HospitalInspections.org

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

1. The facility failed to provide information about condition of admission (a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.), notice of privacy practice (describes how the facility can disclose a patient's protected health information, advance directive (a legal document that informs a healthcare provider a patient's, wishes about their healthcare if the patient is unable to make decisions themselves), and patient rights (ethical principles that apply to patient care such as the right to be involved in care planning and treatment) and responsibilities upon admission for two of 30 sampled patients (Patient 28 and Patient 30) in accordance with the facility's policy and procedure regarding admitting procedures.

This deficient practice resulted in Patient 28 and Patient 30 not knowing their patient rights including arbitration (a procedure in which a dispute is submitted), billing, release of information, financial responsibility, advance directive, privacy rights and patient rights and responsibilities during hospitalization which may negatively affect the patients' involvement in their own care and treatment. (Refer to A-0117)

2. The facility failed to provide and document the use of translator services (helps bridge language barriers and ensure accurate interpretations and translation of medical information) for one of 30 sampled patients (Patient 14) when consent for a procedure was obtained, in accordance with the facility's policy and procedure regarding Patient rights (ethical principles that apply to patient care such as the right to be involved in care planning and treatment), the use of effective communication services, and informed consent (the process in which the healthcare provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention). Patient 14's preferred language was Chinese Cantonese.

This deficient practice had violated Patient 14's rights to receive considerate care by not being provided a means for effective communication when receiving information about a proposed procedure. This deficient practice also had the potential to result in inappropriate treatments thus putting a patient's health at risk. (Refer to A-0129)

3. The facility failed to ensure patients received care in a safe environment, when one of two crash carts (a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency) in the Intensive Care Unit (ICU, provides care to critically ill patients) was not equipped with a backboard (used to provide support when performing cardiopulmonary resuscitation [CPR, an emergency life-saving procedure performed when the heart stops beating] on a patient that is in a bed), in accordance with the facility's policy and procedure regarding crash cart use.

This deficient practice had the potential for emergency supplies to not be readily available in case of an emergency and had the potential to result in a delayed provision of emergency care needed by patients, which may lead to patient harm and/or death. (Refer to A-0144)

4. The facility failed to ensure there is nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) developed and implemented for one of 30 sampled patients (Patient 23) to address restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) while Patient 23 had bilateral wrists restraints at the facility in accordance with the facility's policy and procedure regarding care planning for patients on restraints.

This deficient practice had the potential to result in nursing staff not properly assessing and evaluating Patient 23's need for restraints which may result in patient harm such as skin tears, strangulation, etc. (Refer to A-0166)

5. The facility failed to ensure restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) were applied safely on one of 30 sampled patients (Patient 25) when there was no documentation on the restraints location being applied, in accordance with the facility's policy and procedure regarding restraints use.

This deficient practice resulted in Patient 25 self-extubating (prematurely removal of the endotracheal tube [a tube placed into the windpipe through the mouth to help patient breathing] by the patient) and put Patient 25 at risk for respiratory distress (difficulty breathing). (Refer to A-0167)

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 provide information about condition of admission (a contract between the hospital and patient regarding treatment, payment for services rendered by the facility, etc.), notice of privacy practice (describes how the facility can disclose a patient's protected health information), advance directive (a legal document that informs a healthcare provider a patient's, wishes about their healthcare if the patient is unable to make decisions themselves), and patient rights (ethical principles that apply to patient care such as the right to be involved in care planning and treatment) and responsibilities upon admission for two of 30 sampled patients (Patient 28 and Patient 30) in accordance with the facility's policy and procedure regarding admitting procedures.

This deficient practice resulted in Patient 28 and Patient 30 not knowing their patient rights including arbitration (a procedure in which a dispute is submitted), billing, release of information, financial responsibility, advance directive, privacy rights and patient rights and responsibilities during hospitalization which may negatively affect the patients' involvement in their own care and treatment.

Findings:

1. During a review of Patient 28's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/25/2024, the H&P indicated, Patient 28 was admitted to the facility on 4/25/2024 with diagnoses of acute (new onset) encephalopathy (a broad term for any brain disease that alters brain function or structure), stage IV decubitus ulcers (full thickness skin and tissue loss with exposed or directly palpable fascia [connective tissue], muscle, tendon, ligament, cartilage or bone in the ulcer) with osteomyelitis (bone infection), and possible urinary tract infection (UTI, an infection in any part of the urinary system).

During an interview on 5/3/2024 at 9:17 a.m. with the Performance Improvement Coordinator (PIC), PIC stated the admission packet was not found for Patient 28's electronic medical record.

During an interview on 5/3/2024 at 12:06 p.m. with the Lead Admitting (LA), LA stated it was the responsibility of admitting staff to provide the admission packet to all patients to sign upon admission. LA stated the admission packet informed patients about their rights for arbitration, billing, release of information, financial responsibility, advance directive and privacy rights. LA stated that the admitting staff should also provide a booklet called "Patient Handbook and Visitor Guide" which contained information about patient rights and responsibilities. LA stated that the admitting staff did not provide the admission packet and the booklet to Patient 28.

