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Based on interview and record review, the hospital failed to allow family visitation of minor children under 12 years old when there was a previous exception made for minors under 12 years old to visit on 5/15/24 and no reason was given to justify the decision for the denial of visitation on 6/16/24 for one of three sampled patients (Pt) 3, in accordance with the hospital's policy and procedures (P&P) .

This failure resulted in Pt 3 to feel upset when he was not able to receive visitation on 6/16/2024 (Father's Day) from his family which had the potential to affect Pt 3's psychological well-being.

Findings:

During an interview on 6/17/24 at 3:33 p.m. with Family Member (FM) 1, FM 1 stated on 6/16/24 which was Father's day, FM 1 spoke to House Supervisor (HS) 1 and had requested to visit Pt 3 with children who were under 12 years old. FM 1 stated there had been an exception made on 5/15/24 for the minor children to visit Pt 3 previously. FM 1 stated after she asked HS 1 if an exception could be made as it was Father's day, HS 1 put her on hold and when HS 1 came back on the line, he stated Charge Nurse (CN) 1 said no, therefore his answer was no. FM 1 stated she was not given a reason why her request was denied and was upset her children could not visit Pt 3.

During a review of Pt 3's "Visitation Log (Log)," dated 5/15/24, the Log indicated Pt 3 had seven visitors on 5/15/24. The Log indicated, three visitors visited at various times after 10 a.m. in the morning and around 5:30 p.m., four different visitors checked in within minutes of each other to visit Pt 3.

During a concurrent interview and record review on 6/19/24 at 11:25 a.m. with Registered Nurse Quality (RNQ) 1 and RNQ 5 present, Pt 3's History and Physical (H&P-the complete assessment of a patient and their health problem(s)), dated 5/29/24 was reviewed. The H&P indicated, " ...[Brought in by ambulance] from [name of long term care facility], receiving [intravenous (IV-in the vein)] fluids today, [patient] pulled IV out staff unable to insert new IV, [patient] having limited water and food intake. Altered mental status [times] 2 days ...History of present illness ...[history of] methamphetamine [a highly addictive drug that lets people stay awake for a long period of time] and heroin [a highly addictive and rapidly acting drug derived from a certain poppy plant] dependence, alcohol dependence, [coronary artery disease-blood vessels that carry blood and oxygen to the heart cannot deliver enough oxygen-rich blood to the heart] status post [coronary artery bypass grafting-heart bypass surgery, a medical procedure to improve blood flow to the heart] ...He was transferred to [name of hospital] [emergency room] due to concern for dehydration ..."

During an interview on 6/21/24 at 10 a.m. with Registered Nurse (RN) 3, RN 3 stated visitation was from 10 a.m. to 10 p.m. and sometimes they were able to make exceptions if the family needed to visit sooner than 10 a.m. RN 3 stated the security at the front desk could call the department and ask if the family could visit outside of the normal visiting hours. RN 3 stated the age requirement for visitation was 12 years old and up. RN 3 stated exceptions for minor children and for possible end of life visitations was up to each department's discretion.

During an interview on 6/21/24 at 10:45 a.m. with the Chief Nursing Officer (CNO), the CNO stated patients were allowed two visitors on the inpatient side and one visitor in the Emergency Department (ED) but depending on the situation there could be exceptions made on a case-by-case basis. The CNO stated, "Hospital leadership encouraged nurses to step out of their box and work with patients and family." The CNO stated if a child under 13 years old was allowed to visit previously, nurses needed to set up the expectations for visitation and follow through with communication. The CNO stated, "The importance of visitation for patients was literature showed when family were engaged in the patient's care, from the mental and physical standpoint, the patient progressed in their care." The CNO stated, "Family are the ones caring for the patients when they are discharged so it was a prime time to teach family during the visits." The CNO stated HS 1 should have called her or the Administrator, they could have stopped the line and assisted with the family's request.

