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Based on observation, interview, and record review, the facility failed to protect medical records from unauthorized disclosure for one (1) of thirty-four sampled patients (Patient 2).

This deficient practice had the potential for unauthorized staff or visitors entering Patient 2's room to view Patient 2's private health information which can be used outside of the hospital.

Findings:

During an observation on 2/27/2023, at 12:41 pm, in the Telemetry Unit, a "Wound Care Evaluation" note, dated 2/23/2023, at 12:26 p.m., was posted on the wall across Patient 2's bed and inside Patient 2's room. The note included Patient 2's date of birth, age, medical record number, medical history, medications, skin assessments, and treatments. t

During an interview on 2/27/2023, at 12:41 p.m., with the registered nurse (RN 12), RN 12 stated she (RN 12) posted the note on the wall so she (RN 12) could follow the wound care nurse recommendations for Patient 2's skin treatments. RN 12 said the note contained private information and should not have been posted on the wall because medical records should be private and confidential. RN 12 stated anyone entering the room could see Patient 2's private health information posted on the wall.

A review of Patient 2's Face Sheet indicated Patient 2 was admitted to the facility on 2/22/2023 for hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions) and altered mental status (change in mental function).

A review of Patient 2's "Wound Care Evaluation" note, dated 2/23/2023, at 12:26 p.m., indicated Patient 2's age, date of birth, medical record number, medical history, medications, admission skin assessments, and recommended treatments.

A review of the facility's policy and procedure (P&P) titled, "Patient Rights and Organizational Ethics," dated 4/2021, indicated "Patients have the Right to: Confidential treatment of all communications and records pertaining to patient care and stay in the hospital..."

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

1. Failure to perform a venous thromboembolism (VTE, a condition that occurs when a blood clot forms in a vein) risk assessment and implement preventative measures (application of sequential compression device (SCD-a method of blood clot prevention that improves blood flow in the legs, etc...) for two (2) of thirty-three (33) sampled patients (Patient 4 and Patient 7). This deficient practice had the potential to result in serious harm or death to the patients from a deep vein thrombosis (DVT, a blood clot in the leg) or pulmonary embolism (a blood clot in the lung). (Refer to A-392)

2. Failure to follow the facility's policy and procedure to develop a baseline care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) addressing pain and skin breakdown (damage to the skin's surface) concerns for five (5) of the thirty-three sampled patients (patients 13, 14, 17, 24, and 27). This deficient practice had the potential to delay the provision of necessary care and services due to the absence of an individualized care plan that contains information needed to properly care for the affected patients. (Refer to A-395)

3. Failure to conduct a complete initial assessment for one (1) of thirty-three sampled patients (Patient 1) within 2 hours of admission to the Telemetry Unit (where patients are under constant electronic monitoring for heart rate and rhythm [either fast, slow, irregular] or close observation), and an ongoing assessment, four hours later, in accordance with the facility's policies and procedures. This deficient practice resulted in the facility's inability to identify any potential changes in patient condition and a delay in patient care for Patient 1. (Refer to A-398)

4. Failure to adhere to the policies and procedures regarding Interpretation Services (verbal services bridging the language gap between a patient and a provider) to ensure effective communication between the healthcare provider and the patient when a language barrier exists for two (2) out of 33 sampled patients (Patient 22 and Patient 23). This deficient practice had the potential in providing patients with deficient care due to ineffective communication between healthcare provider and the patient. (Refer to A-398)

5. Failure to adhere to Intravenous (IV-administered through the vein) Therapy guidelines for five (5) (Patient 32, Patient 11, Patient 12, Patient 22, and Patient 23) of 33 sampled patients. Patients 32's and Patient 12's peripheral IV tubing were not labeled and Patients 11, 12, 22, and 23's peripheral IV (in the vein) access site was not labeled in accordance with the facility's IV Therapy policy and procedure manual. These deficient practices had the potential to result in negative consequences for the patients by increasing their (referring to the patients) chances for intravascular (within the blood vessel) catheter related infections. (Refer to A-398)

6. Failure to adhere to the policy and procedure for assessment of a dialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) access site on a continuing basis for one (1) of thirty-three sampled patients (Patient 15). This deficient practice had the potential to put the patient (Patient 15) at risk for unidentified access site life-threatening complications, such as acute blood loss and infection of the access site. (Refer to A-398)

7. Failure to follow the physician's order for the monitoring of blood glucose (sugar) levels and the administration of insulin (a hormone that controls the amount of sugar in the blood) for one (1) of thirty-three (33) sampled patients (Patient 1). This deficient practice had the potential for high blood sugar levels and possibly resulting in a diabetic coma (a life-threatening emergency that can happen when people with diabetes (blood sugar levels get too high) for Patient 1. (Refer to A-405)

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

Based on observation, interview, and record review, the facility failed to perform a venous thromboembolism (VTE, a condition that occurs when a blood clot forms in a vein) risk assessment and implement preventative measures (application of sequential compression device (SCD-a method of blood clot prevention that improves blood flow in the legs, etc...) for two (2) of 33 sampled patients (Patient 4 and Patient 7).

This deficient practice had the potential to result in serious harm or death to the patients from a deep vein thrombosis (DVT, a blood clot in the leg) or pulmonary embolism (a blood clot in the lung).

Findings:

1.a. During a concurrent observation and interview, on 2/27/2023, at 12:15 p.m., with the Telemetry manager (Tele Manager), Patient 4 was observed in bed. Patient 4 was not wearing a sequential compression device (SCD, or leg squeezers.) The family member (FM 1) present at bedside stated Patient 4 had weak legs and was unable to walk. Likewise, the Tele Manager stated Patient 4 needed to use SCDs.

A review of Patient 4's Face Sheet indicated Patient 4 was admitted to the facility on 2/20/2023.

A review of Patient 4's History and Physical (H&P), dated 2/20/2023, indicated Patient 4 presented to the emergency department (ED) for evaluation of low blood pressure. Patient 4's diagnosis included a history of anemia (decreased amount of red blood cells), A-fib (or Atrial Fibrillation, an irregular heartbeat that causes poor blood flow), and chronic renal failure (gradual loss of kidney function).

A review of a physician's order dated 2/21/2023, at 3:07 a.m., indicated Patient 4 had a venous thromboembolism risk score of 3 points (indicating Patient was at moderate risk). The orders included SCD and a foot pump (used for the prevention of venous thromboembolism).

