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Based on observation, interview, and record review, the facility failed to ensure informed consent (a process in which patients are given important information, including possible risks and benefits) was obtained for the facility's condition of admission (COA, a document that include provisions under which the patient provides informed consent for treatment and may also require the patient's confirmation of understanding on various arrangements related to the treatment the patient will receive in the facility) for one of 30 sampled patients (Patient 25), when the patient's (Patient 25) signature did not match the patient's (Patient 25) previous consent form.

This deficient practice resulted in Patient 25 to not be informed of her (Patient 25) rights as a patient which may lead to Patient 25's inability to effectively make decisions regarding her care or treatment.

Findings:

During a concurrent observation and interview on 4/17/2024 at 11:20 a.m. with Registered Nurse (RN) 4, Patient 25 was observed in bed with her (Patient 25) eyes closed. RN 4 stated Patient 25 was admitted with a diagnosis of breast cancer that metastasized (the spread of cancer cells from the place where they first formed to another part of the body) to the brain.

During a review of Patient 25's "Internal Medicine History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 3/29/2024, the H&P indicated, "...Patient (Patient 25) was extubated (removal of the endotracheal tube [a tube to help provide oxygen to the lungs]) but still with altered mental status (a change in mental function that stems from illness, disorders, and injuries affecting the brain), non-verbal (inability to speak) ..."

During a concurrent interview and record review on 4/17/2024 at 3:39 p.m. with the Nursing Manager (NM) 1, Patient 25's "Hospital Conditions of Admission [Inpatient/Outpatient Services]" (COA, a document that include provisions under which the patient provides informed consent for treatment and may also require the patient's confirmation of understanding on various arrangements related to the treatment the patient will receive in the facility), dated 3/31/2024, was reviewed. The COA indicated the document was, "Signed by: [Patient 25's name], Relationship: Self." NM 1 said the signature did not look like Patient 25's name.

During a subsequent review of Patient 25's COA dated 3/19/2024, the COA indicated "Signed by: [Patient 25's name], Relationship: Self". NM 1 verified the signature obtained on 3/19/2024, was the Patient 25's name and the signatures on both COAs did not match.

During a concurrent interview and record review on 4/17/2024 at 4:16 p.m. with the Financial Counselor (FC), Patient 25's COA dated 3/31/2024, was reviewed. The FC stated the signature on the COA did not match the patient's name and was not a valid consent. The FC further stated the facility's practice is to have an admitting office representative obtain the signature. If the patient is unable to sign the consent themselves, a family representative would sign the document and the family representative's name and relationship to the patient would be documented on the COA. However, this was not done for Patient 25.

During a review of the facility's policy and procedure (P&P) titled, "Consent Procedures [Including Illiterate or Non-English]," revised on November 2023, the P&P indicated, " ...The Admission Department is responsible for obtaining appropriate consent on the Conditions of Admission for Hospital Services ... There will be a Conditions of Admissions signed for all hospital admissions/registrations for hospital services ..."

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 10) in accordance with the restraint's manufacturer's instructions and with the facility's policies and procedures regarding restraints use.

This deficient practice resulted in Patient 10 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 an observation on 4/17/2024 at 2:20 p.m., in the Medical Surgical (serves general population such as illness and surgery) and Telemetry (area in hospital where patient undergoes continuous heart monitoring) Unit, the following was observed: Patient 10 sat on a chair in his (Patient 10) room. Patient 10 had a wide belt wrapped around the torso and the back of the chair. The belt was secured or fastened on Patient 10's left side of the body between the abdomen and the back. Certified nurse assistant (CNA) 1 was sitting just outside Patient 10's room, observing Patient 10.

Concurrently, during an interview, on 4/17/2024 at 2:20 p.m., Patient 10 stated he (Patient 10) was unable to get off the chair because the staff "Tied me in."
During an interview on 4/17/2024 at 2:20 p.m., CNA 1 stated Patient 10 was confused. CNA 1 was observing Patient 10 because Patient 10 was at risk for falls (an unintentional event that results in the person coming to rest on the ground or another lower level). CNA 1 said she (CNA 1) was helping Patient 10 with any needs he (Patient 10) may have such as toileting, etc.

During a concurrent interview and record review on 4/17/2024 at 2:25 p.m. with Assistant Nurse Manager (ANM) 1, ANM 1 stated the following: Patient 10 was wearing a support belt (torso belt). ANM 1 reviewed the manufacturer's instructions for the Torso Belt, and verified the instructions indicated the belt was a restraint and required a physician's order. Patient 10 did not have an order for use of the belt. ANM 1 said when patients are placed on restraints, the nurses should monitor patients every two (2) hours for mental status (behavioral and cognitive functioning [thinking, reasoning, remembering]), circulation (blood flow through the body), nutritional needs (food and nutrients), hydration needs (fluid intake such as water, juice, etc.), elimination needs (toileting), and range of motion (movement of limbs). ANM 1 verified Patient 10 was not monitored every two hours by a registered nurse. ANM 1 stated that CNA 1 was monitoring Patient 1's mental status only, every two hours.

During an interview on 4/17/2024 at 2:57 p.m. with Physical Therapist (PT) 1, PT 1 reviewed the Torso Belt's manufacturer's instructions and stated the following: The Torso Belt was used on patients for support and stability. PT 1 was not aware that the Torso belt required a physician's order or that the belt was considered a restraint by the manufacturer.

During a review of Patient 10's History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/13/2024, the H&P indicated the following: Patient 10 was admitted to the facility for weakness and disorientation (a state of mental confusion). Patient more confused/combative than normal and was attempting to get out of bed at home. Patient 10's diagnoses included a history of dementia (a condition characterized by progressive loss of intellectual functioning), paroxysmal atrial fibrillation (irregular, often rapid heart rate, that commonly causes poor circulation). Patient 10 is alert, awake, and oriented to self ...poor strength and tone (amount of tension or resistance to movement in muscles) in all four extremities.

During a review of Patient 1's "Physical Therapy Initial Assessment," dated 4/13/2024 at 10:02 p.m., the Physical Therapy Initial Assessment indicated the following: "Medical diagnosis: weakness. Treating impairments/dysfunction: Impaired mobility (a disability that affects movement such as walking) ...Fall Risk (the likelihood that a person would fall due to risk factors such as impaired mobility) ...Patient 10 is able to sit at the edge of the bed ...Patient 10 is unable to maintain sitting balance without assistance ..."

During a review of the manufacturer's instructions for use titled, "Torso Belt Application Instruction," dated 10/2023, the manufacturer's instructions indicated the following: RX (prescription) Only ...Intended Use: Torso Belts are to be used for patients at risk of leaning and falling from chairs ...Do not use on a patient who is unwilling or unable to follow instructions, and is at risk of a fall or re-injury from self-release. Warning: Caution: Patient should be checked per facility's policy. To guard against the formation of a decubitus ulcers, patient's position should be changed, and patient should be re-evaluated per facility's policy. Incorrect use of this product could result in suffocation or serious injury. Do not cut off circulation - check circulation often ...Monitor according to facility policy ...Patient Restraints: General Precautions & Warning. RX only ... Always follow your facility's policies and procedures and regulations when restraining a patient. Important Information: Please read all instructions, precautions, and warning prior to use. Know your facility's policies and procedures before using any product or device. Follow manufacturer's instructions provided with the product or device.