During a review of the hospital's P&P titled, "PC.AD.1.37 Visitor Policy," dated 9/27/23, the P&P indicated, " ...Visitors play a vital role in our patients' wellbeing as well as assisting in their recovery. The purpose of the Visitor Policy is to ...Ensure patient safety and highest quality of care is provided ...Ensure patients and their families or domestic partners are involved in their care, care planning and decision making as appropriate ...Promote patient/family centered care ...Improve patient and family satisfaction ...Patients have the right to receive visitors and designated person to support them while receiving care at [name of hospital] ...does not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, sexual orientation, gender identity, or disability. Visitation may be delayed, altered, or refused based on the care needs of individual patients as deemed appropriate through agreement between the patient's nurse and physician ...Two (2) visitors per patient can be accommodated at one time ...Inpatient visiting hours are from to 10:00am-10:00pm ...Children/minors age 12 or greater may visit a patient if they are accompanied and supervised by an adult ...reserves the right to impose age restriction visitation as recommended by the Medical Directors of [name of county] County during the flu season and other epidemics. Decisions to restrict or limit presence must be discussed with the patient ..."

During a review of the hospital's document titled, "Patients Rights," dated 9/2014, the document indicated, "You have the right to ...Designate a support person and visitors of your choosing, if you have decision-making capacity, whether or not the visitor is related by blood, marriage, or registered domestic partner status, unless ... No visitors are allowed ...a health facility may establish reasonable restrictions upon visitation, including restrictions upon the hours of visitation and number of visitors. The health facility must inform you (or your support person, where appropriate) of your visitation rights, including any clinical restrictions or limitations. The health facility is not permitted to restrict, limit, or otherwise deny visitation privileges on the basis of race, color, natural origin, religion, sex, gender identity, sexual orientation, or disability ...Have your wishes considered, if you lack decision-making capacity, for the purposes of determining who may visit. The method of that consideration will comply with federal law and be disclosed in the hospital policy on visitation. At a minimum, the hospital shall include any persons living in your household and any support person pursuant to federal law ..."

During a review of a professional resource from Front Public Health, an article titled, "An integrated review: connecting Covid-era hospital visiting policies to family engagement," dated 9/2023, the article indicated, " ...Family engagement has been identified as a construct that is vitally important to successful outcomes for patients, families, providers, hospitals, and communities. Hospitals often are the setting of new or worsening diagnoses for older and seriously ill patients. Family, as defined by the patient, refers to a trusted individual or group of individuals and does not necessarily reflect a legal relationship. Family engagement improves healthcare quality and safety and, therefore, patient outcomes in the hospital ...In addition to improving health outcomes for the patient, family engagement also benefits the hospital. Families provide information, context, care coordination, and help with the transition home ...Family engagement decreases readmission rates ...and reduces overall healthcare utilization ...increasing visitation times can lead to a positive effect on the patient's physiological parameters ...Policies restricting family presence may lead to longer [intensive care unit] stays and delay decisions to limit treatment prior death ...Inconsistent visitor policies contribute to health inequities among minority older adults with limited English proficiency ..."

Based on interview and record review, the hospital failed to ensure medical staff followed Medical Staff Bylaws, Rules and Regulations for one of two Anesthesiologist (Anesthesia A) when Anesthesia A did not meet facility requirements for proctoring and administered General anesthesia instead of Spinal anesthesia to Patient 4.

This failure resulted in Patient (Pt) 4 being administered General Anesthesia (a method of medically inducing loss of consciousness that renders a patient unrousable even with painful stimuli) instead of a Spinal Anesthesia (a technique where a local anesthetic is placed directly in the intrathecal space in the spine) while undergoing a total right hip arthroplasty (the surgical reconstruction or replacement of a joint).

Findings:

During a review of Pt 4's "History and Physical (H&P)," dated 5/29/2024, Pt 4's H&P indicated Pt 4 had diagnoses which included type 2 diabetes (is a disease in which blood glucose, or blood sugar, levels are too high), coronary artery disease ( is a type of heart disease where the arteries of the heart cannot deliver enough oxygen-rich blood to the heart), status post myocardial infarction (heart attack) with stent placement (is a tiny wire mesh tube that keeps an artery propped open to increase blood flow to the heart) and aortic valve replacement (is a surgery to replace a poorly working aortic valve with an artificial valve). Pt 4's surgical consent signed by the patient on 5/29/2024 indicated, "... Total hip (right) arthroplasty... Pt 4's consent for anesthesia, signed by the patient on 5/29/2024 consented to the following... General anesthesia, spinal anesthesia, regional block..."