A review of Patient 4's VTE Risk Assessment, on 2/20/2023, at 11:24 p.m., indicated the VTE risk assessment was not performed upon admission to the Telemetry unit.

During a concurrent interview and record review, on 2/28/2023, at 10:35 a.m., with the Director of Acute Care Services (DACS), Patient 4's VTE risk assessment record was reviewed. The DACS stated Patient 4 was admitted to the Telemetry Unit on 2/20/2023, at 9:40 p.m.. The DACS said Patient 4's VTE risk assessment was not performed by nursing staff upon admission to the Telemetry Unit. The DACS stated the physician ordered SCDs and SCD pump based on Patient 4's VTE moderate risk level score of 3. The DACS stated SCD should have been placed on Patient 4 to help prevent blood clot formation.

A review of the facility's policy and procedure (P&P) titled, "Venous Thromboembolism (VTE) Prophylaxis," dated 5/2021, indicated "the purpose of the policy was to provide Venous thromboembolism (VTE) Prophylaxis (pharmacologic and non-pharmacologic measures to diminish the risk of blood clots and pulmonary emboli (a sudden blockage of a blood vessel in the lung caused by a blood clot) guidelines in an effort to minimize the occurrence of embolus (a blocked artery caused by a foreign body, such as a blood clot)." The P&P further indicated "during admission, the Nurse will assess the adult patients (eighteen and older) by collecting data for VTE risk factors using the VTE Risk Assessment..."

Additional review of the facility's policy and procedure (P&P) titled, "Venous Thromboembolism (VTE) Prophylaxis," dated 5/2021, indicated the Risk Assessment Score will determine whether the patient is high, moderate, or low risk. The VTE Risk Assessment will be documented...the "VTE Risk Factor Assessment" score will populate the Core Measure (national standards of care and treatment processes for common conditions) VTE order where the Physician will select the corresponding "VTE Risk Level" to generate a customized list of orders. The Registered Nurse will ensure the VTE Risk Assessment... has been completed. Enter the patient's risk assessment factors and numerical score in the electronic VTE Risk Factor assessment. Follow-up with the patient's Physician if he/she has not completed the VTE Risk Level and associated orders within twenty-four (24) hours of admission. It is the responsibility of the Physician to assign the necessary VTE Risk Level (low, moderate, high) and treatment based on the total risk level.

1.b. During a concurrent observation and interview, on 2/27/2023, at 3:55 p.m., with the Clinical Nurse Manager (CNM 1), Patient 7 was observed in bed. Patient 7 had a splint (made of metal or plastic for the protection of an injured part of the body) to the right leg and a yellow sock to the left leg. Patient 7 was not wearing SCDs. CNM 1 confirmed that patient 7 was not wearing SCDs.

A review of Patient 7's Face Sheet indicated Patient 7 was admitted to the facility on 2/25/2023.

A review of Patient 7's History and Physical (H&P), dated 2/26/2023, at 5:18 p.m., indicated Patient 7 was admitted for a right ankle fracture (a break in the bone) after falling at home. Patient 7's diagnosis included diabetes mellitus (high blood sugar), hypertension (high blood pressure), and dementia (a group of conditions affecting memory, thinking, and social abilities).

A review of Patient 7's VTE Risk Assessment, dated 2/26/2023, at 2:46 a.m., indicated Patient 7 had a total VTE risk score of 7 (moderate risk for VTE).

During a concurrent interview and record review, on 2/28/2023, at 1:47 p.m., the DACS stated Patient 7 was admitted to the facility on 2/26/2023 for a right ankle fracture. The DACS stated the initial nurse assessment upon admission, on 2/26/2023, at 2:46 a.m., indicated Patient 7 had a VTE risk assessment score of 4 (indicates moderate risk). The DACS verified there was no order for SCD or medication orders by the physician for Patient 7. The DACS stated physicians were required to perform a VTE risk assessment and order interventions, as indicated. The DACS stated the physician should have given orders to prevent blood clot formation.

A review of the facility's policy and procedure (P&P) titled, "Venous Thromboembolism (VTE) Prophylaxis," dated 5/2021, indicated "the purpose of the policy was to provide Venous thromboembolism (VTE) Prophylaxis (pharmacologic and non-pharmacologic measures to diminish the risk of blood clots and pulmonary emboli (a sudden blockage of a blood vessel in the lung caused by a blood clot) guidelines in an effort to minimize the occurrence of embolus (a blocked artery caused by a foreign body, such as a blood clot)." The P&P further indicated "during admission, the Nurse will assess the adult patients (eighteen and older) by collecting data for VTE risk factors using the VTE Risk Assessment..."

Additional review of the facility's policy and procedure (P&P) titled, "Venous Thromboembolism (VTE) Prophylaxis," dated 5/2021, indicated the Risk Assessment Score will determine whether the patient is high, moderate, or low risk for VTE. The VTE Risk Assessment will be documented...the "VTE Risk Factor Assessment" score will populate the Core Measure (national standards of care and treatment processes for common conditions) VTE order where the Physician will select the corresponding "VTE Risk Level" to generate a customized list of orders. The Registered Nurse will ensure the VTE Risk Assessment... has been completed. Enter the patient's risk assessment factors and numerical score in the electronic VTE Risk Factor assessment. Follow-up with the patient's Physician if he/she has not completed the VTE Risk Level and associated orders within twenty-four (24) hours of admission. It is the responsibility of the Physician to assign the necessary VTE Risk Level (low, moderate, high) and treatment based on the total risk level.

Based on observation, interview, and record review, the licensed nursing staff failed to develop a baseline care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) addressing pain and skin breakdown concerns for five (5) of the 33 sampled patients (Patient 13, Patient 14, Patient 17, Patient 24, and Patient 27), in accordance with the facility's policy and procedure regarding care plans.

This deficient practice had the potential to delay the provision of necessary care and services due to the absence of an individualized care plan that contains information needed to properly care for the affected patients.

Findings:

1. a. A review of Patient 13's admission record, dated 2/25/2023, indicated that Patient 13 was admitted to the facility on 2/25/2023 after sustaining a mechanical fall (an event which results in a person coming to rest inadvertently on the ground or floor or other lower level). The admission record also indicated that Patient 13 was able to ambulate before the fall.