During a review of the facility's policy and procedure (P&P) titled, "Restraint Use," dated 9/1/2022, the P&P indicated the following: All patients have the right to be free from restraint or seclusion (involuntary confinement of a patient in a room alone from which the patient is physically prevented from leaving), or any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff ...A restraint is 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. Restraint Orders: Orders for restraint can only be obtained from physicians/licensed practitioners with privileges ...The order shall include the type of restraint to be applied and shall be based on specific behaviors that indicate the need for restraint ...Assessment, monitoring, and documentation of all restraint types: Registered nurses (RN) are responsible for assessment, monitoring and provision of care for patients in restraints ...Patients in non-behavioral restraints are monitored and assessed at least every two (2) hours or sooner ...Assessment at every two (2) hours include: Behavior/mental status; Circulation; Nutritional needs (food/meal); Hydration needs; Elimination needs; Range of Motion (ROM); restraints released and reapplied ...

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 one of five sampled nursing staff (Registered Nurse 6 [RN 6]) had a complete departmental annual competency evaluation (assessment of a clinician's skills, abilities and knowledge to ensure provision of safe and effective care to patients) done in accordance with the facility's policy and procedure on competency evaluation. This deficient practice had the potential to result in patients receiving inadequate care and treatment from staff whose competencies were not completed annually. (Refer to A-0394)

2. The facility failed to obtain a pain assessment (process where a nurse gathers, sorts and analyzes a patient's health information) and reassessment for three of 30 sampled patients (Patient 1, 11, and 22) in accordance with the facility's policy and procedure regarding assessment and re-assessment when:

2.a. Patient 1, who was in the Obstetrics Triage Unit (Unit 1, OB triage, provides immediate, specialized assessment for women at all stages of pregnancy), did not have a documented baseline pain assessment on admission or any reassessment during episodes of contractions (tightening of the uterus that provides the force to expel the fetus [unborn baby] through the birth canal).

This deficient practice had the potential for Patient 1 to have unrelieved pain. Thus, negatively affecting the physical, emotional, and psychosocial (social factors of a person's thoughts and behaviors) well-being of the patient (Patient 1). (Refer to A-0395)

2.b. Patient 11's pain was not assessed prior to receiving pain medication (Tylenol, administered for mild pain). This deficient practice had the potential for Patient 11 to receive pain medications unnecessarily. (Refer to A-0395)

2.c. Patient 22's pain was not addressed for more than two hours after Patient 22 reported a pain level of 10 out of 10 (a score of 0 means no pain, and 10 means the worst pain ever felt). This deficient practice resulted in the delay of appropriate pain management for Patient 22 and had the potential to cause adverse health outcomes such as worsening of pain that takes longer to relieve. (Refer to A-0395)

3. The facility failed to assess fetal (baby in the womb) heart rate and uterine contractions (the tightening and shortening of the uterine muscles) for one of 30 sampled patients (Patient 9) in accordance with the facility's policy and procedure regarding assessment of fetal heart rate and contractions.

This deficient practice had the potential for abnormalities in the baby's heart rhythm and Patient 9's contractions to become unidentified by staff and puts Patient 9 at risk for harm due to lack of assessment which might delay the implementation of necessary interventions needed. (Refer to A-0398)

4. The facility failed to ensure notification of a physician and ensure documentation of physician notification regarding one of 30 sampled patient's (Patient 24) critical serum sodium (NA, the concentration of sodium [salt] in the blood) laboratory result in accordance with the facility's policy and procedure regarding critical results (laboratory test results that exceed established limits either high or low).

This deficient practice had the potential for Patient 24's condition to be left unaddressed leading to consequences of hypernatremia (high sodium in the body) which can lead to seizures (a sudden, uncontrolled burst of electrical activity in the brain), coma (a state of prolonged loss of consciousness), and death. (Refer to A-0398)

5. The facility failed to ensure that a seizure precaution padding (device to prevent the patient from injuring themselves against the hard frame or side rails of the hospital bed) was applied to the lower side rails (safety devices used to prevent patients from falling out of their beds) for one of 30 sampled patients (Patient 25), in accordance with the facility's policy and procedure regarding seizure (a sudden, uncontrolled burst of electrical activity in the brain leading to changes in movements and levels of consciousness) management.

This deficient practice had the potential for Patient 25 to suffer injuries such as bruising, lacerations (cuts), or broken bones when without padded side rails for protection while having a seizure episode. (Refer to A-0398)

6. The facility failed to ensure that one of 30 sampled patient's (Patient 25) sequential compression device (SCD, helps to prevent blood clots from forming in the lower limbs) was turned on while applied to Patient 25's bilateral lower extremities in accordance with a physician order for SCD and with the facility's established protocol regarding the use of SCDs.

This deficient practice had the potential for Patient 25 to develop blood clots in her (Patient 25) lower limbs causing life threatening complications such as pulmonary embolism (a sudden blockage in a lung). (Refer to A-0398)

7. The facility failed to ensure one of 30 sampled patient's (Patient 25) bed alarm (devices that contains sensors that trigger an alarm when the patient tries to get out of bed) was turned on and working and a fall (an unintentional event that results in the person coming to rest on the ground or another lower level) mat (a safety pad placed on the floor beside the bed to prevent injuries resulting from falls) was placed on the floor beside the patient's (Patient 25) bed to prevent injuries resulting from falls in accordance with the facility's protocol regarding fall prevention.

These deficient practices had the potential for Patient 25 to suffer injuries such as bruising, lacerations, and broken bones resulting from a fall. (Refer to A-0398)

8. The facility failed to ensure one of 30 sampled patient's (Patient 24) antibiotic medication (Unasyn, an intravenous [administered through the vein] antibiotic used to treat an infection) was administered in a timely manner (one hour before or one hour after scheduled time) in accordance with the facility's policy and procedure regarding medication administration.

This deficient practice resulted in the delay of treatment for Patient 24 and had the potential to cause adverse health outcomes such as recurring infection (infections that become severe and long lasting, etc. (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 one of five sampled nursing staff (Registered Nurse 6 [RN 6]) had a complete departmental annual competency evaluation (assessment of a clinician's skills, abilities and knowledge to ensure provision of safe and effective care to patients) done in accordance with the facility's policy and procedure on competency evaluation.

This deficient practice had the potential to result in patients receiving inadequate care and treatment from staff whose competencies were not completed annually.

