morphine, administered intravenously [through the vein] to relieve pain) administration for one of 30 sampled patients (Patient 1) in accordance with the facility's policy and procedure regarding pain assessment and management. This deficient practice had the potential for the patient's (Patient 1) response to the pain medication intervention not being assessed and identified in a timely manner and might result in delay of additional treatment thus worsening Patient 1's pain.

1.b. Assess the pain level of one of 30 sampled patients (Patient 28) before and after administering the pain medication (Dilaudid, narcotic pain medication), in accordance with the facility's policy and procedure regarding pain assessment and management. This deficient practice resulted in delay of treatment and had the potential to cause adverse health outcomes which could negatively affect Patient 28's health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death.


2. Notify the primary care provider and document physician notification when one of 30 sampled patients (Patient 8) refused a scheduled administration of blood pressure medication (Amlodipine [a class of medications that lower blood pressure by relaxing the blood vessels of the heart] 5 milligrams [mg, a unit of measurement] taken by mouth), in accordance with the facility's policy and procedure regarding physician notification and documentation. Patient 8 had a blood pressure of 146/96 (high; normal is 120/90) millimeters of Mercury (mmHg, a unit of measurement) and 160/70 (high; normal is 120/90) mmHg, respectively. This deficient practice had the potential for Patient 8's high blood pressure to not be promptly addressed which may result to adverse outcomes such as uncontrolled blood pressure, patient harm or death.

3. Document the revised expiration date (28 days once the vial is opened or punctured) on three of three sampled multi-dose vials (multi-dose vial is a bottle of liquid medication [injectable] that contains more than one dose of medication for use on multiple persons) of insulin (2 vials of Humulin R [a short-acting insulin-starts to work in 30 minutes], a type insulin to lower blood glucose [sugar] and 1 vial of Humulin N [an intermediate acting insulin-a type insulin that lowers blood glucose (sugar) in two to four hours and lasts for 18 hours) after these three multi-dose vials were opened, in accordance with the facility's policy and procedure regarding safe medication labeling.

This deficient practice had the potential to negatively affect the health of patients in the facility if expired insulin was used to control blood sugar levels in people with diabetes (high blood sugar) (Expired or spoiled insulin begins to break down and doesn't work as well to lower the blood glucose levels), which may lead to uncontrolled blood sugar level including diabetic coma (a life threatening disorder that causes unconsciousness which can happen when blood sugar is very high) or death.

4. Implement the Clinical Institute Withdrawal Assessment of Alcohol (CIWA-A, a tool which provides detailed and evidence-based measures for alcohol withdrawal status) for one of 30 sampled patients (Patient 27) as ordered by the physician and in accordance with the facility's policy and procedure regarding Clinical Institute Withdrawal Assessment of Alcohol (CIWA-A).
This deficient practice had the potential to result in the delay of treatment/interventions for a patient having alcohol withdrawal symptoms (a range of symptoms that occur when a person stops or significantly reduce alcohol intake after long-term use. Examples: increased blood pressure, confusion, hallucinations [a false perception of events or events], etc.) thus resulting in the worsening of Patient 27's condition, harm or death.

5. Verify the Peripheral Inserted Central Catheter (PICC, intravenously placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava, and used for intravenous treatment that is required over a long period) placement prior to use for one of 30 sampled patients (Patient 14), in accordance with the facility's policy and procedure regarding intravenous access device placement verification.

This deficient practice had the potential to result in complications such as venous thrombosis (when a blood clot forms in one of the body's deep veins), arrythmia (irregular heartbeat), etc., which may cause patient harm or death.

Findings:

1.a. During a review of Patient 1's Medical Record (MR) titled, "Emergency Department Provider Note," dated 9/15/2023, the MR indicated, Patient 1 was seen in the Emergency Department (ED, responsible for providing medical care to patients arriving at the hospital and are in need of immediate care) for shortness of breath and mild back pain and had past medical history (PMH, a record of information about a person's health) including, but not limited to, follicular lymphoma (a type of blood cancer), interstitial lung disease (a large group of diseases that cause scarring [fibrosis] of the lungs), bladder mass (an abnormal growth that develops in the bladder, a muscular sac in the pelvic region that stores urine), and diabetes (high blood sugar).