A review of Patient 13's History and Physical (H&P), dated 2/28/2023, indicated a computed tomography (CT, a test procedure using a computer linked to an x-ray machine to make a series of detailed pictures) scan was completed for Patient 13. The H&P also indicated that Patient 13 had a right hip fracture (break in the bone) that required surgery. Likewise, Patient 13 and Patient 13's family did not want surgical intervention to address Patient 13's right hip fracture. Examination by the primary physician indicated Patient 13 experienced painful leg rolls with no range of motion (the extent or limit to which a part of the body can be moved around a joint or a fixed point) due to pain.

During a concurrent interview and record review, on 2/28/2023, at 2:30 p.m., with clinical nurse manager 1 (CNM 1), Patient 13's pain assessment record was reviewed. Patient 13's pain assessment record, for patient 13's right leg pain, dated 2/26/2023, indicated Patient 13's pain score was 7 (indicates severe pain) out 10 on a pain scale of 0-10 (a method to measure pain so that medical staff can help plan on how best to manage the pain; 0=no pain, 10=severe pain).

A review of Patient 13's care plan indicated that a care plan for pain management was not initiated until 2/28/2023, three (3) days after Patient 13's admission on 2/25/2023.

During a concurrent observation and interview on 2/27/2023, at 2:55 p.m., with CNM 1, Patient 13 was observed moaning and Patient 13's family members at the bedside were consoling Patient 13. CNM 1 stated that Patient 13 was admitted on, 2/26/2023 for a hip fracture, but the family refused to have Patient 13 undergo surgery.

During an interview on 2/28/2023, at 2:30 p.m. with CNM 1, she (CNM 1) stated that the care plan for pain management should have been initiated immediately on admission for Patient 13. CNM 1 stated that it was important to develop a pain management care plan for Patient 13 because her (Patient 13) pain must be addressed and communicated among nursing care staff.

A review of the facility's policy and procedure (P&P), dated 7/27/2021, titled "Care Planning," indicated that a plan of care should begin within twenty-four (24) hours of the patient's admission. The care plan will be reviewed and/or updated every shift by the registered nurse and as patient needs change. The registered nurse will prioritize the patient's care plan in collaboration with the patient.

A review of the facility's "Medical-Surgical Nursing Competence Validation Checklist," [no date], indicated that one of the requirements that the registered nurse must satisfy is documenting a plan of treatment in accordance with facility policy.

1. b. A review of Patient 14's admission record, dated 2/26/2023, indicated Patient 14 was admitted to the facility on 2/26/2023 with a diagnosis of complication from transurethral resection of the prostate
(TURP, a surgery used to treat urinary problems that are caused by an enlarged prostate) with hematuria (blood in urine).

A review of Patient 14's History and Physical (H&P), dated 2/26/2023, indicated Patient 14 had a TURP surgery completed during the first week of February 2023. Patient 14 had a past medical history of hypertension (high blood pressure) and benign prostatic hypertrophy (a condition in which an overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine).

During a concurrent interview and record review, on 2/28/2023, at 3:00 p.m., with CNM 1, Patient 14's pain assessment record was reviewed. The pain assessment record indicated Patient 14 complained of abdominal pain on 2/26/2023, at 11:43 a.m., and patient 14's pain score was seven (7=indicating severe pain) out of 10 (7/10) on a scale of 0-10 (a method to measure pain so that medical staff can help plan on how best to manage the pain; 0 = no pain, 10 = severe pain).

A review of Patient 14's care plan indicated that a care plan for pain management was not initiated until 2/28/2023, which was more than 24 hours after the patient (Patient 14) was admitted.

During an interview on 2/28/2023, at 2:30 p.m., with CNM 1, she (CNM 1) stated the care plan (for Patient 14) should have been initiated immediately upon admission. CNM 1 stated that it is important to develop a care plan for this patient (Patient 14) immediately because "we want to start intervention to treat his pain." CNM 1 said the care plan is important because it (pertaining to the care plan) allows nurses to evaluate the daily effectiveness of the care they (RNs) provide and make required revisions to care plans at the end of each shift.

CNM 1 also stated that developing a care plan is in accordance with the hospital's policy. CNM 1 stated that each patient is required by hospital policy to have a personalized treatment plan created and given for them (referring to patients) based on data acquired through assessments and reassessments of their (referring to patients) health. CNM 1 also said that developing individualized care plans for individuals enables nurses to prioritize their (referring to RNs) actions more effectively.

A review of the facility's policy and procedure (P&P), dated 7/27/2021, titled "Care Planning," indicated that a plan of care should begin within twenty-four (24) hours of the patient's admission. The care plan will be reviewed and/or updated every shift by the registered nurse and as patient needs change. The registered nurse will prioritize the patient's care plan in collaboration with the patient.

A review of the facility's "Medical-Surgical Nursing Competence Validation Checklist," [no date], indicated that one of the requirements that the registered nurse must satisfy is documenting a plan of treatment in accordance with facility policy.

2. a. A review of Patient 17's admission record, dated 1/10/2023, indicated Patient 17 was admitted to the facility on 1/10/2023 after being found down after a fall (an event which results in a person coming to rest inadvertently on the ground or floor or other lower level). Patient 17's admission record indicated a medical history that included recent left knee surgery, a left hip replacement (removal of the diseased parts of the hip joint and replace them with new, artificial parts), and pulmonary fibrosis (a lung disease that occurs when lung tissue becomes damaged and scarred).

During a concurrent interview and record review, on 3/1/2023, at 11:00 a.m., with clinical nurse manager 1 (CNM 1), Patient 17's nursing skin assessment record, was reviewed. Patient 17's skin assessment record on admission, dated 1/10/2023, indicated a Braden Score (a standardized, evidence-based assessment tool commonly used in healthcare to assess and document a patient's risk of developing a pressure ulcer) of 14. CNM 1 stated that Patient 17's score of 14 placed the patient (Patient 17) at mild risk for developing a pressure ulcer (injuries to the skin and underlying tissue resulting from prolonged pressure).

A review of Patient 17's care plan indicated that a care plan for impaired skin integrity was started on 1/13/2023, which was three days after the patient's (Patient 17) admission. Patient 17 developed a stage one pressure injury (characterized by superficial reddening of the skin but has no breaks or tears) in the sacrum (area located above the tailbone) area on 1/17/2023.

During an interview on 3/1/2023, at 11:00 a.m., with CNM 1, CNM 1 stated that it was important to start Patient 17's care plan within 24 hours of admission, because if no care plan was developed, there will be no interventions carried out to address potential skin breakdown (damage to the skin's surface) and more skin issues might develop.

