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Based on interview and record review, the facility failed to ensure the patient rights were honored, for one of 35 sampled patients (Patient 37), in accordance with the facility's policies and procedures (P&P), when Patient 37 requested a female registered nurse (RN) while on the intensive care unit (ICU, a specialized unit for critically ill patients), and was denied the request without adequate justification or documentation. In addition, Patient 37's Foley catheter (a flexible plastic tube inserted into the bladder to drain urine) was removed by a male RN after Patient 37 requested for a female RN.

This failure resulted in Patient 37's Foley catheter being removed by a male nurse which caused Patient 37 to feel she was sexually assaulted by the male nurse and to feel her personal privacy had been violated.

Findings:

On May 29, 2025, at 10:49 a.m., a review of Patient 37's record was conducted with the Patient Safety Coordinator (PSC). A facility document titled, "History and Physical," dated March 7, 2025, was reviewed and indicated Patient 37, a female, was admitted to the facility on March 7, 2025, and presented to the emergency room by ambulance for evaluation of an overdose. The document indicated, "...per EMS [emergency medical services, ambulance staff], about 30 min's [sic, minutes] prior to their arrival on the scene patient was walking and talking but slowly began having erratic behavior...When EMS arrived on scene patient became more altered [change in behavior]. She was given Narcan [life-saving medication used to reverse opioid overdoses] and became more awake, agitated, and altered. Possible ingestion of pills about an hour prior to arriving in the ER [emergency room]...PHYSICAL EXAM...Constitution: sedated intubated on ventilation [a medical device that helps people breathe when they can't do so on their own]..."

On May 29, 2025, at 10:50 a.m., a review of Patient 37's record was conducted with the PSC. A facility document titled, "Daily Focus Assessment Report," dated March 7, 2025, at 7:54 p.m., was reviewed and indicated, "...Urinary Catheter Insertion...Catheter size: 16 french [unit of measurement]...Foley catheter: MD [medical doctor] order and indication for urinary catheter..."

An untitled facility document, signed by RN 1, a male, dated May 9, 2025, at 5:30 a.m., was reviewed. The document indicated, "...Foley DC [discontinued] at 05:30 PER PT [Patient 37] complaints MD aware..."

During an interview, on May 28, 2025, at 2:43 p.m., conducted with RN 1, RN 1 stated, Patient 37 "didn't like me." RN 1 stated towards the end of the shift, Patient 37 requested a female nurse and he informed the charge nurse. RN 1 stated the charge nurse informed him the other nurses had their own patients, and the assignment couldn't be switched. RN 1 stated he was Patient 37's admitting nurse that night, but there were at least two to three other female nurses present during that shift. RN 1 stated he did not remember if he made any notes in Patient 37's record regarding request for a female RN.

During an interview, on May 28, 2025, at 3:44 p.m., conducted with the ICU supervisor (ICU-S), the ICU-S stated arrangements should be made whenever a female patient is requesting for a female nurse. The ICU-S stated it should not have been an issue to make this type of accommodation since the unit has far more female nurses than male nurses. The ICU-S stated there were two other female RN's working that night based on the staffing assignment sheet for May 7, 2025. The ICU-S stated this assignment could have easily been switched around.

During an interview, on May 29, 2025, at 2:41 p.m., conducted with the Chief Quality Officer (CQO), the CQO stated, "That was a reasonable request and it should have been accommodated."

The facility P&P titled, "PATIENT RIGHTS AND RESPONSIBILITIES," dated November 2022, was reviewed. The P&P indicated, "...The purpose of this policy is to establish the rights that each patient or patients [name of facility] facilities has pertaining to their care...All patients at [name of facility] have the right to: Considerate and respectful care, and to be made comfortable. They have the right to respect for their cultural, psychological, spiritual, personal values, beliefs, and preferences...Reasonable responses to any reasonable requests made for services..."