During a review of Patient 1's Medical Record (MR) titled, "Vital Signs (includes the heart rate, temperature, respiratory rate, blood pressure, and pain level) Flowsheet (contains important data regarding a patient's condition)," dated 9/15/2023 at 8:18 p.m., the MR indicated, Patient 1's back pain level was 6 out of 10 (a pain scale uses numbers from 0 to 10, with 0 representing no pain and 10 representing the worst pain possible; a pain score of 6 indicates moderate pain).

During further review of Patient 1's Medical Record titled, "Medication Administration Record (MAR)," dated 9/15/2023, the MR indicated, on 9/15/2023, at 9:19 p.m., Patient 1 received 6 milligrams (mg, a unit of measurement) of Morphine (pain medication) intravenously (IV, through the vein).

During a concurrent interview and record review on 5/14/2024 at 1:07 p.m., with the quality coordinator (QC), Patient 1's Medical Record (MR) titled, "Vital Signs-Pain Assessment," dated 9/15/2023 through 9/16/2023 was reviewed. The MR indicated, on 9/15/2023, at 8:18 p.m., Patient 1's pain level was recorded 6 out of 10; on 9/16/2024, at 1:16 a.m., Patient 1's pain level was documented to be 2 out of 10; and at 7:41 a.m., Patient 1's pain level was documented to be 0/10. The QC stated, no other pain assessment documentation by nursing was recorded in Patient 1's chart after 8:18 p.m. on 9/15/2023 through 1 a.m. on 9/16/2023 to indicate assessment of Patient 1's response to the Morphine medication which was administered on 9/15/2023 at 9:19 p.m.

During a concurrent interview and record review on 5/17/2024 at 9:41 a.m., with the director of emergency department (DED), Patient 1's medical record titled, Vital Signs-Pain Assessment," dated 9/15/2023 was reviewed. The MR indicated, on 9/15/2023, Patient 1 was assessed for pain level once, upon arrival to the facility at 8:18 p.m. and then Patient 1 was given pain medication (Morphine) at 9:19 p.m.

The DED stated, pain assessment is generally performed on admission, and at a minimum of two hours or with each set of vital signs (measurements of a living organism's essential physiological functions). The DED further stated, pain re-assessment also had to be done by the primary nurse within thirty minutes after Patient 1 received 6 mg of Morphine IV [a pharmacological intervention to address pain) but the primary nurse did not.

During a review of the facility's policy and procedure (P&P) titled, "Pain Assessment and Management," dated 8/2021, the P&P indicated, "If patient has pain, comprehensive pain assessment must be provided based on patient needs, age, and abilities. Assessing and reassessing pain should be done as needed based on the treatment plan, and responses to interventions throughout their hospitalization, including, but not limited to operative and other procedures and prior discharge."

1.b. During a review of Patient 28's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 5/13/2024, the H&P indicated Patient 28 was admitted with a chief complaint of agitation and restlessness. Patient 28's medical history included opiate (narcotic medication) dependence, drug diversion (abuse of prescription drugs), and lumbar (refers to the five bones in the lower back) back pain.

The H&P further indicated the physician from Addiction Medicine was consulted and had recommended for Patient 28 to have Dilaudid (narcotic medication) 1 milligram (mg, a unit of measurement) every 4 hours as needed (PRN) for pain.

During a review of Patient 28's "Medication Administration Record (MAR)," the MAR included a physician's order of Dilaudid 1 mg intravenous (IV, through the veins) one time, to start on 5/13/2024 at 10:30 a.m.

The MAR further indicated Patient 28 was given Dilaudid 1 mg IV x (times) 1 on 5/13/24 at 10:36 a.m. The corresponding "Vitals (Vital signs, include temperature, heart rate, respiratory rate, blood pressure, and pain level) - Pain Documentation Flowsheet" did not have documentation of Patient 27's pain assessment prior to administering the Dilaudid.

The lack of documentation was verified by the Patient Safety Officer (PSO) on 5/16/2024 at 10:32 a.m..

During a review of Patient 28's "MAR," the MAR included a physician's order of Dilaudid 1 mg IV every 4 hours PRN pain, to start on 5/13/2024 at 11:49 a.m.