A review of the facility's policy and procedure (P&P), dated 7/27/2021, titled "Care Planning," indicated that a plan of care should begin within twenty-four (24) hours of the patient's admission. The care plan will be reviewed and/or updated every shift by the registered nurse and as patient needs change. The registered nurse will prioritize the patient's care plan in collaboration with the patient.

A review of the facility's "Medical-Surgical Nursing Competence Validation Checklist," [no date], indicated that one of the requirements that the registered nurse must satisfy is documenting a plan of treatment in accordance with facility policy.

2. b. A review of Patient 24's admission record, dated 2/25/2023, indicated Patient 24 was admitted to the facility on 2/25/2023 with a diagnosis of right leg cellulitis (bacterial skin infection)/wound.

A review of Patient 24's History and Physical (H&P), dated 2/26/2023, indicated Patient 24 arrived at the emergency department (ED) with tachycardia (a heart rate of more than 100 beats per minute) and a worsening wound infection of the right hip fracture (break in the bone).

During a concurrent interview and record review, on 2/28/2023, at 3:40 p.m., with the Telemetry Manager (Tele manager), Patient 24's nursing care plan was reviewed. Patient 24's nursing care plan record indicated no care plan for pain and no care plan to address impaired skin integrity, was started for Patient 24. The Tele manager confirmed that there was no care plan developed for Patient 24 on admission. The Tele manager said that a nursing care plan needed to be developed for a patient (Patient 24) admitted with a wound and who is also in pain. Tele manager also said that every shift, nursing staff reviews and updates the care plans that they (referring to nursing staff) have initiated.

A review of the facility's policy and procedure (P&P), dated 7/27/2021, titled "Care Planning," indicated that a plan of care should begin within twenty-four (24) hours of the patient's admission. The care plan will be reviewed and/or updated every shift by the registered nurse and as patient needs change. The registered nurse will prioritize the patient's care plan in collaboration with the patient.

A review of the facility's "Medical-Surgical Nursing Competence Validation Checklist," [no date], indicated that one of the requirements that the registered nurse must satisfy is documenting a plan of treatment in accordance with facility policy.

3. A review of Patient 27's admission record, dated 1/10/2023, indicated Patient 27 was admitted to the facility on 1/20/2023 with a diagnosis of syncope (a temporary loss of consciousness caused by a fall in blood pressure), and low blood pressure.

A review of Patient 27's History and Physical (H&P), dated 2/26/2023, indicated Patient 27's diagnosis included sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood), dehydration, and urinary tract infection.

During a concurrent interview and record review, on 3/1/2023, at 9:10 a.m., with the Telemetry manager (Tele manager), Patient 27's care plan was reviewed. The Tele manager stated that, after reviewing the patient's (Patient 27) medical records, no care plan was ever started during the patient's (Patient 27) 24-hour hospitalization. The tele manager said that initiating a care plan is in line with the hospital's policy since it (referring to the care plan) enables nurses to assess the daily efficacy of the care they (referring to the RNs) deliver as well as make necessary adjustments to the care plans at the end of each shift. He (Tele manager) also confirmed that, in accordance with hospital policy, each patient is supposed to have a customized care plan developed and provided for them (referring to patients) based on information gathered from assessments and reassessments of their (referring to patients) conditions.

A review of the facility's policy and procedure (P&P), dated 7/27/2021, titled "Care Planning," indicated that a plan of care should begin within twenty-four (24) hours of the patient's admission. The care plan will be reviewed and/or updated every shift by the registered nurse and as patient needs change. The registered nurse will prioritize the patient's care plan in collaboration with the patient.

A review of the facility's "Medical-Surgical Nursing Competence Validation Checklist," [no date], indicated that one of the requirements that the registered nurse must satisfy is documenting a plan of treatment in accordance with facility policy.

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

1. Conduct a complete initial assessment for one (1) of thirty-three (33) sampled patients (Patient 1) within 2 hours of admission to the Telemetry Unit, and an ongoing assessment, four hours later, in accordance with the facility's policies and procedures. This deficient practice resulted in the inability to identify any potential changes in condition and a delay in patient care for Patient 1.

2. Adhere to the policies and procedures on Interpretation Services (verbal services bridging the language gap between a patient and a provider) to ensure effective communication between the healthcare provider and the patient when a language barrier exists for two (Patient 22 and Patient 23) out of 33 sampled patients. This deficient practice had the potential in providing patients with deficient care due to ineffective communication between healthcare provider and the patient.

3. Adhere to Intravenous (IV-into the vein) Therapy guidelines for 5 (Patient 32, Patient 11, Patient 12, Patient 22, and Patient 23) of 33 sampled patients. Patients 32 and 12's peripheral IV tubing were not labeled (indicating patient name, date, type of solution, initials of preparer) and Patients 11, 12, 22, and 23's peripheral IV (in the vein) access sites were not labeled (date, time, and initials of person who started IV) as indicated by facility's IV Therapy policy and procedure manual. These deficient practices had the potential to result in negative consequences for the patients by increasing their chances for intravascular (within the blood vessel) catheter related infections.

4. Adhere to the policy and procedure for assessment of a dialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) access site on a continuing basis for one (1) of thirty-three sampled patients (Patient 15). This deficient practice had the potential to put the patient at risk for unidentified access site life-threatening complications, such as acute blood loss and infection of the access site.

Findings:

1. A review of Patient 1's History and Physical (H&P), dated 8/9/2022, at 9:19 p.m., indicated Patient 1 had a history of diabetes (when blood sugar is too high), hypertension (high blood pressure), and hemodialysis (treatment to filter wastes and water from the blood). Patient 1 was brought in at the facility for evaluation of bleeding from left upper extremity AV (arteriovenous) fistula (an abnormal connection between an artery and vein used for hemodialysis).

A review of Patient 1's vital signs on 8/10/2022, at 6:51 p.m., indicated Patient 1's temperature was 102 Fahrenheit (F, unit of measurement, [normal range 97.7 to 100.1 F]), Pulse (heart) rate was 110 (normal range is 60-100), Respiratory rate was 24 (normal range is 12-24), Blood Pressure was 152/67 (normal range is less than 120/80).