During an interview on 6/20/2024, at 4:47 p.m. with Pt 4's surgeon (MD 1), MD 1 stated he likes to use spinal and regional blocks (local anesthetics are applied to a targeted set of nerves to block sensation and movement) for anesthesia because they "were good for patient recovery." MD 1 recommended to anesthesiologist (Anesthesia A) to administer a spinal anesthesia to Pt 4 because of Pt 4's "high risk" cardiac history. Anesthesia A made two to three unsuccessful attempts to insert the spinal anesthetic and instead had to administer a general anesthetic. MD 1 stated Anesthesia A was frequently not at the head of the table monitoring the patient's status and pain level. MD 1 stated Anesthesia A was "walking around the Operating Room" MD 1 stated when Pt 4 started to move on the table during surgery, he yelled to Anesthesia A "what are you doing" as Anesthesia A ran back to the head of the table to give additional medication. MD 1 stated Anesthesia A told him he would administer a regional block (to provide more post-op pain control) to Pt 4 because of his inability to provide spinal anesthesia. The regional block was never administered.

During an interview on 6/19/2024, at 3:17 p.m., with the Circulating Nurse RN (ORN 1), ORN 1 stated she remembered Pt 4's surgery because of the special orthopedic instrumentation used during surgery. ORN 1 stated Anesthesia A attempted to insert the spinal anesthesia three to four times with all attempts unsuccessful.

During a concurrent interview and record review on 6/19/2024 at 3 p.m., with the Director of the Medical Staff (DMS) on on 6/19/2024 at 3:00 p.m., the DMS reviewed Anesthesia A's Medical Staff file. The DMS stated Anesthesia A applied for privileges in 2022, left for a few months after privileges were granted and was re-instated in 2023. The DMS was unable to find any documentation to support Anesthesia A had participated in any proctoring, concurrent or retrospective, or if proctoring was waived. The DMS stated, "He fell through the cracks." The DMS stated all physicians and allied health professionals must make an application to be a member of the Medical Staff and must follow the requirements which required proctoring.

During a review of a review the Anesthesia Record dated 5/29/2024 specific to Pt 4's surgical procedure, the surgery started at 13:05 pm, and ended at 15:35 pm. Anesthesia A documented "attempted spinal anesthesia X 3." No documentation that a Regional Block had been attempted or administered to Pt 4.

During review of the facility's current policy and procedure (P&P) titled, "Medical Staff Rules and Regulations", "Proctorship", dated 2/23/2022, the P&P indicated, "... All practitioners granted appropriate membership and privileges by the Governing Board at this facility shall be proctored regardless of board certification and/or prior experience. Proctorship shall be for a period specified according to specialty requirements. Proctored cases from other facilities may be considered under department chairman's review. 1-a. Anesthesia proctor requirements: first three (3) cases including craniotomy, epidural, c-section and spinal anesthesia. A total of ten (10) cases must be completed within twelve (12) months of appointment..."

Based on interview and record review the facility failed to follow its policy titled, "Documentation Policy" for one of twelve patients (Patient (Pt) 2) when Pt 2 had a change in condition (COC- clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. "Clinically important" means a deviation that, without intervention, may result in complications or death) that required a doctor to be contacted and this was not done.

This failure resulted in Pt 2 not having her COC addressed timely and had the potential to result in Pt 2's medical condition to declined, which resulted in Pt 2 to be moved to the Intensive Care Unit (ICU- higher level of care for more critical patients).

Findings:

During a review of Pt 2's Admission Record (AR), dated 4/15/24, the AR indicated Pt 2 was admitted on 4/8/24 at 5:43 p.m. and discharged on 4/12/24 at 11:59 p.m. Pt's 2's AR indicated Pt 2 was a 56 year old female with a chief complaint of ESRD (End Stage Renal Disease- a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) on dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly).