Based on observation, interview, and record review, the facility failed to ensure care plans were initiated in accordance with the facility's policies and procedures (P&P), for one of 35 sampled patients (Patient 37), when the care plan for the insertion of a Foley catheter (a flexible plastic tube inserted into the bladder to drain urine) was not initiated.

This failure had the potential to compromise patient safety and cause a delay in treatment and interventions.

Findings:

On May 29, 2025, at 10:49 a.m., a review of Patient 37's record was conducted with the Patient Safety Coordinator (PSC). A facility document titled, "History and Physical," dated March 7, 2025, was reviewed and indicated Patient 37, a female, was admitted to the facility on March 7, 2025, and presented to the emergency room by ambulance for evaluation of an overdose. The document indicated, "...per EMS [emergency medical services, ambulance staff], about 30 min's [sic, minutes] prior to their arrival on the scene patient was walking and talking but slowly began having erratic behavior...When EMS arrived on scene patient became more altered [change in behavior]. She was given Narcan [life-saving medication used to reverse opioid overdoses] and became more awake, agitated, and altered. Possible ingestion of pills about an hour prior to arriving in the ER [emergency room]...PHYSICAL EXAM...Constitution: sedated intubated on ventilation [a medical device that helps people breathe when they can't do so on their own]..."

On May 29, 2025, at 10:50 a.m., a review of Patient 37's record was conducted with the PSC. A facility document titled, "Daily Focus Assessment Report," dated March 7, 2025, at 7:54 p.m., was reviewed and indicated, "...Urinary Catheter Insertion...Catheter size: 16 french [unit of measurement]...Foley catheter: MD [medical doctor] order and indication for urinary catheter...Unit where Urinary Catheter inserted: Emergency Department [ED]..."

On May 29, 2025, at 10:55 a.m., a review of Patient 37's record was conducted with the PSC. A facility document titled, "Admission Assessment Report," dated March 7, 2025, at 8 p.m., was reviewed and indicated, "...Toileting: Urinary catheter...Foley catheter: Urinary Catheter secured...Urinary catheter care completed...Urinary catheter to gravity drainage...Urinary Catheter Indication...Critical-sedated..."

There was no documented evidence a care plan was initiated for the insertion of the Foley catheter on Patient 37.

During a concurrent interview with the PSC, she stated a care plan should have been initiated by the nurse who inserted the Foley catheter in the ED or by the admitting nurse when the patient arrived on the intensive care unit [ICU, unit for critically ill patients] within 24 hours of the Foley catheter insertion.

The facility P&P titled, "INITIAL PATIENT ASSESSMENT AND REASSESSMENT AND PLAN OF CARE," dated May 2024, was reviewed. The P&P indicated, "...Nursing assessments are performed, and care plans are developed by registered nurses. Care plans are focused on those patient problem/diagnosis requiring active treatment...TIMELINESS:...Care plans should be initiated within 24 hours..."

Based on observation, interview, and record review, the facility failed to ensure patient care was delivered in accordance with the facility's policy and procedure (P&P), for two of 35 sample patients (Patients 34 and 36), when:

1. For Patient 34, pain medication was not administered when Patient 34 was experiencing severe pain. This failure resulted in Patient 34's pain to not be addressed timely; and

2. For Patient 36, medication reconciliation was not conducted during the admission process.

These failures had the potential for delay in the patients' treatment and recovery.

Findings:

1. A review of Patient 34's records was conducted on May 28, 2025, at 1:18 p.m., with the Intensive Care Unit Supervisor (ICU-S).

A facility document titled, "History and Physical," dated, May 3, 2025, was reviewed. The document indicated Patient 34 was admitted to the facility for left hip fracture (a break or a crack in the hip bone) due to a fall at home.

A facility document titled, "Therapy Verification," dated May 3, 2025, was reviewed. The document indicated, "...Order Information...Start: 05/03/2025 [May 3, 2025] 17:14 [5:14 p.m.]...Stop: 05/04/2025 [May 4, 2025] 11:36 [11:36 a.m.]...Route...intravenous [administered through a vein]...Frequency...every 4 [four] hours as needed...Drug: Hydromorphone [a pain medication]...Dose:0.5mg [milligram, unit of measurement]/0.5ml [milliliter, unit of measurement]...indication: severe pain..."