The MAR further indicated on the following dates and times:

- On 5/14/2024 at 7:47 p.m., Patient 28 was given Dilaudid 1 mg IV. The corresponding "Vitals - Pain Documentation Flowsheet" did not have documentation of Patient 28's pain reassessment after Dilaudid was given;

- On 5/15/2024 at 12:22 a.m., Patient 28 was given Dilaudid 1 mg IV. The corresponding "Vitals - Pain Documentation Flowsheet" did not have documentation of Patient 27's pain assessment and reassessment before and after Dilaudid was given; and,

- On 5/16/2024 at 2:15 a.m., Patient 28 was given Dilaudid 1 mg IV. The corresponding "Vitals - Pain Documentation Flowsheet" did not have documentation of Patient 28's pain reassessment after Dilaudid was given.

The lack of documentation was verified by the Patient Safety Officer (PSO) on 5/16/2024 at 10:32 a.m..

During an interview on 5/16/2024 at 10:32 a.m., with the PSO, the PSO stated the patient's pain should be assessed prior to giving pain medication to ensure the patient would receive the correct pain medication and to know the patient's baseline of his/her pain.

In the same interview, the PSO stated the patient's pain should be reassessed after giving the pain medication to know if the pain medication was effective or need to adjust if pain was not managed.

During a review of the facility's policy and procedure (P&P) titled, "Pain Assessment and Management," revised in 8/2021, the P&P indicated the following:

- Ongoing Pain Management. Assess and reassess all patients with pain for pain intensity, quality, location, precipitating factors, and response to interventions throughout their hospitalization ...

- Reassess pain, depending on the characteristic of the analgesic selected. In the Critical Care areas and the Emergency Department where continuous assessment of vital signs may occur, the RN will determine the appropriate intervals for pain assessment based on the qualities of the pain present and the analgesic agent used.

- Documentation. Record Pain/Comfort Assessment, interventions, response to intervention, level of sedation (state of calmness or sleepiness caused by certain drugs) in the Electronic Medical Record.

2. During a review of Patient 8's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 5/11/2024, the H&P indicated, Patient 8 was admitted with a diagnosis of sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock [when infection causes low blood pressure], and death) due to urinary tract infection (UTI, a bacterial infection in the urinary system, which includes the kidneys, ureters [tube that carries urine], bladder [organ that stores urine]) and had past medical history (PMH, a record of information about a person's health) of hypertension (high blood pressure), atherosclerosis of aorta (a condition that occurs when plaque builds up on the inner walls of the aorta, a large blood vessel in the body) and hypothyroidism (a condition that occurs when the thyroid gland [a small, butterfly-shaped gland in the front of the neck ] doesn't produce enough thyroid hormones [regulates the rate at which the body uses energy]).

During a review of Patient 8's Medical Record (MR) titled, "Medication Administration Record (MAR)," dated 5/12/2024 and 5/15/2024, the MR indicated, on 5/12/2024 at 9 a.m., primary nurse documented "Patient refused medication," and did not administer amlodipine (a class of medications that lowers blood pressure by relaxing the blood vessels of the heart) tablet 5 milligrams (mg, a unit of measurement). The MR further indicated, on 5/15/2024 at 8:15 a.m., the primary nurse documented "Patient refused medication," and did not administer 5 mg amlodipine tablet.

During a concurrent interview and record review on 5/15/2024 at 10:26 a.m. with registered nurse/stroke coordinator (SC), Patient 8's medical record (MR) titled, "Vital Signs," dated 5/12/2024 at 9 a.m., was reviewed. The MR indicated, Patient 8's blood pressure was 146/96 (high; normal is 120/90) millimeters of mercury (mmHg, a unit of measurement). SC verified, no subsequent timely blood pressure monitoring and measurement was recorded on 5/12/2024 after Patient 8 refused Amlodipine 5 mg tablet. The MR further indicated, the next blood pressure measurement on 5/12/2024 was obtained only at 3:00 p.m. The MR also indicated, on 5/15/2024 at 8:00 a.m., Patient 8's blood pressure was recorded 160/77 mmHg (high; normal is 120/90). SC verified, no subsequent timely blood pressure monitoring and measurement was recorded on 5/15/2024 after Patient 8 refused Amlodipine 5 mg tablet at 8:10 a.m. with a documented blood pressure of 160/77 mmHg.