During a review of Pt 2's History and Physical (H&P), dated 4/12/24, the H&P indicated Pt 2's "CHIEF COMPLAINT: Rectal pain/Weakness HISTORY OF PRESENT ILLNESS: 56-year-old female with past medical history of hypertension (high blood pressure), COPD (Chronic obstructive pulmonary disease is a chronic inflammatory lung disease that causes obstructed airflow from the lungs- oxygen levels 89-91% are normal for patients with COPD), PTSD (Post-traumatic stress disorder is a mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it), diabetes mellitus (DM- a disease of inadequate control of blood levels of glucose), ESRD on HD (Hemodialysis) MWF (Monday, Wednesday, Friday), missed her session on Monday, recurrent abscesses (occur when an area of tissue becomes infected and the body's immune system tries to fight and contain it), who initially presented for evaluation of weakness and rectal pain. Has not been compliant with her home medications. This morning at approximately 1150, while eating lunch, patient's oxygen requirements went up to 5 L (Liters-unit of measurement), sudden ALOC (altered level of consciousness) although per daughter, patient had been encephalopathic (appears confused, memory loss, personality changes) throughout the day. Rapid Response was called over head for unresponsiveness (not reacting to anyone). On BVM (bag valve mask- device that provides air to the patient) in route to ICU and hypotensive (low blood pressure), bradycardic (heart rate) in 40s, intubated (tube place in one's mouth to secure patient's airway is open and secured) and started on dopamine (medication- used to treat low blood pressure, low heart rate, and cardiac arrest). CODE STROKE (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts) was initially activated but subsequently cancelled as she is moving all extremities, no obvious focal deficits and PERRL (pupils are equal, round and react to light) ..."

During a concurrent interview and record review on 6/21/24, at 8:15 a.m., with Registered Nurse (RN) 2 and Shift Manager (SM) 1, Pt 2's electronic medical record (EMR) for her admission starting 4/8/24 was reviewed. RN 2 stated she did not recall Pt 2 but was Pt 2's nurse on the night 4/11/24 and the morning of 4/12/24. RN 2 stated she believes she incorrectly documented Pt 2's vital signs at 8:57 p.m. on 4/11/24 when she typed in heart rate (HR) 123 and blood pressure (BP) of 56/60, she stated she would not have given any of her medications if this was accurate, she believed it should have been a BP of 123/56 and HR 60. RN 2 reviewed her note dated 4/12/24, at 5:53 a.m. which indicated Pt 2 had confusion and "Pt sees ants on the wall". RN 2 stated Pt 2's baseline earlier in her shift on 4/11/24 patient was alert and oriented and was not seeing anything and after reviewing Pt 2's EMR Pt 2 had not had any confusion since admission on 4/8/24. RN 2 stated she was not quite sure why she placed Pt 2 on 5 liters nasal canula for oxygen around the same time as the confusion (no nursing note to explain this increase in oxygen). RN 2 stated she would consider this a change of condition (COC) since it was not her baseline but did not call the doctor. RN 2 stated when there is a COC she would notify the doctor, would worry the patient might be septic (widespread infection) and the doctor would have come and assessed the patient. SM 1 stated Pt 2 seeing things and needing her oxygen increased should have been considered a COC and a doctor should have been called.

During a review of the flowsheet for Pt 2's vital signs dated 4/11/24 at 7 a.m. to 4/12/24 9 p.m., the flowsheet indicated on 4/11/24 at 8:57 p.m. BP 56/60, HR 123; on 4/12/24 at 4 a.m. BP 135/72, HR 52, 91 % oxygen (O2) saturation (sats) on nasal cannula (number of liters not documented note on 4/11/24 at 8:31 p.m. Pt 2 was on 2 Liters (L) nasal cannula (NC)); 4/12/24 at 4:59 a.m. 91% O2 sats on 5 L NC; on 4/12/24 at 6:05 p.m. Pt 2 is 91% on 10 L oxygen mask.

During a review of the hospital's policy and procedure titled, "PC.AD.1.08 Documentation Policy," date approved 9/28/22, indicated, "I. SCOPE: This policy applies to [name of hospital] and [name of behavioral center associated with hospital]. This policy applies to any department providing patient care. II. PURPOSE: To outline responsibilities related to documentation of patient care from admission through discharge. III. POLICY: ... the patient medical record reflects the complete picture of the patient's health status, treatment, and progress from admission to discharge from which other health professionals can take over responsibility for the patient concerned ... 1. All Medical Record entries should be made as soon as possible after the care is provided, or an event or observation is made ... 3. Charting by exception is to be utilized as a method of charting designed to minimize clerical activities; a notation (annotation) is made only when there is a deviation from the baseline or expected outcome ... 10 ... g. Changes in patient condition are documented within the appropriate EHR system review; along with physician notifications ... Appendix A: ICU Documentation Protocol ... Reassessment is ongoing, based on patient condition ... as needed for significant changes from previous assessment, and per physician's orders ... Examples of significant changes in condition that require a focused reassessment include (not an all inclusive list) Neuro Change in neuro status Resp Significant drop in O2 saturation ... CV Significant drop/increase in BP/HR/hemodynamics ... For new and/or abnormal findings, chart the finding, intervention, and response (if applicable) ..."