During a review of the facility's policy and procedure (P&P) titled, "Admitting Procedures - Complete," dated 2/2022, the P&P indicated, "Goals: to assist all patients with their registration process, informing patients of their rights, answering all patient questions, having patients sign all appropriate admission forms required and bring patient to the appropriate areas of the hospital ... At the time of admission, the Admission representative is responsible to complete the registration process by completing the following process ... Explains and obtains signatures on all required admission forms (Condition of Admission, Notice of Privacy Practice, Advance Directive, Message for Medicare) upon arrival... Required admission forms:

1. Condition of Admission (COA): Arbitration, consent to medical procedures, nursing care, teaching, medication, legal relationship between hospital and physician, release of information, personal valuables, consent to photography/video, emergency/laboring patient, financial agreement, insurance assignment of benefits and etc.
2. Notice of Privacy Practice (NPP): the Privacy Rule requires that [the facility] gives all patients an important document called the Notice of Privacy Practices (Notices). The Notice explains to patient the ways [the facility] is allowed to use their health information and lists the rights patients have with respect to their health information.
3. Advance Directive: [the facility] provides the advance directive form/instruction to every emergency, inpatient and outpatient surgery patients. This form explains that patient has the right to give instruction about their own health care and the right to name someone else to make healthcare decision for him/her.
4. Important Message from Medicare about Patient's Rights: as an inpatient patient, he/she has the right to receive Medicare covered services, be involved in any decision about his/her hospital stay and to know who will pay for it and report any concern patient has about the quality of care received."

2. During a review of Patient 30's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 5/1/2024, the H&P indicated, Patient 30 was admitted to the facility with diagnoses of end stage renal disease (ESRD, a stage where the kidneys can no longer support the body's needs for waste removal and fluid balance) on dialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly), hyperphosphatemia (a condition in which there is too much phosphate [an essential mineral necessary for the structure of the bone and teeth] in the blood), and leukocytosis (high white blood cell count [helps fight infections in the body]).

During an interview on 5/3/2024 at 10:47 a.m. with the Performance Improvement Coordinator (PIC), PIC stated the admission packet was not found for Patient 30's electronic medical record.

During an interview on 5/3/2024 at 12:06 p.m. with the Lead Admitting (LA), LA stated it was the responsibility of admitting staff to provide the admission packet to all patients to sign upon admission. LA stated the admission packet informed patients about their rights for arbitration, billing, release of information, financial responsibility, advance directive and privacy rights. LA stated that the admitting staff should also provide a booklet called "Patient Handbook and Visitor Guide" which contained information about patient rights and responsibilities. LA stated that the admitting staff did not provide the admission packet and the booklet to Patient 30.

During a review of the facility's policy and procedure (P&P) titled, "Admitting Procedures - Complete," dated 2/2022, the P&P indicated, "Goals: to assist all patients with their registration process, informing patients of their rights, answering all patient questions, having patients sign all appropriate admission forms required and bring patient to the appropriate areas of the hospital ... At the time of admission, the Admission representative is responsible to complete the registration process by completing the following process ... Explains and obtains signatures on all required admission forms (Condition of Admission, Notice of Privacy Practice, Advance Directive, Message for Medicare) upon arrival... Required admission forms:

1.Condition of Admission (COA): Arbitration, consent to medical procedures, nursing care, teaching, medication, legal relationship between hospital and physician, release of information, personal valuables, consent to photography/video, emergency/laboring patient, financial agreement, insurance assignment of benefits and etc.
2. Notice of Privacy Practice (NPP): the Privacy Rule requires that [the facility] gives all patients an important document called the Notice of Privacy Practices (Notices). The Notice explains to patient the ways [the facility] is allowed to use their health information and lists the rights patients have with respect to their health information.
3. Advance Directive: [the facility] provides the advance directive form/instruction to every emergency, inpatient and outpatient surgery patients. This form explains that patient has the right to give instruction about their own health care and the right to name someone else to make healthcare decision for him/her.
4. Important Message from Medicare about Patient's Rights: as an inpatient patient, he/she has the right to receive Medicare covered services, be involved in any decision about his/her hospital stay and to know who will pay for it and report any concern patient has about the quality of care received."

Based on interview and record review the facility failed to provide and document the use of translator services (helps bridge language barriers and ensure accurate interpretations and translation of medical information) for one of 30 sampled patients (Patient 14) when consent for a procedure was obtained, in accordance with the facility's policy and procedure regarding Patient rights (ethical principles that apply to patient care such as the right to be involved in care planning and treatment), the use of effective communication services, and informed consent (the process in which the healthcare provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention). Patient 14's preferred language was Chinese Cantonese.

This deficient practice had violated Patient 14's rights to receive considerate care by not being provided a means for effective communication when receiving information about a proposed procedure. This deficient practice also had the potential to result in inappropriate treatments thus putting a patient's health at risk.