A review of Patient 1's "ECC (Emergency Care Center) Nursing Note (Emergency nurse documentation that captures complete, accurate, and succinct details about a patient's care while in the Emergency department)," dated 8/10/2022, at 7:29 p.m., indicated that admitting MD was paged. Patient 1's recorded vital signs (measurement of heart rate, respiratory rate, etc...) triggered SIRS (Systemic Inflammatory Response Syndrome, a serious condition in which there is swelling throughout the whole body) pending call back.

A review of Patient 1's nurses note titled, "ECC Nursing Note," dated 8/10/2022, at 8:10 p.m., indicated report was given to registered nurse 10 (RN 10-Telemetry unit receiving nurse). The ECC Nursing Note indicated Patient 1 was alert and oriented times two (when a patient knows who they are and where they are, but not what time it is or what is happening to them). The ECC Nursing Note further indicated "respirations are even and unlabored (no exertion or undue effort), No acute distress (means patient will not become unstable in the next 5 minutes)...Patient (Patient 1) transferred to floor (telemetry unit)."

A review of Patient 1's Vital Signs record dated 8/11/2022, at 12 a.m., indicated Patient 1's temperature was 97.1, Pulse rate was 122, Respiratory rate was 20, and Blood Pressure was 170/82.

A review of Patient 1's "Code Blue (hospital emergency code to indicate the critical status of a patient) Record," dated 8/11/2022, at 2:42 a.m., indicated Patient 1 was unconscious (without awareness, sensation or cognition), pulseless (no pulse), apneic (not breathing). Patient 1 was intubated (insertion of a tube in the airway for ventilation) at 2:48 a.m. Epinephrine (an emergency medication that promotes muscle contractions and airway widening) was given multiple times. Resuscitation efforts (methods used to try to restart the heart and lungs) ended at 3:16 a.m. Patient 1 expired (pronounced dead by physician).

A review of Patient 1's respiratory care note, dated 8/11/2022, at 4:04 a.m., indicated "Code Blue (a patient's heart or respirations has stopped and requires immediate medical attention) called at 2:42 a.m., Patient (Patient 1) seen, no palpable pulses noted, CPR (cardiopulmonary resuscitation, an emergency procedure performed with the heart stops beating) in progress with ACLS (advanced life support) medications given without success, CPR stopped at 3:16 a.m. and patient (Patient 1) pronounced dead by ER (Emergency Room) MD (Physician 1)."t

A review of Patient 1's physician note titled, "ER Physician Inpatient Consult," dated 8/11/2022, at 4:56 a.m., indicated Physician 1 was called for a code blue event for Patient 1. Patient 1 went into asystolic arrest (when heart stops beating entirely) after having been found completely unresponsive with an asystolic arrest. CPR was in progress when ER MD (Physician 1) arrived. The physician note indicated "Patient 1 reportedly went bradycardic (slower than expect heart rate, less than 60 beats per minute) and then arrested (when heart stops beating), upon my arrival in the room patient (Patient 1) appeared to have exsanguinated (lost blood) from her (Patient 1) left arm fistula (abnormal connection between two body parts)."

Further review of Patient 1's physician note titled, "ER Physician Consult," dated 8/11/2022, at 4:56 a.m., also indicated "there was no active bleeding but there was fresh blood all over the stretcher beneath and around the patient (Patient 1) as well as pooled (referring to the blood) on the floor below...Patient (Patient 1) remained in asystolic arrest the entire time...Since acute blood loss was a suspected etiology (cause) I did order 2 units of Type-O blood (most common blood type), and continue to code (resuscitation efforts to restore heartbeat) the patient for multiple rounds until some blood product could be given. A code transpired for a long period of time and then once one (1) unit of blood was given and we saw no change in condition, the code was terminated. Findings: Patient 1 expired."t

A review of a "Late Entry" nurses note, dated 8/11/2022, at 6:23 a.m., documented by Registered Nurse 10 (RN 10), indicated Patient 1 arrived at the Telemetry unit on 8/10/2022. The Late entry nurses note also indicated Patient 1 "appeared lethargic (marked by drowsiness and unusual lack of energy or mental alertness), opened eyes when asked to and answered questions. Patient (Patient 1) transferred to the bed, times four (x 4 person) assist. Patient (referring to Patient 1) did not complain of pain or mention any concerns with fistula. Patient 1's dressing was dry and intact when brought up to unit (Telemetry unit)."t

During a concurrent interview and record review, on 2/28/2023, at 2:25 p.m., with the Director of Acute Care Services (DACS), Patient 1's assessment record was reviewed. The DACS stated Patient 1 arrived at the emergency department (ED) on 8/9/2022 due to bleeding from her (Patient 1) AV (arteriovenous) fistula (irregular connection between an artery and a vein). The DACS stated Patient 1 was originally going to be admitted to the Medical-Surgical unit, however the order was changed to admit Patient 1 to the Telemetry Unit due to abnormal vital signs (elevated heart rate 110, and respirations of 24) at 6:52 p.m., which triggered a possible SIRS (Systemic Inflammatory Response Syndrome, a serious condition in which there is swelling throughout the whole body) in Patient 1.

During an interview on 2/28/2023, at 2:25 p.m., with the Director of Acute Care Services (DACS), the DACS stated Patient 1 arrived at the Telemetry Unit on 8/10/2022, at 8:10 p.m.. The DACS verified a complete assessment by the registered nurse (RN 10) including vital signs (VS, heart rate, respirations, temperature, blood pressure) were not documented for Patient 1 within 2 hours of arrival at the Telemetry Unit. The DACS stated that patients should have a complete assessment by the RN, including VS within two (2) hours of admission. The DACS also verified that an ongoing assessment, which could have helped identify any bleeding from Patient 1's AV fistula, was not documented by the RN 10, four (4) hours later after admission in the Telemetry unit, as per the facility policy.

During an interview on 2/28/23, at 2:25 p.m., with the Director of Acute Care Services (DACS), the DACS verified that RN 10 documented one "Late Entry" nursing note on 8/11/2023, at 6:23 a.m., indicating that when Patient 1 arrived at the unit on 8/10/2022, Patient 1 was lethargic, but opened eyes and answered questions. The DACS confirmed that Patient 1's vital signs was taken and recorded at 12 a.m. (4 hours after arrival to the Telemetry unit), on 8/11/2022. The DACS stated RN 10 was not available for interview because RN 10 was a traveling nurse (a registered nurse with a clinical background working in a non-permanent or temporary nursing role to fill gaps in staffing needs for hospitals) and no longer worked at the facility. The DACS verified a code blue was called for Patient 1 on 8/11/2022, at 2:42 a.m., and Patient 1 expired at 3:16 a.m. There was no documentation to indicate that RN 10 assessed the AV fistula site of Patient 1 for any bleeding between 12 a.m. on 8/11/2022 (when the vital signs was taken) and 2:42 a.m. (when the code blue was called). The DACS stated Patient 1 should have been assessed by RN 10 to identify any changes in condition prior to the code blue.