Based on interview and record review the hospital failed to ensure medications were administered in accordance with professional standards of practice for one of 12 sampled patients (Patient (Pt) 2), when Pt 2 was ordered Propranolol (blood pressure medication, a medication that lowers one's blood pressure and heart rate) without blood pressure parameters for administration. Registered Nurse (RN) 2 administered Pt 2 Propranolol when Pt 2's blood pressure was not within normal limits (blood pressure (BP) 90-140 on top; 60-90 on bottom; heart rate (HR) 60-100).

This failure contributed to Pt 2's blood pressure and heart rate to drop which resulted in Pt 2 to become unresponsive and had to be transferred to the intensive care unit (ICU- higher level of care).

Findings:

During a review of Pt 2's Admission Record (AR), dated 4/15/24, the AR indicated Pt was admitted on 4/8/24 at 5:43 p.m. and discharged on 4/12/24 at 11:59 p.m. Pt's 2's AR indicated Pt 2 was a 56 year old female with a chief complaint of ESRD (End Stage Renal Disease- a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) on dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly).

During a review of Pt 2's History and Physical (H&P), dated 4/12/24, the H&P indicated Pt 2's "CHIEF COMPLAINT: Rectal pain/Weakness HISTORY OF PRESENT ILLNESS: 56-year-old female with past medical history of hypertension (high blood pressure), COPD (Chronic obstructive pulmonary disease is a chronic inflammatory lung disease that causes obstructed airflow from the lungs), PTSD (Post-traumatic stress disorder is a mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it), diabetes mellitus (DM- a disease of inadequate control of blood levels of glucose), ESRD on HD (Hemodialysis) MWF (Monday, Wednesday, Friday), missed her session on Monday, recurrent abscesses (occur when an area of tissue becomes infected and the body's immune system tries to fight and contain it), who initially presented for evaluation of weakness and rectal pain. Has not been compliant with her home medications. This morning at approximately 1150, while eating lunch, patient's oxygen requirements went up to 5 L (Liters-unit of measurement), sudden ALOC (altered level of consciousness) although per daughter, patient had been encephalopathic (appears confused, memory loss, personality changes) throughout the day. Rapid Response was called over head for unresponsiveness (not reacting to anyone). On BVM (bag valve mask- device that provides air to the patient) en route to ICU and hypotensive (low blood pressure), bradycardic (heart rate) in 40s, intubated (tube place in one's mouth to secure patient's airway is open and secured) and started on dopamine (medication- used to treat low blood pressure, low heart rate, and cardiac arrest). CODE STROKE (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts) was initially activated but subsequently cancelled as she is moving all extremities, no obvious focal deficits and PERRL (pupils are equal, round and react to light) ..."

During a concurrent interview and record review on 6/20/24, at 3 p.m., with Registered Nurse (RN) 1, Pt 2's Electronic health records (EHR) for her admission starting 4/8/24 were reviewed. RN 1 stated he was Pt 2's day nurse on 4/12/24, RN 1 confirmed Pt 2 had an order for Propranolol (blood pressure medication) 20 mg (milligrams- unit of measurement) to be given twice daily and Methadone (scheduled II opioid analgesic, used for severe pain, and has high risk of abuse and addiction) 145 mg once daily. RN 1 stated vital signs at the beginning of his shift were BP 115/54, HR 52 and he did give Pt 2 her Propranolol and Pt 2's Methadone at 9:32 a.m. and he remembers Pt 2 was stable at that time. RN 1 stated around lunch time the family came and tried to feed her and he was waved down by the daughter and when he entered the room Pt 2 was not responsive and he called for a rapid response. Pt 2's EMRs indicated the next set of vs at 1:15 p.m. on 4/12/24 where BP was 78/26, HR 43, RR 14, RN 1 stated looking back at Pt 2's vital signs prior to giving the propranolol and methadone he should have held the medications and called the doctor. RN 1 stated usually there are parameters on the blood pressure medications and knew they could affect her blood pressure and her heart rate.