Findings:

During a concurrent interview and record review on 4/18/2024 at 2:22 p.m. with Assistant Nurse Manager 2 (ANM 2), the Human Resources Consultant (HRC) and the Director of Professional Development and Education (DPDE), Registered Nurse 6's (RN 6) personnel file was reviewed. HRC and DPDE stated the following: RN 6 was hired on 11/26/2018. RN 6's last departmental annual competency evaluation was 8/31/2021. ANM 2 stated the following: The departmental annual competency should be completed once per year by December 31st. RN 6 was on a leave of absence from 6/28/2022 through 9/2/2022, 9/28/2022 through 11/26/2023, and 12/4/2023 through 1/6/2024.
RN 6 returned to work on 1/6/2024. As of 4/18/2024, RN 6 is still catching up to complete the departmental annual skills competency and this is not completed. RN 6's annual skills competency evaluation should have been scheduled and completed immediately when she (RN 6) returned to work from her (RN 6) leave of absence on 1/06/2024. The departmental annual evaluation is important to make sure the employee is competent with the skills they are performing.

During a review of the facility's policy and procedure (P&P) titled, "Education/Competency," dated 11/2023, the P&P indicated the following: "Purpose: To ensure all staff are competent to fulfill their assigned job duties ... Policy: ...each employee in the Medical Center will have his/her individual performance reviewed on an annual basis utilizing all related medical center-wide competencies, in addition, each employee will have his/her performance reviewed on department-specific competencies chosen for the year ..."

Based on observation, interview and record review, the facility failed to obtain a pain assessment (process where a nurse gathers, sorts and analyzes a patient's health information) and reassessment for three of 30 sampled patients (Patient 1, 11, and 22) in accordance with the facility's policy and procedure regarding assessment and re-assessment when:

1. Patient 1, who was in the Obstetrics Triage Unit (Unit 1, OB triage, provides immediate, specialized assessment for women at all stages of pregnancy), did not have a documented baseline pain assessment on admission or any reassessment during episodes of contractions (tightening of the uterus that provides the force to expel the fetus [unborn baby] through the birth canal).

This deficient practice had the potential for Patient 1 to have unrelieved pain. Thus, negatively affecting the physical, emotional, and psychosocial (social factors of a person's thoughts and behaviors) well-being of the patient (Patient 1).

2. Patient 11's pain was not assessed prior to receiving pain medication (Tylenol, administered for mild pain). This deficient practice had the potential for Patient 11 to receive pain medications unnecessarily.

3. Patient 22's pain was not addressed for more than two hours after Patient 22 reported a pain level of 10 out of 10 (a score of 0 means no pain, and 10 means the worst pain ever felt). This deficient practice resulted in the delay of appropriate pain management for Patient 22 and had the potential to cause adverse health outcomes such as worsening of pain that takes longer to relieve.

Findings:

1. During an observation on 4/15/2024 at 2:27 p.m., in the Obstetrics Triage Unit (Unit 1, OB triage, provides immediate, specialized assessment [process where a nurse gathers, sorts and analyzes a patient's health information] for women at all stages of pregnancy), nine triage bays were observed in Unit 1. There were two patients in the unit.

During a concurrent interview and closed record review on 4/16/2024 at 9:48 a.m. with Labor & Delivery Manager (L&DM) and Registered Nurse (RN) 2, Patient 1's medical record (a record of a patient's medical information) was reviewed. RN 2 verified the following information in the medical record: Patient 1 was admitted to Unit 1 on 3/6/2024 at 9:01 p.m. with a diagnosis of pre-term labor (labor [uterine contractions] occurring between after 20 and before 37 weeks during pregnancy) with uterine contractions (the tightening and shortening of the uterine muscles). The uterine contraction intensity was every 7 minutes and moderate. RN 2 stated that moderate uterine contractions were assessed by feeling the stomach.

During a concurrent interview and closed record review on 4/16/2024 at 2:17 p.m. with Registered Nurse 2 (RN 2), Clinical Informatics Specialist (CIS), and the Regional Director of Maternal Child Health (RDMCH), Patient 1's medical record was reviewed. CIS, RN 2 and RDMCH verified the following information: Patient 1 did not have a documented pain assessment or reassessment, when admitted to Unit 1. There was only one pain assessment documented on discharge from the facility, dated 3/6/2024 at 1:34 a.m., which indicated 3/10 pain (mild pain). RDMCH stated that on admission, Patient 1 should have had an admission pain assessment to determine a baseline (a minimum or starting point used for comparisons) for pain and to provide interventions for the patient to address pain. RN 2 stated the following: Pain should have been reassessed to establish if interventions were effective. Contractions could have caused pain and discomfort, so Patient 1 should have been assessed for pain when Patient 1 had complaints of contractions. Pain reassessments were supposed to be done within one hour from the time a patient complains of pain or were medicated for pain.

During an interview on 4/17/2024 at 8:53 a.m. with Registered Nurse 3 (RN 3), RN 3 stated the following: Pain is included in the Registered Nurses admission assessment, per policy. Pain is assessed with vital signs (includes temperature, heart rate, respiratory rate, blood pressure, and pain level) or when the patient states they are having pain, per unit protocol. Pain is assessed at least once unless there are abnormal vital signs. Patient 1 should have had at least one pain assessment indicating how strong uterine contractions were, to establish a baseline. The pain assessment is given numerically by the patient using a pain scale 0-10 (zero is no pain, 10 is severe pain). The pain assessment should be documented in the medical record.

During a review of the facility's policy and procedure (P&P) titled, "Pain Management," dated 3/2023, the P&P indicated the following: "Policy Statement: The physicians and staff are committed to providing appropriate pain management that is evidence-based practice and proven to be safe and effective ... Policy: Nursing will collaborate interprofessional with the patient, physicians and other treatment team members to devise an effective patient specific pain management plan. Patients are screened, assessed and re-assessed for pain utilizing a comprehensive pain assessment based on patient condition, age, and abilities ... Procedure: Pain intensity ratings will be recorded as part of the initial admission patient assessment ... Ongoing Pain Management: Assess and re-assess all patients with pain for pain intensity, quality, location precipitating factors, and responses to interventions throughout their hospitalization. Pain will be assessed at a minimum with routine shift assessments, operative or other procedures and prior to discharge ... Adult Pain Scale: 0-10 ..."

During a review of the facility's policy and procedure (P&P) titled, "Evaluation of Obstetrical Outpatients by Registered Nurses in Triage/Labor and Delivery," dated 11/2023, the P&P indicated the following: "Procedure: 1. Assess the following: ... g. Maternal vital signs including temperature, pulse, respiratory rate, blood pressure, pain level, and DTR's Deep tendon reflex's (involuntary response of muscles in response to a stimulus) (if indicated) ... Procedure- Pre-procedure: 1. Conduct initial patient assessment. 2. Reassess the patient within 1 hour if the initial assessment not definitive of labor or other indication for hospital admission. Reassessment to include the following, Fetal Heart Rate, uterine activity, vital signs, pain level. 3. Document findings on the triage assessment form ..."

2. During a review of Patient 11's History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/15/2024, the H&P indicated the following: Patient 11 was admitted to the facility for altered level of consciousness (a change in the patient's state of awareness [ability to relate to self and the environment] and alertness) after he (Patient 11) was found down in a parking lot. Diagnoses included stroke (a blockage of blood supply to the brain). Patient 11's past medical history included hypertension (high blood pressure) and diabetes (high blood sugar).