During a concurrent interview and record review on 5/15/2024 at 10:26 a.m., with registered nurse/stroke coordinator (SC), Patient 8's MAR, dated 5/12/2024 and 5/15/2024 was reviewed. SC stated, when Patient 8 refused Amlodipine 5 mg on 5/12/2024 at 9:00 a.m., and on 5/15/2024 at 8:10 a.m., the facility's practice should have been to notify the physician regarding patient's (Patient 8) refusal of blood pressure medication and document physician notification in Patient 8's medical record, but the primary nurse did not do both (to notify the physician and to document).

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," dated 8/2021, the P&P indicated, "Patient has the right to refuse medications, the nurse documents the refusal in patient medical record and reports to the prescribing physician on duty as appropriate."

3. During an observation on 5/14/2024 at 3:30 p.m., at the medical surgical (serves general population such as illness and surgery)/telemetry unit (area in hospital where patient undergoes continuous heart monitoring), in a locked medication room, three multi-dose vials (multi-dose vial is a bottle of liquid medication [injectable] that contains more than one dose of medication for use on multiple persons) of insulin (2 vials of Humulin R [a short-acting insulin- starts to work in 30 minutes], a type insulin to lower blood glucose (sugar) and 1 vial of Humulin N [an intermediate acting insulin-a type insulin that lowers blood glucose in two to four hours and lasts for 18 hours]) were observed. All three multi-dose insulin vials were opened and had no documentation of the date when these vials were opened or when each of the vials expire.

During a concurrent observation and interview on 5/14/2024 at 3:30 p.m. with charge nurse (CN 1), three multi-dose opened insulin vials (2 Humulin R and one vial of Humulin N) were observed. CN 1 confirmed all three insulin vials were not labeled with the revised expiration date. CN 1 further stated, nursing staff should label all multi-dose vials with the date when first used/opened or label with the revised expiration date which is 28 days after first use.

During a review of the facility's policy and procedure (P&P) titled, "Safe Medication Labeling," dated 12/2022, the P&P indicated, "Multi-dose vials is a bottle of liquid medication (injectable) that contains more than one dose of medication and is approved by the Food and Drug Administration (FDA) for use on multiple persons. Multi-dose vials are to be discarded 28 days after first use unless the manufacturer specifies a shorter or longer expiration date. All multi-dose vials need to be labeled with the revised expiration date once multi-dose vial is opened or punctured. Place expiration date of 28 days after open or puncture of multi-dose vial."

4. During an observation on 5/13/2024 at 2:07 p.m. with Registered Nurse (RN) 4, Patient 27 was observed alert and awake in bed with a sitter (a staff member who provides continuous observation of a patient in a hospital to prevent patient harm by alerting nurses or other healthcare personnel when needed) at the bedside. RN 4 stated Patient 27 was admitted for alcohol withdrawal (a range of symptoms that occur when a person stops or significantly reduce alcohol intake after long-term use. Examples: increased blood pressure, confusion, hallucinations [a false perception of events or events], etc.) and on Clinical Institute Withdrawal Assessment of Alcohol (CIWA-A, a tool which provides detailed and evidence-based measures for alcohol withdrawal status) every two hours.

During a review of Patient 27's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 5/11/2024, the H&P indicated, Patient 27 was admitted to the facility for acute alcohol intoxication (a clinically harmful condition that usually follows the ingestion of large amounts of alcohol). The H&P included plan for Patient 27 to be on CIWA-A protocol.