During a concurrent interview and record review on 6/21/24, at 8:20 a.m. with the Shift Manager (SM) 1for Medical Surgical floor, Pt 2's EMR for her admission starting 4/8/24 was reviewed. SM 1 stated Pt 2's Propranolol should not have been given if her HR was below 60 and the nurse should have contacted the doctor to see what the doctor wanted done.

During a concurrent interview and record review on 6/21/24, at 9:47 a.m., with the Director of Pharmacy (DOP), Pt 2's medication order for Propranolol and Pt 2's vital signs were reviewed for Pt 2's hospital stay starting 4/8/24. The DOP stated the order for Propranolol did not have parameters and the physician would be the one to request parameters be placed on this order. The DOP stated not all blood pressure medications will have parameters. The DOP stated when a medication is sent to the pharmacy as an order, it is reviewed by a pharmacist, they look at the home medication list, compare the name and dosage but do not look to see if the patient is still currently taking it or not. The DOP stated Propranolol affects the blood pressure and heart rate and both should be monitored and checked prior to giving this medication. The DOP stated if the HR is below 60 the nurse should contact the MD to see if the medication should be held or discontinued but not to give it until this is clarified with the MD. The DOP stated the hospital uses Lexicomp and when Propranolol is typed there is no black box warning, but the DOP knows there should be a black box warning (the most serious warning the food and drug administration can give for a medication) because it is a betablocker and stopping abruptly can cause heart issues.

During an interview on 6/21/24, at 10:46 a.m., with the Chief Nursing Officer (CNO), the CNO stated, "I don't think we set our nurses up for success, there was not a parameter on when to give or hold (referring to the giving of Propranolol)". The CNO stated she thinks the nurse should have known no to give this medication based on Pt 2's vital signs (BP 115/54, HR 52). The CNO stated, "I don't know that the cause of the drop in Pt 2's BP was due to this medication, but it definitely could have been or a cumulative effect" of the medications she was taking.

Review of a professional referenced titled, "Medscape", dated 2024 the following medication was reviewed and Medscape indicated, "Propranolol ... Indicated for management of hypertension ... Monitor Closely ... (with) insulin lispro ... Use Caution/Monitor: Non selective beta blockers delay recovery of normoglycemia after insulin induced hypoglycemia; however they also inhibit insulin secretion, so long term beta blocker Tx may result in reduced glucose tolerance ... Adverse Effects ... Bradycardia Hypotension ... Hyper/hypoglycemia ... Respiratory Distress ... Warnings Contraindications Asthma, COPD, Severe sinus bradycardia or 2/3 heart block ... Uncompensated congestive heart failure ... Cautions ... Use caution in bronchospastic disease, cerebrovascular insufficiency, congestive heart failure, diabetes mellitus, hyperthyroidism/thyrotoxicosis, liver disease, renal impairment, peripheral vascular disease ... May worsen bradycardia or hypotension; monitor HR and BP ... Mechanism of Action ... inhibition results in decreases in heart rate, myocardial contractility, myocardial oxygen demand, and blood pressure..."

Review of a professional referenced titled, "Medscape", dated 2024 the following medication was reviewed and Medscape indicated, "Methadone ... Classes: Opioid Analgesics ... Schedule II ... Pain Management Indicated for the management of pain severe enough to require daily, around-the-clock, long-term opioid treatment and for which alternative treatment options are inadequate ... Adverse Effects ... Bradycardia, Cardiac arrest, coma ... Myocardial infarction ... Respiratory arrest, Respiratory/Circulatory depression ... Sedation ... Mechanism of Action Narcotic agonist-analgesic of opiate receptors; inhibits ascending pain pathways, thus altering perception and response to pain; produces analgesia, respiratory depression, and sedation ... Cautions ... Serious, life-threatening, or fatal respiratory depression reported (see Black Box Warnings) ..."