During a concurrent interview and record review on 4/18/2024 at 1:08 p.m. with Assistant Nurse Manager (ANM) 1, ANM 1 stated the following: ANM 1 said Patient 11 had an order to be given Tylenol for mild pain. On 4/18/2024 at 10:09 a.m., Patient 11 received Tylenol 650 milligrams (mg, a unit of measurement) by mouth. The pain intensity, location, character, or duration of the pain was not assessed prior to administering the Tylenol. This was verified by ANM 1. ANM 1 stated she (ANM 1) did not know the reason Tylenol had been given and that it (reason) should have been documented in the medical record.

During a review of Patient 11's "Medication Administration Record (MAR)," dated 4/18/2024 at 10:06 a.m., the MAR indicated Patient 11 was given Tylenol 650 mg by mouth.

During a review of Patient 11's pain assessments, dated 4/18/2024, the pain assessments indicated the following: At 4:11 a.m., pain score was 0 (no pain). At 10:45 a.m., pain score was documented as "sleeping."

During a review of the facility's policy and procedure (P&P) titled, "Pain Management," dated 3/2023, the P&P indicated the following: Patients are screened, assessed and re-assessed for pain utilizing a comprehensive pain assessment based on patient condition, age, and abilities ... Assess and re-assess all patients with pain for pain intensity, quality, location, precipitating factors, and responses to interventions throughout their hospitalization."

3. During a review of Patient 22's medical record (MR) titled, "Emergency Department (ED, responsible for the provision of medical care to patients arriving to the hospital in need of immediate care) Service Note," dated 4/16/2024, the MR indicated, Patient 22 presented to the ED complaining of right lower back pain and had past medical history (information about the patient's medical, personal and family history that might be relevant to the presenting illness) of diabetes (high blood sugar), hypertension (high blood pressure), and lumbar spondylosis (a condition in which there is abnormal wear on the cartilage [connective tissue protecting the bones and joints] and bones of the back and is a common cause of chronic back pain).

During a review of Patient 22's medical record (MR) titled, "Patient Care Timeline," dated 4/17/2024, the MR indicated, Patient 22 arrived at the Emergency Department (ED) on 4/16/2024, at 5:30 a.m., complaining of severe back pain, reporting a pain level 10/10 (a score of 0 means no pain, and 10 means the worst pain ever felt).

During further review of Patient 22's MR titled, "Patient Care Timeline," dated 4/16/2024, the MR indicated, Patient 22 was taken to a room at 6:22 a.m. on 4/16/2024.

During a review of Patient 22's MR, titled, "Vital Signs," dated 4/16/2024, at 7:00 a.m., Patient 22's MR indicated, Patient 22's pain level was recorded 10/10 on 4/16/2024, at 7:00 a.m.

During a review of Patient 22's MR titled, "Vital Signs," dated 4/16/2024, the MR indicated, on 4/16/2024, at 8:01 a.m., Patient 22 reported pain level 10/10 again.

During a review of Patient 22's MR titled, "Patient Care Timeline," dated 4/16/2024, the MR indicated, Patient 22 received pain managing medication, Ofirmev (acetaminophen injection used to treat mild to moderate pain) 1,000 milligrams (mg, a unit of measurement) on 4/16/2024, at 8:16 a.m.

During a concurrent interview and record review on 4/18/2024, at 9:35 a.m., with Clinical Director of Emergency Department (CDED), Patient 22's medical record titled, "Patient Care Timeline," dated 4/16/2024, was reviewed. The MR indicated, on 4/16/2024, Patient 22 reported a pain level of 10/10 at 5:30 a.m., at 7:00 a.m., and at 8:00 a.m., but was not treated for pain until 8:16 a.m. CDED stated, per facility's policy, nursing shall address pain in a timely manner and patients should not be waiting for pain management for a long time. CDED further said, Patient 22 reported severe pain (10/10), and nursing could escalate to obtain medication orders from the physician to initiate pain management treatment, but did not do it.

During a review of the facility's policy and procedure (P&P) titled, "Pain Management," dated 3/2023, the P&P indicated, "Pain is subjective, and exists when the patient states he/she has pain. patient self-report of pain is the best indicator for the existence of pain and is all that is needed to initiate treatment. Nursing will collaborate with the patient and physicians to devise an effective patient specific pain management plan. Patients have the right to be treated for pain and receive treatment in a timely manner and should notify the physician if the patient has reported pain upon admission for pain management orders, if not already present on admitting orders."

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

1. Assess fetal (baby in the womb) heart rate and uterine contractions (the tightening and shortening of the uterine muscles) for one of 30 sampled patients (Patient 9) in accordance with the facility's policy and procedure regarding assessment of fetal heart rate and contractions. This deficient practice had the potential for abnormalities in the baby's heart rhythm and Patient 9's contractions to become unidentified by staff and puts Patient 9 at risk for harm due to lack of assessment which might delay the implementation of necessary interventions needed.

2. Ensure notification of a physician and ensure documentation of physician notification regarding one of 30 sampled patient's (Patient 24) critical serum sodium (NA, the concentration of sodium [salt] in the blood) laboratory result in accordance with the facility's policy and procedure regarding critical results (laboratory test results that exceed established limits either high or low).

This deficient practice had the potential for Patient 24's condition to be left unaddressed leading to consequences of hypernatremia (high sodium in the body) which can lead to seizures (a sudden, uncontrolled burst of electrical activity in the brain), coma (a state of prolonged loss of consciousness), and death.

3. Ensure that a seizure precaution padding (device to prevent the patient from injuring themselves against the hard frame or side rails of the hospital bed) was applied to the lower side rails (safety devices used to prevent patients from falling out of their beds) for one of 30 sampled patients (Patient 25), in accordance with the facility's policy and procedure regarding seizure (a sudden, uncontrolled burst of electrical activity in the brain leading to changes in movements and levels of consciousness) management.

This deficient practice had the potential for Patient 25 to suffer injuries such as bruising, lacerations (cuts), or broken bones when without padded side rails for protection while having a seizure episode.

4. Ensure that one of 30 sampled patient's (Patient 25) sequential compression device (SCD, helps to prevent blood clots from forming in the lower limbs) was turned on while applied to Patient 25's bilateral lower extremities in accordance with a physician order for SCD and with the facility's established protocol regarding the use of SCDs.

This deficient practice had the potential for Patient 25 to develop blood clots in her (Patient 25) lower limbs causing life threatening complications such as pulmonary embolism (a sudden blockage in a lung).

5. Ensure one of 30 sampled patient's (Patient 25) bed alarm (devices that contains sensors that trigger an alarm when the patient tries to get out of bed) was turned on and working and a fall (an unintentional event that results in the person coming to rest on the ground or another lower level) mat (a safety pad placed on the floor beside the bed to prevent injuries resulting from falls) was placed on the floor beside the patient's (Patient 25) bed to prevent injuries resulting from falls in accordance with the facility's protocol regarding fall prevention.