During a review of the facility's policy and Procedure (P&P) titled, "Clinical Institute Withdrawal Assessment of Alcohol (CIWA-A)," revised on 2/2023, the P&P indicated the following:

Example of Physician CIWA-A and IV (intravenous - through the vein) Lorazepam (a sedative that can be used for seizure disorders (a burst of uncontrolled activity between the brain cells that can cause abnormalities in movements, behaviors, etc.), and/or to relieve anxiety) Orders:

CIWA-A 0-9, no medication. Assess CIWA-A every 2 hours ...
CIWA-A 10-12, 2 mg (milligrams, a unit of measurement) Lorazepam (also known as Ativan). Reassess CIWA-A in 2 hrs (hour).
CIWA-A 13-15, 3 mg Lorazepam. Reassess CIWA-A in 2 hrs.
CIWA-A 16-19, 4 mg Lorazepam. Reassess CIWA-A in 1 hr.
CIWA-A 20-30, 5 mg Lorazepam. Reassess CIWA-A every hr & PRN (as needed) worsening symptoms.
CIWA-A greater than or equal to 31, 6 mg Lorazepam. Reassess CIWA-A every hr & PRN worsening symptoms.
Notify physician if greater than 24 mg of Lorazepam given in less than or equal to 24 hours.

During a review of Patient 27's "Medication Administration Record (MAR)," the MAR included a physician's order for Ativan (also known as Lorazepam, a sedative that can be used for seizure disorders and/or to relieve anxiety) 0-6 milligram (mg) intravenous (IV - through the vein) as needed, "see administration instruction (CIWA-A protocol)."

During a review of Patient 27's "CIWA-A Documentation Flowsheet" the flowsheet indicated the following CIWA-A assessment for Patient 27:

- On 5/12/2024 at 8 a.m., Patient 27's CIWA-A was 20. The corresponding MAR indicated Patient 27 was given Lorazepam 5 mg IV at 8:16 a.m.;

- On 5/12/2024 at 9 a.m., Patient 27's CIWA-A was 22 (CIWA-A score of 20-30, give 5 mg Lorazepam). The MAR had no documentation Patient 27 was given Lorazepam per CIWA protocol as ordered by the physician.; and,

- On 5/13/2024 at 8 a.m., Patient 27's CIWA-A was 15 (CIWA-A 13-15, give 3 mg Lorazepam). The MAR had no documentation Patient 27 was given Lorazepam per CIWA-A protocol as ordered by the physician.

The lack of documented evidence in Patient 27's MAR was verified by the Patient Safety Officer (PSO) on 5/14/2024 at 1:15 p.m.

During an interview on 5/14/2024 at 1:15 p.m., with the PSO, the PSO stated Patient 27's record review was accurate. The PSO stated the CIWA-A protocol as ordered by the physician was not implemented when Patient 27's CIWA-A score was high and required Lorazepam dose on 5/12/2024 at 9 a.m. and on 5/13/2024 at 8 a.m.

In the same interview, the PSO stated CIWA-A protocol should be followed for treatment of alcohol withdrawal symptoms to prevent delay in treatment and worsening of the patient's symptoms and condition.

5. During a review of Patient 14's "Face Sheet (FS, a document that gives a patient's information at a quick glance and includes the patient's name, date of birth, address, etc.)," dated May 2024, the Face Sheet indicated Patient 14 was admitted to the facility on 5/06/2024 at 12:53 p.m. for AML (Acute Myeloid Leukemia, a type of cancer that starts in the blood forming cell of the bone marrow [spongy tissue in the hollow center of a person's long bones]).

During a review of Patient 14's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 5/2024, the "H&P" indicated the following: Patient 14 with a history of Hypertension (high blood pressure), Hyperlipidemia (excess fats in the blood), and AML, admitted for chemotherapy (the use of drugs to destroy cancer cells).

During a review of Patient 14's "Flow Sheet (a tool to help clinicians document patient data in a grid-like format)," dated 5/2024, the Flow Sheet indicated the following: Patient 14 had a Peripheral Inserted Central Catheter (PICC, intravenously placed catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body where the tip of the catheter is position in a location at the superior vena cava, and used for intravenous treatment that is required over a long period) line to the right upper arm.

During a concurrent interview and record review on 5/17/2024 at 9:08 a.m. with the Department Administrator East Oncology (DAEO) 1, Patient 14's "Orders," dated 5/2024 was reviewed. The Orders indicated, on 5/06/2024, there was no Chest X-ray (uses radiation to produce images of the heart, lung, etc. for better visualization and diagnosis) order to verify placement of the PICC line prior to use. DAEO 1 stated the following: Confirmed there was no Chest X-ray order to verify placement of the PICC line prior to use. The current PICC line policy was to do chest Xray for patient admitted to the unit. The Chest X-ray was done to make sure PICC line was in the right place so staff can use it safely to administer medication to the patient.