A facility document titled, "Therapy Verification," dated May 4, 2025, was reviewed. The document indicated, "...Order Information ...Start: 05/04/2025 11:36...Stop: 05/10/2025 [May 10, 2025] 16:01[4:01 p.m.]...Route...intravenous...Frequency...every 4 hours as needed...Drug: Hydromorphone...Dose: 1mg/1 ml...indication: severe pain..."

An untitled facility document, dated May 4, 2025, was reviewed. The document indicated, "...10:49 a.m...Pain Score...hip left...8 [pain score, with a score of seven to 10 meaning severe pain]..."

An untitled facility document, dated May 4, 2025, was reviewed. The document indicated, "...11:55 a.m...Pain score...hip left...9..."

An undated facility document titled, "Med Admin - PRN [Pro re nata, as needed]," was reviewed. There was no documented evidence pain medication was administered to Patient 34 when Patient 34 experienced severe pain with a pain score of 8 and 9 on May 4, 2025, at 10:49 a.m., and at 11:55 a.m., respectively.

An interview was conducted on May 28, 2025, at 2:30 p.m., with the ICU-S. The ICU-S stated that the policy was not followed when pain medication was not administerd to Patient 34 for severe pain.

A review of the facility P&P titled, "Pain Management," dated September 2024, was conducted. The P&P indicated, "...Treatment of Pain...inpatients shall receive treatment for any active pain issue...when intensity exceeds their acceptable level. Treatment shall be consistent with the patient's clinical presentation and objective findings. The treatment modality selected shall be appropriate for the patient's needs. Treatment is to be provided in a timely manner...Numeric Pain Tool...The patients rate their pain numerically...Physicians order pain medication related to...Severe pain...7-10..."

2. On May 29, 2025, at 10:49 a.m., a review of Patient 36's record was conducted with the Patient Safety Coordinator (PSC). A facility document titled, "History and Physical," dated March 19, 2025, was reviewed and indicated Patient 36 was admitted to the facility on March 19, 2025, for abdominal pain, nausea, and vomiting for two weeks. The document indicated Patient 36 had a Port-a-Cath (a medical device placed under the skin, which provides easy access to a large vein for the administration of medications and fluids) on the left chest, a drain for the stomach on the right lower quadrant (an area of the stomach) and a drain for fluid in the lungs on the left lower quadrant (lower part of the left lung). The document indicated Patient 36 had a history of stomach cancer and liver cirrhosis (hardening of the liver decreasing its ability to function).

During an interview, on May 29, 2025, at 10:49 a.m., was conducted with the PSC. The PSC stated there was no documentation a medication reconciliation for Patient 36 was conducted upon the patient's admission to the facility. The PSC stated the only documentation the medication reconciliation was completed was during Patient 36's discharge from the facility on May 23, 2025. The PSC further stated a medication reconciliation should always be conducted during a patient's admission and discharge, especially for a patient undergoing cancer treatment.

The facility P&P titled, "MEDICATION RECONCILIATION," dated May 2024, was reviewed. The P&P indicated, "...[name of facility] will implement and maintain a process to obtain and document a complete list of a patients current medications upon admission...Medication reconciliation/verification will be performed...Upon admission/entry into the facility...Emergency Department...The nurse completing the admission assessment will obtain and document the patient's current medications taken at home...physicians shall review the medication reconciliation in order to make decisions about drug therapy and to document the reason(s) to discontinue, change, and or hold medications..."

Based on observation, interview, and record review, the facility failed to ensure the facility's physical environment was maintained and supplies were current when:

1. An expired box of moisture wicking fabric (a fabric used to keep skin folds dry and and help prevent infection) was observed readily available for patient use;

2. Mulitple expired laboratory vacutainers (blood collection tubes) were observed on the third floor Medical-Surgical-Telemetry Unit medication room, readily available for use; and

3. An acrylic box for holding the moisture-wicking fabric and a pair of scissors in the box holder were observed to have debris and grime.