These deficient practices had the potential for Patient 25 to suffer injuries such as bruising, lacerations, and broken bones resulting from a fall.

Findings:

1. During a concurrent interview and record review on 4/17/2024 at 10:12 a.m., with Regional Director for Maternal Child Health (RDMCH), the RDMCH stated the following: Patient 9 arrived at the OB (Obstetrics) triage (provides immediate, specialized assessment for women at all stages of pregnancy) on 3/26/2024 at 11:51 a.m. because Patient 9 fainted, felt dizzy, and complained of a headache. When Patient 9 arrived at the OB triage, the patients are placed on a fetal heart monitor to check the baby's heart rate and the mother's uterine contractions for a least 20 minutes in order to interpret the results and make an assessment of the baby's and the mother's condition.
The assessment should be documented in the medical record. A normal interpretation of the fetal heart rate and the mother's contractions should be documented prior to patients being discharged. The RDMHC stated that Patient 9 was placed on a fetal heart monitor on 3/26/2024 from 12:15 p.m. to 12:49 p.m. There was no evidence of an interpretation or assessment of the fetal (baby) heart rate or of the mother's uterine contractions by a registered nurse. Patient 9 was discharged home on 3/26/2024 at 12:50 p.m.

During a review of Patient 9's History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 3/26/2024 at 12:32 p.m., the H&P indicated the following: Patient 9 felt faint feeling in bed at 9 a.m. Patient 9 with an intrauterine pregnancy (when a fertilized egg is implanted in the uterus [where an unborn baby develops and grows] and starts to develop within it) at 33 weeks and 3/7 (days).

During a review of Patient 9's "Fetal Monitoring Note," dated 3/26/2024 from 12:15 p.m., through 12:32 p.m., the note indicated there was no assessment of the baby's heart rate or the Patient 1's uterine contractions.

During a review of the facility's policy and procedure (P&P) titled, "Evaluation of Obstetrical Outpatients by Registered Nurses in Triage/Labor and Delivery," dated 3/2023, the P&P indicated the following: Assess the following: Contraction pattern including frequency, duration, and intensity of contractions; Fetal heart rate/pattern.

2. During a concurrent observation and interview on 4/17/2024, at 11:39 a.m., with the Registered Nurse (RN) 5, Patient 24 was observed in bed with his eyes closed. RN 5 stated the patient (Patient 24) was admitted for hypernatremia (high sodium [salt] in the body) and failure to thrive (when an older adult has loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal).

During a review of Patient 24's "Internal Medicine History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/15/2024, the H&P indicated, Patient 24 was admitted on 4/15/2024, and " ...presents to the hospital with 2 week history of progressively worsening generalized weakness and 2 day history of poor oral intake and increasing confusion. His wife present at bedside reports that he barely ate or drank anything yesterday ... His lab work was notable for ...serum sodium 160 ..."

During a concurrent interview and record review on 4/17/2024, at 3:07 p.m., with the Nursing Manager (NM) 1, Patient 24's laboratory results dated were reviewed:

1. April 16, 2024, at 2:54 a.m., Sodium (salt) 160 (normal is 135 to 145 milliequivalents per liter (mEq/L, concentration of a substance in a liter of fluid)

2. April 16, 2024, at 9:23 a.m., Sodium 159

During an interview with NM 1 on 4/17/2024 at 3:07 p.m., NM 1 was unable to provide documentation of the physician being notified of the critical laboratory values indicated in Patient 24's electronic medical record. NM 1 further stated the facility's practice is for the physician to be notified of critical laboratory results within 15 minutes of receiving the results and to document the notification to the physician in the patient's medical record. NM 1 stated that critical laboratory results are reported to the physician by the RN to ensure interventions are ordered for the patient.

During a review of the facility's policy and procedure (P&P) titled, "Critical Results," revised on October 2021, the P&P indicated, " ...Responsibilities of the person receiving the critical result: ... the staff can use [Name of flowsheet] to document the receipt of such information, which includes ...Name of the Provider Notification ...Time of Provider Notification ..." Further review of the P&P indicated " ...Definitions: 1) Critical Results: Critical laboratory values and diagnostic test results that require an immediate and/or emergent response by a physician or if the lack of intervention is likely to cause significant morbidity/mortality within 24 hours. Critical laboratory values are levels which exceed a pre-determined upper or lower limit beyond which the patient's health is or could be significantly at risk ..." The P&P indicated critical results for sodium were less than 120 milliequivalents per liter (mEq/L- concentration of a substance in a liter of fluid) and greater than 158 mEq/L.

3. During an observation on 4/17/2024 at 11:15 a.m., in Patient 25's room, Patient 25 was observed lying in bed with her eyes closed. All four side rails were raised with the two upper side rails padded and the lower two side rails unpadded.

During a concurrent observation and interview on 4/17/2024 at 11:20 a.m. with the Registered Nurse (RN) 4, in Patient 25's room, RN 4 verified all four side rails were raised and the two upper side rails were padded for seizure (a sudden, uncontrolled burst of electrical activity in the brain leading to changes in movements and levels of consciousness) precautions. RN 4 stated Patient 25 was admitted for breast cancer that metastasized (the spread of cancer cells from the place where they first formed to another part of the body) to the brain and seizures. RN 4 further stated the two upper side rails were padded to protect Patient 25's head from injury during a seizure.

During a concurrent interview and record review on 4/17/2024 at 3:50 p.m., with the Nursing Manager (NM) 1, Patient 25's electronic health record flowsheet (flowsheet, a tool to help clinicians document patient data in a grid-like format) titled "Safety Interventions: Seizure Precautions," dated 4/17/2024, was reviewed. The flowsheet indicated, on 4/17/2024 at 8:00 a.m., all four side rails were padded for safety. NM 1 stated according to facility policy, all four side rails are raised and padded for seizure precaution patients due to the patient possibly suffering injury to the upper and lower body during a seizure.

During an interview on 4/18/2024 at 3:21 p.m. with the Quality Assurance Registered Nurse (QARN), the QARN stated the facility does not have a policy and procedure (P&P) for seizure precautions, but the facility follows the [Name of Publishing Company] guidelines for seizure precautions.
During a review of [Name of Publishing Company] guidelines titled "Seizure Management," revised on 12/11/2023, the guidelines indicated " ...Patients at risk for seizures need precautionary measures to help prevent injury if a seizure occurs. Equipment ...Padding for side rails ..."

During a review of Patient 25's nursing care plan (care plan - contains relevant information about a patient's diagnosis, the goals of treatment, and interventions to meet the goal) titled "Plan of Care Problem: Seizure, Active Management" dated 4/18/2024, the care plan indicated " ...Goal: Absence of Seizures/Seizure Related Injury, Intervention: Prevent Seizure-Related Injury ...enclosure bed used ..."
During a review of the facility's policy and procedure (P&P) titled, "Restraint Use," revised date on 9/1/2022, the P&P indicated, " ...Side rails: A restraint does not include methods that protect the patient from falling out of bed. Examples include raising the side rails when a patient is ... experiencing involuntary movement ... to prevent the patient from falling out of the bed ... Patient is placed on seizure precautions and all side rails raised and padded ..."