During an interview, on 3/1/2023, at 9:55 a.m., the emergency department physician (Physician 1) stated he (Physician 1) responded to a code blue on 8/11/2022, at 2:42 a.m. for Patient 1. Physician 1 stated the following: Patient 1 had already bled out by the time he (Physician 1) arrived. Patient 1 had no signs of life, no pulse, and in cardiac arrest (the sudden loss of all heart activity). There was no active bleeding but assumed Patient 1 bled out from the AV fistula. There was a lot of blood on the floor, on the gurney (referring to Patient 1's bed where Patient 1 was transferred upon arrival to the Telemetry unit), and underneath the patient (Patient 1). Patient 1 did not respond to multiple rounds of CPR
(Cardiopulmonary Resuscitation, life-saving procedure performed when the heart stops beating). Physician 1 tried to revive Patient 1 with a blood transfusion (a procedure in which whole blood or parts of blood are administered into a patient's bloodstream through the vein), since Patient 1 had lost a lot of blood. Physician 1 stated all life saving measures (includes chest compressions, medications, etc.) were unsuccessful, and Patient 1 was pronounced (dead) at 3:16 a.m.

During an interview, on 3/1/2023, at 11:50 a.m., with Registered Nurse 9 (RN 9), RN 9 stated she (RN 9) worked in the Telemetry unit. RN 9 stated patients should have a complete assessment by a registered nurse, including vital signs, within 2 hours of admission to the Telemetry Unit, then ongoing assessments should be performed every four (4) hours, thereafter. RN 9 stated patients should be assessed to identify any changes in condition such as when a patient is bleeding from any site and notify the physician if necessary.

A review of the facility's policy and procedure (P&P) titled, "Assessment of Patient," dated 1/2021, indicated each admitted patient's initial assessment is conducted within a time frame identified by the service...Nursing Telemetry assessment time frame is completed within two hours of arrival. Reassessment time frame is every four (4) hours.

2. a. During a concurrent observation and interview on 2/27/2023, at 8:20 a.m., Patient 22 was observed in bed, with a phlebotomist (a medical professional who is trained to perform blood draws) at bedside. Patient 22 appeared calm. The phlebotomist was observed to leave the room thanking patient 22 using the English language. Registered Nurse 3 (RN 3) stated Patient 22 speaks either Chinese or Vietnamese language and that Patient 22 spoke very little English. RN 3 also said that she (RN 3) did not use the facility provided translator services for Patient 22. RN 3 stated that Patient 22 communicates with RN 3 through gestures and limited English. In addition, RN 3 said that she (RN 3) was not able to communicate with Patient 22 the plan of care such as not being allowed to eat or drink anything pending a speech evaluation order. RN 3 also admitted to assessing Patient 22 without using translator services. RN 3 said she (RN 3) does not know what the hospital policy on interpretation services indicated.

During an interview on 2/27/2023, at 9:00 a.m., with Patient 22, she (Patient 22) stated she (Patient 22) did not know how to use her (Patient 22) call light (a visual cue that a patient needs assistance), and if she (Patient 22) needed to call the nurse, she (Patient 22) would just yell "hey, nurse" to get some attention. Patient 22 further said that she communicates with the nurse (RN 3) by using gestures and no interpretation/translator services was provided to her (Patient 22). A review of Patient 22's admission record, dated 2/28/2023, indicated Patient 22 was Vietnamese-speaking only. In addition, Patient 22 was admitted for sepsis (a life-threatening condition caused by an infection) and hypotension (low blood pressure).

2.b. During an interview, on 02/28/2023, at 9:19 a.m., Patient 23 stated her (Patient 23) primary language is Vietnamese, and she (Patient 23) did not speak any English. Patient 23 stated she (Patient 23) was only able to communicate with the nurse by gestures. Patient 23 said her (Patient 23) son helped to translate when he (Patient 23's son) came to visit. Patient 23 also stated that nurses never asked about her (Patient 23) preferences for using translation services.

During the concurrent interview with Patient 23's bedside care nurse, RN 7, RN 7 stated it was the preference of the patient to use her son as a translator. RN 7 stated she (RN 7) can understand gestures and when patient (Patient 23) says "Dao," it means pain. RN 7 also said she (RN 7) never used the interpretation services with the patient (Patient 27), but she (RN 7) knew there was a phone that she (RN 7) could use to call for the interpretation services if she (RN 7) needed to find a translator. RN 7 stated she (RN 7) did not know if there was a policy on Interpretation Services.

A review of Patient 23's admission record, dated 2/28/2023, indicated Patient 23 was admitted to the facility for syncope (fainting or passing out) and cholecystitis (inflammation of the gallbladder). The admission record also indicated Patient 23's preferred language was Vietnamese.

During an interview, 3/01/2023, at 11:30 a.m., with the Administrative Director of Quality & Risk Management (DQRM), the DQRM stated that translating services policy needed to be updated. Currently, there was no certification process for interpreters in the hospital as indicated in the policy. The hospital uses interpretation services for patients.

A review of the facility's policy and procedure (P&P), titled Interpretation Services, last updated on 04/27/2023, indicated that the hospital will provide interpretive services at no cost to the patient to ensure effective communication delivery between the healthcare provider and the patient (I.). The staff members needing translation assistance shall use the CyraCom System that can be found at each nursing unit in the designated area (III. F.1.). The utilization of relatives that accompany the patient can only be used upon the request of the patient (G. 3.). If a family member is used as an interpreter, the record must show the patient requested him/her to interpret (L.1.).

3. a. During an observation on 2/27/2023, at 12:00 p.m., Patient 32's IV (intravenous-into the vein) tubing set was found to contain no label with date, time, and initials of the nurse.