During a review of the facility's policy and procedure (P&P) titled, "Central and Non-Central Venous Access Device Policy," dated 2023, the "P&P" indicated, "Purpose: To minimize risk of device related complications and optimize patient outcomes. Provisions/Procedures: All patients with indwelling central lines admitted to inpatient setting should have placement verified by X-ray prior to use."

Based on observation, interview and record review, the facility failed to ensure for three of 30 sampled patients (Patients 27, 29, and 30) the following:

1. Patient 27's Lorazepam (also known as Ativan, a sedative that can be used for seizure disorders [a burst of uncontrolled activity between the brain cells that can cause abnormalities in movements, behaviors, etc.] and/or to relieve anxiety) was administered as ordered by the physician and in accordance with the Clinical Institute Withdrawal Assessment of Alcohol (CIWA-A, a tool which provides detailed and evidence-based measures for alcohol withdrawal status) protocol.

2.a. Patient 29's Flagyl (antibiotic medication for treatment of infection) was administered as ordered by the physician and in accordance with the facility's policy and procedure regarding Medication administration.

2.b. Patient 29's fentanyl (narcotic pain medication) titration (is the process of adjusting the dose of a medication for the maximum benefit without adverse effects) was followed as ordered by the physician and in accordance with the facility's policy and procedure regarding Medication administration.

3. Patient 30's Norco (narcotic pain medication) was administered as ordered by the physician and in accordance with the facility's policy and procedure regarding Medication administration.

These deficient practices resulted in delay of treatment and had the potential to cause adverse health outcomes which could negatively affect Patients 27, 29, and 30's health and safety due to unsafe medication administration and may lead to prolonged hospitalization and/or death.

Findings:

1. During an observation on 5/13/2024 at 2:07 p.m., with Registered Nurse (RN) 4, Patient 27 was observed alert and awake in bed with a sitter (a staff member who provides continuous observation of a patient in a hospital to prevent patient harm by alerting nurses or other healthcare personnel when needed) at the bedside. RN 4 stated Patient 27 was admitted for alcohol withdrawal (a range of symptoms that occur when a person stops or significantly reduce alcohol intake after long-term use. Examples: increased blood pressure, confusion, hallucinations [a false perception of events or events], etc.) and on Clinical Institute Withdrawal Assessment of Alcohol (CIWA-A, a tool which provides detailed and evidence-based measures for alcohol withdrawal status) protocol every two hours.

During a review of Patient 27's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 5/11/2024, the H&P indicated, Patient 27 was admitted to the facility for acute alcohol intoxication (a clinically harmful condition that usually follows the ingestion of large amounts of alcohol). The H&P included plan for Patient 27 to be on CIWA-A protocol.

During a review of the facility's policy and procedure (P&P) titled, "Clinical Institute Withdrawal Assessment of Alcohol (CIWA-A)," revised on 2/2023, the P&P indicated the following:

Example of Physician CIWA-A and IV (intravenous - through the vein) Lorazepam Orders:

CIWA-A 0-9, no medication. Assess CIWA-A every 2 hours ...
CIWA-A 10-12, 2 mg (milligrams, a unit of measurement) Lorazepam (also known as Ativan, a sedative that can be used for seizure disorders [a burst of uncontrolled activity between the brain cells that can cause abnormalities in movements, behaviors, etc.] and/or to relieve anxiety). Reassess CIWA-A in 2 hrs (hour).
CIWA-A 13-15, 3 mg Lorazepam. Reassess CIWA-A in 2 hrs.
CIWA-A 16-19, 4 mg Lorazepam. Reassess CIWA-A in 1 hr.
CIWA-A 20-30, 5 mg Lorazepam. Reassess CIWA-A every hr & PRN (as needed) worsening symptoms.
CIWA-A greater than or equal to 31, 6 mg Lorazepam. Reassess CIWA-A every hr & PRN worsening symptoms.
Notify physician if greater than24 mg of Lorazepam given in less than or equal to 24 hours.