4. During a concurrent observation and interview on 4/17/2024 at 11:20 a.m., with the Registered Nurse (RN) 4, in Patient 25's room, the sequential compression device (SCD, helps to prevent blood clots from forming in the lower limbs) sleeves were observed applied to Patient 25's lower limbs. However, the SCD device was unplugged from a power source. RN 4 validated the SCD was not plugged into a power source and thus was not in proper use. RN 4 stated the SCD should be turned on according to facility protocol.

During a review of Patient 25's "Internal Medicine Progress Note" (progress note) dated 3/30/2024, the progress note indicated to apply prophylaxis (intervention to prevent a future problem such as blood clots forming in lower extremities) SCDs.

During a review of Patient 25's physician's orders dated 3/30/2024, the order indicated " ...Apply knee length sequential compression device ..."

During an interview on 4/18/2024 at 3:21 p.m. with the Quality Assurance Registered Nurse (QARN), the QARN stated the facility does not have a policy and procedure (P&P) for VTE prevention but follows the [Name of Publishing Company] guidelines for VTE prevention.

During a review of [Name of Publishing Company] guidelines titled "Sequential compression therapy," revised on 5/22/2023, the guidelines indicated " ...This safe, effective, noninvasive therapy massages the legs in a wavelike, milking motion that promotes blood flow in the lower extremities to decrease risk of thrombosis (developing blood clots) ...Operating the system ...Plug the compression controller into the proper wall outlet. Turn on the power ..."

5.a. During a concurrent observation and interview on 4/17/2024 at 11:25 a.m., with the Registered Nurse (RN) 4 and the Charge Nurse (CN) 5, in Patient 25's room, Patient 25 was observed lying in bed, with her eyes closed, and the hospital bed alarm (devices that contains sensors that trigger an alarm when the patient tries to get out of bed) was not engaged (turned on and working). RN 4 and CN 5 validated the bed alarm was not engaged. RN 4 stated the facility practice for fall (an unintentional event that results in the person coming to rest on the ground or another lower level) risks patients include bed alarm being engaged.

During a concurrent interview and record review on 4/17/2024 at 3:50 p.m., with the Nursing Manager (NM) 1, Patient 25's fall risk assessment (FRA, a tool a health care provider uses to check to see how likely a patient will fall) titled "Hester Davis Fall Risk Assessment," dated 4/17/2024 at 8:30 a.m., the FRA indicated a total score of 28 (a score of 15 or greater means patient is a high risk for fall). NM 1 stated facility fall precautions include the bed alarms being engaged so the nurse will be notified that the patient is trying to get out of bed, and the nurse can intervene before the patient hurts him or herself.

During a review of Patient 25's nursing care plan (care plan, contains relevant information about a patient's diagnosis, the goals of treatment, and interventions to meet the goal) titled, "Adult Inpatient Plan of Care," dated 4/18/2024, the care plan indicated " ...Problem: HD (Hester Davis) Fall Risk Goal: Patient will remain as independent as possible. Patient will have lower fall risk, lower injury risk, and remain safe from falls and injury ...Intervention: High Fall Risk Interventions ... (Scores 15 or greater) ... bed alarm/mat while in bed ..."

During a review of the facility's policy and procedure (P&P) titled "Adult Falls Prevention Policy" dated 12/19/23, the P&P indicated " ...In-Patient Adult Units ... Scores greater than or equal to 15 High Risk: Implement ...bed/chair alarms ..."

5.b. During a concurrent observation and interview on 4/17/2024 at 11:27 a.m., with Registered Nurse (RN) 4 and Nursing Manager (NM) 2, in Patient 25's room, two fall mats (a safety pad placed on the floor beside the bed to prevent injuries resulting from falls [an unintentional event that results in the person coming to rest on the ground or another lower level]) were leaning against the wall near the doorway. NM 2 stated facility protocol is for fall mats to be placed on the floor on one or both sides of the patient's bed.

During a concurrent interview and record review on 4/17/2024 at 3:50 p.m., with NM 1, Patient 25's fall risk assessment (FRA - a tool a health care provider uses to check to see how likely a patient will fall) titled "[Trademarked Name] Fall Risk Assessment," dated 4/17/2024 at 8:30 a.m., the FRA indicated a total score of 28 (A score of 15 or greater means patient is a high risk for fall). NM 1 stated facility fall precautions include placing fall mats on one or both sides of the patient's bed to prevent further injury if the patient falls out of bed.

During a review of Patient 25's nursing care plan (care plan, contains relevant information about a patient's diagnosis, the goals of treatment, and interventions to meet the goal) titled "Adult Inpatient Plan of Care" dated 4/18/2024, the care plan indicated " ...Problem: [Trademarked name] Fall Risk Goal: Patient will remain as independent as possible. Patient will have lower fall risk, lower injury risk, and remain safe from falls and injury ...Intervention: High Fall Risk Interventions ... (Scores 15 or greater) ... bed alarm/mat while in bed ...place fall mats on one or both sides of the bed ..."

During a review of the facility's policy and procedure (P&P) titled, "Adult Falls Prevention Policy" dated 12/19/2023, the P&P indicated " ...In-Patient Adult Units ... Scores greater than or equal to 15 High Risk: Implement ...placement of floor mat ..."

Based on observation, interview, and record review, the facility failed to ensure one of 30 sampled patient's (Patient 24) antibiotic medication (Unasyn, an intravenous [administered through the vein] antibiotic used to treat an infection) was administered in a timely manner (one hour before or one hour after scheduled time) in accordance with the facility's policy and procedure regarding medication administration.

This deficient practice resulted in the delay of treatment for Patient 24 and had the potential to cause adverse health outcomes such as recurrent infection (infections that become severe and long lasting), etc.

Findings:

During a concurrent observation and interview on 4/17/2024, at 11:39 a.m., with the Registered Nurse (RN) 5, Patient 24 was observed in bed with his (Patient 24) eyes closed. RN 5 stated the patient (Patient 24) was admitted for hypernatremia (high sodium in the body) and failure to thrive (when an older adult has loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal).

During a review of Patient 24's "Internal Medicine History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/15/2024, the H&P indicated Patient 24 was admitted on 4/15/2024, and " ...presents to the hospital with 2 week history of progressively worsening generalized weakness and 2 day history of poor oral intake (food and/or beverage intake that is less than established referenced standards or recommendations based on physiological needs) and increasing confusion. His (Patient 24) wife present at bedside reports that he (Patient 24) barely ate or drank anything yesterday ... His lab (Laboratory) work was notable for ... white count 18.6 (white blood cell count - values greater than 11 indicate a possible infection) ... Aspiration Pneumonia, suspected (an inflammation and infection of the lungs or large airways. Occurs when food or liquid is breathed into the airways or lungs instead of being swallowed) ... continue IV Unasyn (ampicillin-sulbactam - an antibiotic used to treat an infection) ..."