During an interview on 2/27/2023, at 12:55 p.m., with Registered Nurse 8 (RN 8), RN 8 stated current hospital guidelines for IV medication administration set required nursing staff to label medications and the IV tubing prior to its use to ensure it is the right patient, right medication, right order. RN 8 stated that the process to hang IV medications or fluids included labeling the tubing with date and time and nurse's initials, so the tubing can only be used for up to 72 hours without the risk for infection and as per hospital's policy. RN 8 stated she (RN 8) did not label the IV tubing before using it because she (RN 8) forgot. RN 8 said the reason she (RN 8) needed to follow the process is to ensure safety of the patient, potency of the administration set, and infection control to prevent cross-contamination (the transfer of harmful bacteria from one substance or object to another) and bacterial growth.

A review of Patient 32's admission record, dated 2/12/2023, indicated Patient 32 was admitted to the facility for lactic acidosis (too much acid in the body) and hyponatremia (low levels of sodium [salt] in the blood).

3. b. During an observation on 2/27/2023, at 3:00 p.m., Patient 12's IV administration set and Peripheral IV site to the right upper arm had no labeling with time, date, and initials of the person who inserted the IV catheter.

During an interview, on 2/27/2023, at 4:15 p.m., with Registered Nurse 18 (RN 18), RN 18 stated that there was no IV administration set labeling and also verified there was no date, time, and initials label on the Peripheral IV site of Patient 12. RN 18 stated the reason for labeling the IV tubing and the IV site was necessary for the nurses to know when the IV tubing or the IV catheter (used to administer fluids or medication into the bloodstream) should be changed again.

A review of the facilityâ Euro (Trademark)s Policy and Procedure Manual on Intravenous (IV) Therapy guidelines, last revised 7/27/2021, indicated that the standards for prevention of intravascular catheter related infections is to "change the peripheral IV Tubing and sites every 72-96 hours and as needed (F. d.); routine IV administration sets, including Piggyback (IVPB) tubing has to be changed, should be changed every 72-96 hours intervals, but at least every 7 days (Q); one set of secondary tubing may be used for all IVPB (intravenous piggyback, a method of intravenous medication administration) medications and should be changed no more frequently than at 96 hours interval but at least 7 days (R); label intravenous sites with date, time, and initials of the person inserting the IV or changing a dressing ( S.); each IV medication bag, bottle, and tubing must be labeled appropriately prior to administration (W)."

3. c. During a concurrent observation and interview on 2/27/2023, at 12:50 p.m., with Registered Nurse 5 (RN 5), Patient 11's peripheral IV site was observed. RN 5 verified that Patient 11's Peripheral IV site had no label indicating the date, time, or the initials of the person inserting the IV. RN 5 stated that the Peripheral IV site had no label indicating the date and time when it (referring to the IV catheter) was inserted. RN 5 stated she (RN 5) didn't get a chance to do the proper labeling upon insertion but verified that it should be labeled with date, time, and initials of the inserter as soon as the IV catheter is placed. RN 5 stated it was important to label the IV site with a date, so nurses will know when it (the IV catheter) needs to be changed.

3. d. During an observation on 02/27/2023, at 3:00 p.m., Patient 12's IV administration set and Peripheral IV site to the right upper arm had no labeling with time, date, and initials of the person who inserted the IV catheter.

During an interview, at 4:15 p.m., with Registered Nurse 18 (RN 18), RN 18 stated that there was no IV administration set labeling and verified there was no date, time, and initials label on the Peripheral IV site of Patient 12. RN 18 stated the reason for labeling the tubing and the IV site is necessary for the nurses to know when it (referring to the IV tubing and the IV catheter) should be changed again.

3. e. During a concurrent observation and interview, on 02/28/2023, at 8:15 a.m., with Registered Nurse 3 (RN 3), Patient 22's Peripheral IV site was observed to have no label with date, time, and initials of the person who inserted the IV. RN 3 stated the IV catheter site needs to be dated, with time and initials of the RN who inserted the IV catheter so other nurses know when it (referring to the IV catheter) needs to be changed.

3. f. During a concurrent observation and interview on 02/28/2023, at 9:15 a.m., with Registered Nurse 7 (RN 7), Patient 23's Peripheral IV line to the left arm was observed and had no label with date, time, and initials of the person inserting the IV. RN 7 verified the IV insertion site needs to be labeled. During an interview, on 02/28/2023, at 2:41 p.m., with Telemetry Manager (Tele Manager), he (Tele manager) stated that the process for the IV insertion site is to label the site with time, date, and initials of the nurse after IV insertion. The Tele Manager stated it is the expectation from the nursing staff as per hospital's guidelines to adhere to current policy and procedure manual pertaining to IV Therapy and labeling.

During an interview on 03/02/2023, at 08:28 a.m., with the Director of the Infection Prevention (DIP), he (DIP) stated that IV tubing sets and IV insertion sites need to be labeled by the nursing staff because it is an important nursing procedure and needs to be adhered to due to reasons such as infection control and cross contamination issues. DIP further said labeling the IV tubing sets with the date and time helps to ensure that they (referring to the IV tubing) are changed at the appropriate time and as per facility's policy and helps to prevent infections that can arise from contaminated tubing or prolonged use of tubing or Peripheral IV.

A review of the facility's Policy and Procedure Manual on Intravenous (IV) Therapy guidelines, last revised 7/27/2021, indicated that "the standards for prevention of intravascular (within the blood vessel) catheter related infections is to change the peripheral IV Tubing and sites every 72-96 hours and as needed (F. d.); routine IV administration sets, including Piggyback (IVPB) tubing has to be changed should be changed every 72-96 hours intervals, but at least every 7 days (Q); one set of secondary tubing may be used for all IVPB medications and should be changed no more frequently than at 96 hours interval but at least 7 days (R); label intravenous sites with date, time, and initials of the person inserting the IV or changing a dressing ( S.); each IV medication bag, bottle, and tubing must be labeled appropriately prior to administration (W)."

4. A review of Patient 15's admission record, dated 2/21/2023, indicated Patient 15 was admitted to the facility on 2/21/2023 for pneumonia (infection that causes inflammation of the lungs). The admission record also indicated Patient 15 was transferred from the dialysis (removal of excess fluid and waste products from the blood when the kidneys are not able to) center to the hospital after episodes of shortness of breath.

A review of Patient 15's History and Physical (H&P), dated 2/23/2023, indicated Patient 15's medical history included diagnoses of end-stage renal disease (a medical condition in which a person's kidneys cease functioning), diabetes mellitus (elevated blood sugar level)), and hypertension (high blood pressure).