During a review of Patient 27's "Medication Administration Record (MAR)," the MAR included a physician's order for Ativan (also known as Lorazepam, a sedative that can be used for seizure disorders and/or to relieve anxiety) 0-6 milligram (mg) intravenous (IV - through the vein) as needed, "see administration instruction (CIWA-A protocol)."

During a review of Patient 27's "CIWA-A Documentation Flowsheet" the flowsheet indicated the following CIWA-A assessment for Patient 27:

- On 5/12/2024 at 8 a.m., Patient 27's CIWA-A was 20. The corresponding MAR indicated Patient 27 was given Lorazepam 5 mg IV at 8:16 a.m.;

- On 5/12/2024 at 9 a.m., Patient 27's CIWA-A was 22 (CIWA-A score of 20-30, give 5 mg Lorazepam). The MAR had no documentation Patient 27 was given Lorazepam per CIWA-A protocol as ordered by the physician.; and,

- On 5/13/2024 at 8 a.m., Patient 27's CIWA-A was 15 (CIWA-A 13-15, give 3 mg Lorazepam). The MAR had no documentation Patient 27 was given Lorazepam per CIWA-A protocol as ordered by the physician.

The lack of documented evidence in Patient 27's MAR was verified by the Patient Safety Officer (PSO) on 5/14/2024.

During an interview on 5/14/2024 at 1:15 p.m., with the PSO, the PSO stated Patient 27's record review was accurate. The PSO stated the CIWA-A protocol as ordered by the physician was not implemented when Patient 27's CIWA-A score was high and required Lorazepam dose on 5/12/2024 at 9 a.m. and on 5/13/2024 at 8 a.m.

In the same interview, the PSO stated CIWA-A protocol should be followed for treatment of alcohol withdrawal symptoms to prevent delay in treatment and worsening of the patient's symptoms and condition.

2. During a review of Patient 29's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 5/12/2024, the H&P indicated Patient 29 was directly admitted to the Intensive Care Unit (ICU, where critical patients are cared for) from outside hospital for shortness of breath (difficulty breathing).

The H&P further indicated Patient 29 arrived in the ICU intubated (placement of breathing tube through the mouth and down the throat into the lungs), on fentanyl and Precedex for sedation. Patient 29's treatment plan included treatment of aspiration pneumonia (a lung infection that occur when food, liquid or other material enters the lungs through the mouth or stomach instead of being swallowed).

2.a. During a review of Patient 29's "Medication Administration Record (MAR)," the MAR included a physician's order of Flagyl 500 milligram (mg, a unit of measurement) intravenous (IV, through the veins) every 8 hours, to start on 5/12/2024 at 2:30 p.m.

Further review of Patient 29's MAR indicated Flagyl 500 mg IV was administered to the patient (Patient 29) on the following dates and times:

- On 5/12/2024 at 3:22 p.m. (first dose given);

- On 5/12/2024 at 8:13 p.m. (5 hours from the last dose of Flagyl; 3 hours advance ); and,

- On 5/13/2024 at 6:05 a.m. (10 hours from the last dose of Flagyl: 2 hours late).

During an interview on 5/14/2024 at 2:57 p.m., with the Patient Safety Officer (PSO), the PSO stated Patient 29's record review was accurate. The PSO stated Patient 29's Flagyl was not given on time as ordered by the physician.

In the same interview, the PSO stated if an adjustment of the dose scheduling was needed, the pharmacy should have been contacted to adjust the administration time of Flagyl for Patient 29. The PSO stated IV antibiotics should be given on time to ensure treatment of infection.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," reviewed on 8/16/2021, the P&P indicated the following:

- Medications are administered according to the Five (5) Rights of Medication Administration ...Right time

- In order to be considered timely, medications are administered up to sixty (60) minutes before or after the scheduled due time

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration Times," reviewed in 6/2021, the P&P indicated, "Medications shall be administered at the following times, unless specified otherwise by the provider: q (every) 8 h (hour): 0600, 1400 (2 p.m.), 2200 (10 p.m.)"