During a concurrent interview and record review on 4/17/2024 at 2:35 p.m., with the Nursing Manager (NM) 1, Patient 24's Medication Administration Report (MAR) was reviewed. The MAR indicated a physician's order of Unasyn three grams (gm- unit of measurement) to be given intravenously (into the vein), every six hours. The MAR further indicated:

1. On 4/16/2024 at 3:07 p.m., indicated Patient 24 was administered Unasyn, three hours after the scheduled dose at 12:00 p.m.

2. On 4/17/2024 at 2:17 p.m., indicated Patient 24 was administered Unasyn, two hours after the scheduled dose at 12:00 p.m.

During an interview on 4/17/2024 at 2:35 p.m. with NM 1, NM 1 stated the facility protocol was to administer medications within a one-hour window before or after the scheduled due time. NM 1 further stated medications should be administered at the scheduled time to maintain a therapeutic level in the patient's body for the infection to not worsen.

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration and Documentation," revised on November 2023, the P&P indicated " ...In order to be considered timely, medications are administered up to sixty (60) minutes before or after the scheduled due time ..."

Based on interview and record review, the facility failed to ensure that a patient's complete and accurate information necessary to monitor patient's condition was documented in the patient's medical record for one of 30 sampled patients (Patient 1). The facility failed to document the following, as appropriate: Patient 1's gestational age (term used during pregnancy to describe how far along the pregnancy is), accurate and complete prenatal care history (medical care received during pregnancy), pain assessment upon admission to the facility, current medication updated record (medications the patient is presently taking including all prescriptions, over-the-counters, herbals and vitamin/mineral/dietary [nutritional] supplements, with each medication's name, dosage, frequency and administered route), and discharge diagnosis (the main reason of illness or condition due to which a patient was seen) is provided in Patient 1's "After Visit Summary" (AVS, is given to patients after medical evaluation to summarize their health and guide future care), and the record confirming all new prescriptions were transmitted to the pharmacy of choice.

This deficient practice had the potential to result in poor quality of care delivered to Patient 1 due to inadequate documentation of important information necessary to guide Patient 1's treatment plan and also had the potential to negatively affect Patient 1's outcomes after discharge from the facility.

Findings:

During a review of Patient 1's medical record (MR) titled "L&D Triage Evaluation," dated 3/6/2024, the MR indicated, Patient 1 arrived to Labor & Delivery Triage (L&D Triage is a specialized area that involves assessing pregnant women of 20 and above weeks of gestation [pregnancy], labor condition and fetal [unborn baby] well-being and preparing tests and interventions for obstetric [relating to childbirth] problems), complaining of regular uterine contractions (tightening and shortening of the uterine muscles). The MR further indicated, primary nurse documented, "Unknown" gestational age (term used during pregnancy to describe how far along the pregnancy is) of Patient 1's pregnancy. The MR also indicated, primary nurse documented Patient 1 does prenatal care (medical care received during pregnancy and record of, if any, complications associated with the pregnancy, medical provider's information and address) outside of the facility, no records available, and has history of diabetes (high blood sugar) controlled with diet and Metformin (medication used to control high blood sugar).

During a review of Patient 1's medical record titled, "Medication History List," dated 3/6/2024, the MR indicated, on 3/6/2024, the primary nurse marked as "reviewed" Patient 1's medication record (Medications the patient is presently taking including all prescriptions, over-the-counters, herbals and vitamin/mineral/dietary [nutritional] supplements with each medication's name, dosage, frequency and administered route), but did not document Metformin in Patient 1's current medication list and did not indicate which medications Patient 1 was currently taking or not taking.

During further review of Patient 1's medical record (MR), no information of Patient 1's prenatal care history (medical care received during pregnancy and record of, if any, complications associated with the pregnancy, medical provider's information and address) was recorded in Patient 1's medical chart.

During an interview on 4/16/2024 at 9:22 a.m., with L&D manager (L&DM) and registered nurse (RN) 2, L&DM stated, if a patient is not the facility's organization member, primary nurse should attempt to obtain medical records to establish patient's prenatal history. Likewise, RN 2 said, primary nurse shall obtain a detailed medical history, conduct patient's initial assessment, and document the findings in patient's medical chart.

During a concurrent interview and record review, on 4/16/2024 at 9:22 a.m., with L&DM, Patient 1's "Prior-to-Admission (PTA) Medications" list and nursing initial assessment, dated 3/6/2024, was reviewed. The record indicated, primary nurse did not document Metformin (medication to help lower blood sugar) in Patient 1's PTA Medication record and Patient 1's gestational age was documented as "unknown." L&DM stated, all current medications taken by the patient should be reviewed by the primary nurse during the initial assessment and documented in a medical record as "taking" or "not taking." L&DM further stated, Patient 1's gestational age should also be documented by the primary nurse, but the primary nurse did not.

During a record review of Patient 1's medical record (MR) titled, "Nursing Flowsheet (integrated tool developed to help clinicians document patient data in a grid-like format)," dated 3/6/2024, the MR indicated, primary nurse did not record Patient 1's initial pain assessment.

During an interview on 4/16/2024, at 3:40 p.m., with RN 2, RN 2 stated, initial pain assessment should be done upon admission, especially if a patient presents with contractions. In the case of Patient 1, RN 2 verified that there was no documentation of Patient 1's initial pain assessment upon arrival to the facility.

During an interview on 4/16/2024, at 3:40 p.m., with the Regional Director, Maternal/Child Health (RDMCH), RDMCH stated, primary nurse should obtain a baseline (an initial measurement of a condition that is taken at an early point and used for comparison over time to look for changes) pain assessment on admission and carry out interventions (action taken to improve the situation) based on initial findings (results).

During a concurrent interview and record review on 4/17/2024, at 8:55 a.m., with Patient 1's primary nurse, (RN 3), Patient 1's MR titled, "Nursing Flowsheet," dated 3/6/2024, was reviewed. RN 3 stated, Patient 1's initial pain assessment was not documented on 3/6/2024 and RN 3 said the standard practice was to document pain assessment, but RN 3 was unsure as to why the assessment for Patient 1 was not documented and stated, that, maybe, there was no time to document. RN 3 also stated, typically, primary nurses don't document patient's gestational age, but primary nurses shall document patient's medical history, prenatal care, and chart current medications and mark the medication list as "reviewed." In the case of Patient 1, RN 3 confirmed that these information (prenatal care, current medication, marking medication list as "reviewed") were not documented in Patient 1's medical chart.

During a review of Patient 1's MR titled, "L&D Triage Evaluation," dated 3/6/2024, the MR indicated, Patient 1 presented to the facility complaining of regular uterine contraction. The MR further indicated, physician documented Patient 1 was 24 weeks and 4 days pregnant with twins, as per patient report, had preterm uterine contractions (preterm uterine contractions can cause premature labor) with no evidence of preterm labor (occurs when regular contractions results in the opening of cervix [narrow end of the womb] after week 20 and before week 37 of pregnancy), and was diagnosed with bacterial vaginosis (a condition as a result of imbalance of "good" and "harmful" bacteria in a vagina, and if left untreated is associated with an increased risk of preterm labor).