A review of Patient 15's nursing initial assessment, dated 2/21/2023, with Clinical Nurse Manager 1 (CNM 1), indicated no bruit (sound of blood flowing through a narrowed portion of an artery) or thrill
(motion of blood flowing through the AVF shunt) to the left upper extremity arteriovenous fistula (AVF) shunt (dialysis access). No other assessment was documented since the initial assessment of Patient 15's left AVF shunt. There was no documentation of notification to the physician regarding the absence of bruit and thrill.

During a concurrent interview and record review on 2/28/2023, at 3:30 p.m., with CNM 1, Patient 15's nursing assessment record (from 2/22/2023 to 2/28/2023), was reviewed. CNM 1 stated she (CNM 1) could not find other docuemntation of the assessment of Patient 15's left AVF shunt after the initial assessment, dated 2/21/2023. CNM 1 added that there was no record that the nurse notified the doctor after discovering no bruit or thrill in the left AVF. CNM 1 stated, the nurse was required to notify the physician of the AVF shunt without bruit or thrill. CNM 1 further said all licensed nurses were required to follow the facility's policy to assess a nonfunctioning AVF shunt. CNM 1 stated the evaluation must be continuous; on telemetry, the registered nurse must conduct the assessment every four hours, and on the medical surgical unit, must be done every shift.

During a concurrent interview and record review of Patient 15's nursing assessment record with RN 17, on 3/1/2023, at 3:30 p.m., Patient 15's nursing assessment record, was reviewed. RN 17 stated she (RN
17) could not find any documentation of the assessments made after the initial assessment of the left AVF shunt on 2/21/2023.

During an interview on 3/1/2023, at 2:30 p.m., with Patient 15 in the presence of CNM 1, Patient 15 stated the nurse had not asked him (Patient 15) about his (Patient 15) shunt to the left arm. Patient 15 stated the nurse did not look at the shunt on his (Patient 15) left arm. Patient 15 stated that "nobody in the hospital asks about the shunt on my left arm." Patient 15 stated he (Patient 15) cannot extend his (Patient 15) left arm because of the shunt.

During a concurrent interview and record review, on 3/1/2023, at 2:34 p.m., with the Director of Acute Care Services (DACS), the facility's reassessment flowsheet was reviewed. The DACS showed a flow sheet that has the time frame for when the reassessment of a patient's AVF shunt must be completed. The flow sheet indicated that for the telemetry unit, an assessment of the AVF shunt must be done every four hours, and for the medical surgical unit, it must be completed every shift.

A review of the facility's policy and procedure (P&P) titled, "Structure Supporting Patient Care," dated 3/23/2021, indicated a full system reassessment must be completed minimally every shift and at unit-specified intervals.

A review of the facility's policy and procedure (P&P) titled "Dialysis: Patient Management," dated 3/23/2021, indicated the licensed nurse assigned to the patient will be responsible for the patient's care of the AVF shunts; the licensed nurse will assess access site and check for patency (absence of blockage or obstruction) every shift.

Based on interview and record review, the facility failed to follow the physician's order for the monitoring of blood glucose (sugar) levels and the administration of insulin (a hormone that controls the amount of sugar in the blood) for one (1) of thirty-three (33) sampled patients (Patient 1).

This deficient practice had the potential for high blood sugar levels and possibly resulting in a diabetic coma (a life-threatening emergency that can happen when people with diabetes (blood sugar levels get too high) for Patient 1.

Findings:

During a concurrent interview and record review, on 3/01/2023, at 1:52 p.m., with the Director of Acute Care Services (DACS), Patient 1's blood sugar record, was reviewed. The DACS stated Patient 1 had a history of diabetes (high amount of sugar in the blood). The DACS stated Patient 1's blood sugar should be checked every six (6) hours and insulin should be given as ordered by the physician, per the sliding scale (the progressive increase in the pre-meal or night-time insulin dose based on pre-defined blood glucose ranges).

During an interview on 3/01/2023, at 1:52 p.m., with the Director of Acute Care Services (DACS), the DACS stated that on 8/10/2022, at 6:50 p.m., Patient 1's blood sugar level was 241 mg/dl (milligrams per deciliter-a unit of measurement), and 6 Units of insulin should have been given to Patient 1. However, there was no documentation as to why the insulin was not administered. In addition, the DACS stated Patient 1's blood sugar (BS) level should have been checked on 8/11/20222, at 12 a.m. However, the BS level had not been checked, and no insulin had been given. The DACS stated insulin should have been given to prevent the sugar level in the blood from becoming too high and possibly resulting in a diabetic coma.

A review of Patient 1's History and Physical (H&P), dated 8/9/2022, at 9:19 p.m., indicated Patient 1 had a history of diabetes, hypertension (high blood pressure), and hemodialysis (treatment to filter wastes and water from the blood).

A review of a physician's order dated 8/10/2022, at 1:01 a.m., and renewed at 6 a.m., indicated the following: Give Regular insulin 100 Units/ ml [milliliter, a unit of measurement]), every six (6) hours, subcutaneously (under the skin);

If Glucose (or blood sugar, BS) level is less than 60, give no insulin...,

If BS is 60 to 150, give no insulin

If BS is 151 to 200, give 4 Units of insulin

If BS is 201 to 250, give 6 Units of insulin

If BS is 251 to 300, give 8 Units of insulin

If BS is 301 to 350, give 12 Units of insulin

If BS is 351 to 100, give 16 Units of insulin

If BS is greater than 400, call the MD...

A review of the medication administration record (MAR) for Patient 1, dated 8/10/2023, indicated that at 6:50 p.m., Patient 1's BS level was 241 mg/dl, and insulin had not been given. There was no documentation indicating the reason why the insulin was not given. In addition, there was no record that the BS was checked on 8/11/2022 at 12 a.m., nor documentation indicating the reason why the BS was not checked or the reason why insulin was not given.

A review of the facility's policy and procedure (P&P) titled, "Administration of Medication," dated 6/2016, indicated to perform the eight rights of: Right patient, right medication, right dose, right route, right time, right documentation, right reason, and right response.

A review of the facility's policy and procedure (P&P) titled, "Medication Insulin: Storing, Distribution and Administration," dated 5/2021, indicated for Sliding Scale Insulin Doses Using Insulin Vial: 1. The Nurse will perform the glucose scan and verify the dose needed either with the original order or with the MAR...11. The nurse will document the time that the insulin was administered on the MAR.