Review of a professional reference titled, "National Library of Medicine (NIH)" an article titled, "Nursing Rights of Medication Administration," dated 9/4/23, retrieved from https://www.ncbi.nlm.nih.gov/books/NBK560654/ indicated, " ... Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration.[1] It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. These 'rights' came into being during an era in medicine in which the precedent was that an error committed by a provider was that provider's sole responsibility and patients did not have as much involvement in their own care.[2] The five traditional rights in the traditional sequence include: 'Right patient' ... 'Right drug' ... 'Right Route' - Medications can be given to patients in many different ways, all of which vary in the time it takes to absorb the chemical, time it takes for the drug to act, and potential side-effects based on the mode of administration ... It is crucial that nurses remain educated and up to date on newer medications or less commonly administered medications to learn how they are safely delivered to patients before being asked to do so in clinical practice. Additionally, nurses must have at least a minimal basic understanding of the physiology influencing drug absorption rates and time of drug onset, as these principles relate to medication administration ... 'Right time' ... 'Right dose' ... Medical errors are a reality that will inevitably occur, as nurses, patients, and medical personnel are human and, therefore, prone to error. Examples of human error are lack of medical knowledge, lack of attention to detail or care, failing to verify information in an effort to save time, disorganization of workplace or supplies, and miscommunication among healthcare professionals or with a patient. While human nature does account for the majority of circumstances that may incite potential for medication administration errors, administrative or environment-related errors may also explain ADEs, such as lack of labeling or inadequate labeling systems or overwhelming workload with limited staffing.[3] Errors are usually multifaceted and can occur at any point within the complex process of medication administration ... Patient safety and quality of care are essential components of nursing practice and priorities that demand consideration to enable the delivery of high-quality, patient-centered care, and overall well-being. Medical errors are unfortunately very common in clinical practice, and in addition to compromising a patient's personal safety, they can also be extremely costly for hospitals. ADEs qualify as unintended injuries or insults directly related to medical interventions involving a drug resulting in disability at discharge, death, or extended hospital stay that is the result of health care management rather than by the patient's underlying disease process.[5]..."

Based on observation, interview, and record review, the hospital failed to maintain a clean and sanitary environment to avoid sources and transmission of infections for all patients, visitors, and staff when:

1. Two of the two endoscopes (a thin, flexible tube-like instrument equipped with a camera used to look at tissues inside the body) were not stored in an endoscope cabinet in accordance with facility policy and instruction for use (IFU). The two endoscopes were stored with the distal end (the part farthest from the origin) with camera touching the bottom of the cabinet (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect).

2. One of five staff members (RNM 1) was seen with their fingernails that passed the tips of RNM 1's fingers.

These failures placed staff and patients at risk of cross contamination, infection and potentially expose patients to hospital acquired infections.

Findings:

1. During a concurrent observation and interview on 6/18/24 at 2:56 p.m., with the Director of Surgery (DOS) and the Registered Nurse Manager for Endo (RNM 1) in the clean endoscopy room, two endoscopes with the distal end of the scopes were touching the bottom of the endoscope cabinet. The DOS stated the hospital fixed the other cabinets in the endoscopy storage room so that none of the scopes would touch but that this cabinet was missed. The DOS stated he was aware that this was an issue that he felt was addressed on the prior survey but was not informed of this separate cabinet and had not looked for other cabinets. The DOS stated the scopes were not stored correctly and would get this issue fixed, it placed the safety of patients at risk due to possible cross contamination.

During an interview on 6/21/24, at 10:46 a.m., with the Chief Nursing Officer (CNO), the CNO stated the facility has been auditing the scopes to make sure they are not touching nor touching the bottom of the cabinets but recognizes this cabinet was missed and the facility will need to broaden their observations of other areas that house scopes. The CNO stated when scopes touch the bottom or each other there is a risk of infection, a risk of the scope not being effective, scopes may get worn down and micro holes may form, and this is not what is best for the patients.

During a review of facility's document sterile processing manual procedure (SPMP) titled, "ST.P.1.34 Flexible Scopes", with the approval date of 5/23/18, the SPMP indicated, " ...Ensure cleaning and processing is conducted by the individuals who have received education and completed competency verification activities related to endoscope processing ....STORING ...Store mechanically processed flexible endoscopes in a cabinet that is both designed and intended for horizontal storage of flexible endoscopes or is of sufficient height, width, and depth to allow the endoscopes to hang vertically, without coiling and without touching the bottom of the cabinet ..."