These failures had the potential to compromise patient safety, increase the risk of exposure to bacteria, increase the risk for infection, and may cause a delay in the patients' treatment.

Findings:

1. On May 27, 2025, at 10:15, am a tour of the facility was conducted with the Patient Advocate (PTA), the Local Chief Medical Officer (LCMO), the Chief Nursing Officer (CNO), and the Emergency Department Manager (EDM).

On May 27, 2025, at 10:24 a.m., during a continued tour of the facility, in the clean utility closet, a box of antibacterial wicking sheets was observed. The box was observed to be labeled with an expiration date of October 2024. A concurrent interview was conducted with the EDM. The EDM stated expired products should not be available for patient use. She stated the box of antibacterial wicking sheets should have been removed and replaced with a new box.

2. On May 27, 2025, at 10:22 a.m., a tour of the third floor Medical-Surgical-Telemetry Unit was conducted with the Patient Safety Coordinator (PSC).

On May 27, 2025, at 10:42 a.m., during a continued tour of the unit, the following were observed in a drawer in the medication room:

- Two green top laboratory vacutainers, labeled with an expiration date of April 30, 2025;
- Three clear top laboratory vacutainers, labeled with an expiration date of March 31, 2025;
- Two yellow top laboratory vacutainers, labeled with an expiration date of January 1, 2025;
- One lavender top laboratory vacutainer, labeled with an expiration date of December 1, 2024; and
- 100 blue top laboratory vacutainers, labeled with an expiration date of April 30, 2024.

On May 27, 2025, at 10:50 a.m., an interview was conducted with the PSC. The PSC verified the vacutainers listed above were expired and stated, "These should not be here." The PSC further stated the expectation would be for the nurses to carefully check the supplies and discard any expired patient care supplies.

A review of the facility's policy and procedure (P&P) titled, "Central Supply-General Organization," dated April 2024, was conducted. The P&P indicated, "...All supply items should be reviewed weekly and upon issuance in respect to expiration dates...All expired items should be immediately removed from the storage location and placed in a holding area until proper disposition can be made..."

3. On May 27, 2025, at 10:51 a.m., an observation was made of the moisture-wicking fabric box holder mounted on a wall in an alcove where clean supplies are stored. The box was observed to have grey debris and a white powdery substance in the holder. A pair of scissors was observed in the box holder with a thick buildup of black and brown colored sticky grime on its blades. The scissors holder was observed to have multiple clumps of grey fuzzy particles.

An interview was conducted on May 27, 2025, at 10:55 a.m., with the PSC. The PSC stated the moisture wicking fabric is a material used to keep the patients' skin folds (areas on the body where skin overlaps and rubs against itself) dry. The PSC stated the scissors are used to cut the moisture wicking fabric. The PSC stated the moisture wicking fabric box holder should be kept clean regularly. The PSC stated the scissors and the box holding the scissors were dirty and needed to be cleaned. The PSC further stated the pair of scissors should have been cleaned after each use.

An interview was conducted on May 27, 2025, at 2:50 p.m., with the Medical-Surgical-Telemetry Unit Manager (MSTM) regarding the dirty wicking fabric box holder, scissors, and scissors holder found on her unit. The MSTM stated, "I know. I saw and they it should have been cleaned after every use."

A review of the facility P&P titled, "Material Resource Management," dated May 2024, was conducted. The document indicated, "...It is the responsibility of the Materials Management Leader and the department's personnel staff to ensure that proper rotation of all supply items is maintained...All supply items should be reviewed weekly and upon issuance in respect to expiration dates...All expired items will be immediately removed from the storage location..."

A review of the facility P&P titled, "Equipment cleaning," dated March 23, 2025, was conducted. The policy indicated, "...Equipment will be cleaned with a hospital approved disinfectant after each patient use, or if visibly soiled and on a regular schedule..."