2.b. During a review Patient 29's medication order, the order indicated fentanyl 10 microgram/milliliter (mcg/ml, a unit of measurement) to administer 0-100 mcg/hr (microgram per hour, a unit of measurement) intravenous (IV, through the vein) continuous, "Admin Instructions: Start at 25 mcg/hr. Titrate (adjusting the dose of a medication for the maximum benefit without adverse effects) by 12.5 mcg/hr every 15 minutes to achieve CPOT (Critical Care Pain Observation Tool, a tool used to rate critically ill patients' pain based on clinical observation) less than or equal to 2 (A CPOT total score of less than or equal to a score of 2 points suggests there is no pain)," start date/time: 5/12/2024 at 2:30 a.m.

During a review of Patient 29's "Medication Administration Record (MAR)," the MAR indicated Patient 29's fentanyl was started with a new bag on 5/12/2024 at 2:35 a.m., with a rate of 100 mcg/hr.

Further review of the MAR indicated, Patient 29's fentanyl rate of 100 mcg/hr was verified on 5/12/2024 at 3 a.m., 4 a.m., 5 a.m., 6 a.m., 7 a.m., 8 a.m., and 9 a.m.

The corresponding CPOT of Patient 29 was assessed on 5/12/2024 at 3 a.m., 6 a.m., 8 a.m., 9 a.m., and 10 a.m. Patient 29's CPOT score were 0 (titration goal was to achieve CPOT less than or equal to 2).

During an interview on 5/15/2024 at 2:28 p.m., with the Department Manager of Critical Care (DMCC), the DMCC stated Patient 29's record review was accurate. The DMCC verified Fentanyl titration order was to start at 25 mcg/hr and titrate to 12.5 mcg/hr to achieve a CPOT of less than or equal to 2.

In the same interview, the DMCC stated Patient 29's fentanyl was started on 5/12/2024 at 2:35 a.m., at the rate of 100 mcg/hr. The DMCC stated Patient 29 came from another hospital intubated and was on Fentanyl at 100 mcg/hr and Patient 29's assigned Registered Nurse (RN) must have continued the fentanyl from the other hospital.

Furthermore, the DMCC stated the RN should have called the physician to clarify the titration order if Patient 29 was already on fentanyl drip. The DMCC stated Patient 29's CPOT was not assessed every 15 minutes because the fentanyl titration was not followed as ordered by the physician.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," reviewed on 8/16/2021, the P&P indicated the following:

- Medications are administered according to the Five (5) Rights of Medication Administration ...Right dose

- Licensed personnel are responsible for the following related to medication administration: questioning and clarifying unclear, incomplete, or inappropriate orders

3. During a review of Patient 30's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 5/2/2024, the H&P indicated Patient 30 was admitted to the facility status post (after) neurosurgery (a surgical operative procedure to manage a wide variety of disorders affecting the brain) for a brain mass.

During a review of Patient 30's "Medication Administration Record (MAR)," the MAR included the following physician's order:

- Norco 5-325 milligram (mg, a unit of measurement) 1 tablet by mouth every 6 hours as needed (PRN) for moderate pain (pain score of 4-6 is moderate pain); and,

- Norco 5-325 milligram (mg) 1 and 1/2 tablet by mouth every 6 hours as needed (PRN) for severe pain (pain score of 7-10 is severe pain).

Patient 30's MAR further indicated Norco was given at the following dates and times:

- On 5/10/2024 at 6:36 p.m., Patient 30 was given Norco 325 mg 1 tab for moderate pain.

The corresponding pain assessment indicated Patient 30's pain assessment score was 7 (severe pain); and,

- On 5/11/2024 at 7:29 a.m., Patient 30 was given Norco 325 mg 1 tab for moderate pain.

The corresponding pain assessment indicated Patient 30's pain assessment score was 7 (severe pain).

During an interview on 5/15/2024 at 2 p.m., with the Patient Safety Officer (PSO), the PSO stated Patient 30's record review was accurate. The PSO stated Patient 30 did not received the correct amount of pain medication as ordered by the physician on 5/10/2024 at 6:36 p.m. and on 5/11/2024 at 7:29 p.m.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," dated 08/16/2021, the P&P indicated, "Verifying the medication is being administered at the proper time, at the prescribed dose, and by the correct route."