During a review of the [Endoscope Brand Name] IFU for "[Brand Name] Ultrasonic Gastrovideo Scope (special endoscope that uses high frequency sound waves to examine all major organ of digestive system)", the IFU indicated, "...reprocessing and storage after use ...After using this instrument, reprocess and store it according to the instructions given ...Improper and/or incomplete reprocessing or storage can present an infection control risk ...Storage and Disposal ... Keep the reprocessed endoscope and accessories away from the contaminated equipment after cleaning and disinfection or sterilization. If the clean endoscope and accessories become contaminated between procedures, they could present an infection control risk to patients and/or operators in the subsequent procedures ...Hang the endoscope in the storage cabinet with the distal end hanging freely. Make sure that the insertion tube hangs vertically and as straight as possible ..."

During a professional reference review retrieved from (https://www.aami.org/docs/default-source/bi-t/bit/drying-storing-endoscopes---bit-may-june-2020.pdf) titled, " Drying and storage of Flexible Endoscopes: An Area of Growing Concern", dated 2020, the reference indicated " ...Store endoscopes and accessories in a manner that prevents recontamination, protects equipment from damage, and promotes drying ... Store processed flexible endoscopes in a cabinet of sufficient height, width and depth to allow flexible endoscopes to hang vertically without coiling or touching the bottom of the cabinet or in one designed and intended for horizontal storage..."

2.During a concurrent observation and interview on 6/18/24, at 3 p.m., with the Director of Surgery (DOS) and the Registered Nurse Manager (RNM 1), RNM 1 was observed having fingernails that went beyond her fingertips. RNM 1 stated she does do perform direct patient care when asked for assistance by her staff. RNM 1 stated the long nails could be an infection risk to the patients and put the patients at risk of being scratched. The DOS did not say anything just shook his head in agreeance with what RNM 1 stated.

During an interview on 6/21/24, at 10:46 a.m., with the CNO, the CNO stated she expected her staff to follow the hospitals policies and for her leadership team to set the example to keep staff and patients safe. CNO stated having long nails puts the patient at risk of getting an infection because the nails can harbor bacteria and place the patient at risk of being scratched.

During a review of the facility's policy titled, "Hand Hygiene Policy," approved on 10/26/22, indicated, " ... II. PURPOSE: The purpose of this policy is to outline hand hygiene requirements to reduce the risk of infection transmission from patient to patient. Patient to health care provider and health care provider to patient. III. DEFINITIONS A. Hand hygiene means hand washing, antiseptic hand wash, antiseptic hand rub or surgical antisepsis.... IV. POLICY: The hospital has adopted the Centers for Disease Control and Prevention (CDC) Guidelines for hand hygiene in healthcare settings with enhanced comments from the World Health Organization (WHO) ... V. PROCEDURE: ... B. Fingernails Hands with long fingernails, artificial nails and nail tips carry higher bacterial and fungal counts. Natural nails of healthcare workers are to be kept short (less than ¼ inch) and should not extend beyond the fingertips. (Refer to Clinical Quality Policy MOD PC.AD.1.44, Artificial Nail Policy) ..."

During a review of the facility's policy titled, "Artificial Nail Policy," approved 5/27/20, indicated, " ... II. PURPOSE: The purpose of this policy is to define when artificial nails and/or nail polish may be worn by healthcare providers and facility staff. III. DEFINITIONS: ... D. "Healthcare providers and workers" means all paid and unpaid persons working in healthcare settings who have the potential for exposure to infectious materials, including contaminated medical supplies. Healthcare providers might include, but are not limited to: physicians, nurses, nursing assistants, therapists, technicians, emergency medical service personnel, dental personnel, pharmacists, pharmacy personnel, laboratory personnel, autopsy personnel, students and trainees, contractual staff and persons, i.e., clerical, dietary, housekeeping, maintenance and volunteers not directly involved in patient care but potentially exposed to infectious agents that can be transmitted to and from the healthcare provider. IV. POLICY: The Hospital is committed to the prevention of healthcare-acquired infections. There is mounting evidence concerning the role of artificial nails in the transmission of infection. Data shows that wearers of artificial nails are unable to adequately wash their hands and remove transient flora compared to those without such nails. There is a tendency to harbor Pseudomonas and yeast beneath nails and on fingertips even after hand washing. Therefore, the Hospital prohibits the wearing of artificial nails/nail jewelry for all healthcare providers and workers, as defined above, who may touch a patient, or items a patient may use or touch. V. PROCEDURE: A. Nail Hygiene It is the responsibility of all direct patient care providers to maintain short (less than a ¼ inch long) fingernails. Nails should not extend beyond the tips of the fingers ..."