During further review of the MR, dated 3/6/2024, the MR indicated, physician documented the plan for Patient 1 was to be discharged home with a new prescription for an antibiotic, Flagyl (used to treat an infection) 500 milligrams (mg, measuring unit) to be taken orally, twice a day for 7 days and a follow up with primary obstetrician (a physician specializing in caring for mothers and babies during pregnancy) on 3/8/2024. The MR contained no record of how and when the new prescription for Flagyl 500 mg was sent to Patient 1's pharmacy of choice.

During a review of Patient's 1 MR titled, "After Visit Summary," (AVS) dated 3/6/2024-3/7/2024, the MR indicated, Patient 1's medication list was not reviewed, no diagnosis of bacterial vaginosis was recorded, no documentation of new prescription provided to Patient 1 was documented, no instructions for a follow up with primary obstetrician in two days were documented in the AVS record or provided to Patient 1 prior to leaving the facility.

During an interview on 4/16/2024 at 3:40 p.m. with the Director of Perinatal Services (DPNS), DPNS stated, all prescribed medications shall be included as provided in AVS record space for a patient's education.

During an interview on 4/17/2024 at 8:53 a.m. with Patient 1's primary nurse (RN 3), RN 3 stated, on 3/7/2024, RN 3 provided Patient 1 with a printed copy of AVS. RN 3 stated, there was no documentation of Patient 1's diagnosis of bacterial vaginosis in the AVS copy provided to Patient 1 but should have been documented. RN 3 said, Flagyl 500 mg (medication prescribed to Patient 1 for bacterial vaginosis) education was verbally provided to Patient 1 prior to departure, but RN 3 did not document in Patient 1's AVS record that Patient 1 was prescribed Flagyl 500 mg for bacterial vaginosis. RN 3 further stated, per facility's policy, physicians don't give out physical prescriptions to patients anymore, and the physician was responsible for calling in the prescription to Patient 1's pharmacy of choice. RN 3 also stated, RN 3 did not know if the prescription for Flagyl 500 mg was called in and to what pharmacy.

During an interview on 4/17/2024 at 2:54 p.m., with the Clinical Director of Emergency Department (CDED), CDED stated, the facility's discharge process includes providing patients with After Visit Summary (AVS) which shall indicate the reason for being seen and a diagnosis specific to patient's condition. CDED further stated, the AVS record shall include current medications which should be reviewed prior to departure, and all new prescriptions, if ordered by physician. CDED also stated, follow up care instructions shall be recorded in the AVS and a hard copy of AVS is provided to the patient before departure.

During an interview on 4/19/2024 at 8:31 a.m. with Risk and Safety Medical Director (MD2), MD 2 stated, per facility's policy, physicians do not give physical prescriptions to patients prior to discharge. MD 2 further stated, if a patient is the facility's organization member, all prescriptions can be routed to the facility's pharmacy that is open 24 hours a day, but if a patient is not the facility's organization member, new prescriptions must be called in to the pharmacy of patient's preference. MD 2 also stated, per facility's protocol, the expectation for all physicians, prescribing a new medication, is to document the information into the patient's medical record, such as when and where the prescription was called to.

During a concurrent interview and record review on 4/19/2024 at 8:31 a.m. with MD 2, Patient 1's AVS record, dated 3/7/2024 was reviewed. Patient 1's AVS record contained no information where and when was Flagyl 500 mg prescription for Patient 1 was called to. MD 2 stated, there was no documentation of Flagyl 500 mg being called in to a pharmacy and stated, the physicians are expected to document this information in patient's medical record, but the physician who discharged Patient 1 did not.

During a review of the facility's policy and procedure (P&P) titled, "Registration/assessment/Admission for Labor and Delivery," dated 04/2022, the P&P indicated, triage RN will be accountable to obtain patient information. The RN will record patient's vital signs and pain level and document in electronic patient care record and will enter all information and review patient information in electronic medical record-OB Nursing Navigator: Observation.

During a review of the facility's policy and procedure (P&P) titled, "Evaluation of Obstetrical Outpatients by Registered Nurses (RNs) in Triage/Labor and Delivery," dated 11/2023, the P&P indicated, "Evaluation of obstetrical patients by RN in the Triage/labor and Delivery units in order to facilitate appropriate disposition includes performing and documenting the following assessments: reviewing chart, including history and gestational age by assessing chief complaint including onset, duration, precipitation factors, current medications, and relevant signs and symptoms. Obstetrical history including complications of pregnancy, gravida, parity, and previous labor experience, gestational age, including last menstrual period and expected date of confinement (childbirth), maternal vital signs, including temperature, respiratory rate, blood pressure, and pain level.

During a review of the facility's policy and procedure (P&P) titled, " Medication Reconciliation across the Continuum of Care," dated 5/2023, the P&P indicated, " All patients presenting for emergency care, for inpatient admission or for performance of a procedure must have a complete list of medications created as a part of the initial assessment with input from the patient/significant other. The patient's past medical records and admission orders shall be reviewed to screen for omissions, discrepancies, and adverse drug interactions. The medication list must include the patient's current medications, including vitamins, over-the-counter medications. Medication reconciliation must occur as soon as possible to meet patient safety standards per Medical Center policy.

During a review of the facility's policy and procedure (P&P) titled, "Medication Reconciliation across the Continuum of Care," dated 5/2023, the P&P indicated, "Medication reconciliation must occur at the time of discharge or exit from the organization. A) A complete list of medication that the patient is to be taking following discharge shall be developed and reconciled. B) the discharge list shall include not only the medications that are prescribed at the time of discharge, but any other medications the patient will be taking, including over the counter medications, vitamins, etc. C) A copy of discharge medication list, along with the discharge instructions, must be given to the patient at the time of discharge with patient-friendly instructions. E) IF a patient is to be treated by a health care provider outside of the organization, the discharging provider/designee will print the appropriate report and if the identity of the provider is unknown, the list of medications shall be given to the patient so he/she can present it to the provider at their follow-up appointment.

During a review of the facility's policy and procedure (P&P) titled, "Medication Reconciliation across the Continuum of Care," dated 5/2023, the P&P indicated, " At the time of discharge, RN is responsible to ensure to confirm the correct pharmacy with the patient/family and that patient/family has all needed prescriptions and transmitted order to the pharmacy. For patients receiving care in the outpatient or emergency department setting, based within the hospital, an After Visit Summary (AVS) will be provided instead of discharge instructions.

During a review of the facility's policy and procedure (P&P) titled, "Medication Reconciliation across the Continuum of Care," dated 5/2023, the P&P indicated, "The physician must review and sign all orders. For patients who will be using non-facility's pharmacy to fill prescriptions, print a hard copy of the prescriptions and authorize them with signature. If the patient is being discharged home, copy Discharge Medication list from discharge summary to discharge instructions. The discharge medication list shall include not only the medications that are prescribed, but any other medications the patient will be taking, including over-the counter medications, vitamins, etc."