Findings:

During a review of Patient 14's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 3/11/2024, the H&P indicated, Patient 14 was admitted on 3/11/2024, due to common bile duct obstruction (a blockage in the tubes that carry bile [fluid released by the liver that aids with digestion] from the liver to the gallbladder and small intestine), and needed to have endoscopic retrograde cholangiopancreatography (ERCP, a procedure used to identify the presence of stones, tumors, or narrowing in the biliary and pancreatic ducts [carries bile from the liver and gallbladder]).
During a review of Patient 14's medical record (MR) titled, "Nursing Initial Assessment," dated 3/11/2024, the MR indicated, Patient 14's preferred language was Chinese Cantonese (a language within the Chinese (Sinitic) branch of the Sino-Tibetan languages).

During a concurrent interview and record review on 5/2/2024 at 2:05 p.m. with registered nurse (RN) 6, Patient 14's informed consent (a process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) for ERCP, dated 3/12/2024, was reviewed. The informed consent indicated, Patient 14 signed the consent on 3/12/2024 at 5:03 p.m. and the primary nurse witnessed obtaining the consent by signing in the allocated space. RN 6 verified, "Translator," space was not filled out, indicating primary nurse did not document using translator services for Patient 14 whose primary language was Chinese-Cantonese.

During an interview on 5/2/2024 at 3:09 p.m. with RN 6, RN 6 stated, if patient's primary language was not English, the preferred language was noted on the patient's face sheet (a document that provides a patient's information at a quick glance) and medical record. RN 6 further stated, a proper language interpreter shall be provided as needed and the primary nurse should document that services of the interpreters were provided by recording the information on the consent in the allocated space.

During a review of the facility's policy and procedure (P&P) titled, "Consent and Informed Consent (the process in which the healthcare provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention)," dated, 7/2023, the P&P indicated, "Procedure for filling out consent form when there is language barrier, shall include obtaining interpreter and recording the Interpreter's name and or ID number in the space provided on the consent."

During a review of the facility's policy and procedure (P&P) titled, "Provision of Culturally Competent and Effective Communication Services for Patients with Special Needs," dated 7/2023, the P&P indicated, "Upon admission, the facility will collect oral and written communication needs including the patient's preferred language for discussing healthcare. The primary language will be noted in medical records and on the patient's face sheet. A proper language interpreter will be provided when needed and for medically related services. the appropriate care giver will document that services of the interpreters were employed."

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibilities," dated 7/2023, the P&P indicated, "In order to protect the personal welfare and safeguard dignity of a patient as a human being, the facility will provide considerate and respectful cultural and preferred care. Patients have the right to effective communication."

Based on observation, interview, and record review, the facility failed to ensure patients received care in a safe environment, when one of two crash carts (a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency) in the Intensive Care Unit (ICU, provides care to critically ill patients) was not equipped with a backboard (used to provide support when performing cardiopulmonary resuscitation [CPR, an emergency life saving procedure performed when the heart stops beating] on a patient that is in a bed), in accordance with the facility's policy and procedure regarding crash cart use.

This deficient practice had the potential for emergency supplies to not be readily available in case of an emergency and had the potential to result in a delayed provision of emergency care needed by patients, which may lead to patient harm and/or death.

Findings:

During an observation on 4/30/3024 at 9:10 a.m., in the Intensive Care Unit (ICU, provides care to critically ill patients), two crash carts (a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency) were observed on the unit. One of the crash carts did not have a backboard (used to provide support when performing cardiopulmonary resuscitation [CPR, an emergency life-saving procedure performed when the heart stops beating] on a patient that is in a bed).

During an interview on 4/30/2024 at 9:10 a.m. with the Director of ICU (DICU) and the Clinical Shift Supervisor (CSS) 1, the DICU and the CSS 1 stated there should be a backboard on the crash cart. The backboard was used during a Code (Code blue, indicates a life-threatening medical emergency such as a cardiac arrest or when the heart stops beating) by placing the backboard under the patient and perform effective chest compressions. CSS 1 stated it was used yesterday (4/29/2024) during a Code and normally, central supply (a department that issues supplies, and equipment needed in patient care) brings another backboard, when the one on the crash cart has been used. However, in this case, the backboard was missing.

During a review of the facility's policy and procedure (P&P) titled, "Crash Cart and Defibrillator (a device that applies an electrical charge to the heart to restore a normal heartbeat) Check," dated 3/2023, the P&P indicated the following: Staff member is assigned to check Crash Cart per shift ...check supplies and equipment on top and sides of cart ...If any of the components ...Crash Cart is deficient, the person doing the shift check is responsible to take immediate action to correct the deficiency ..."

During a review of the document on top of the crash cart, in the ICU titled, "Defibrillator and Crash Cart AM (morning) Check," dated 4/2024 the document indicated the Back Board was one of the items to be checked every morning.

Based on interview and record review, the facility failed to ensure there is nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) developed and implemented for one of 30 sampled patients (Patient 23) to address restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) while Patient 23 had bilateral wrists restraints at the facility in accordance with the facility's policy and procedure regarding care planning for patients on restraints.

This deficient practice had the potential to result in nursing staff not properly assessing and evaluating Patient 23's need for restraints which may result in patient harm such as skin tears, strangulation, etc.

Findings:

During a review of Patient 23's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/26/2024, the H&P indicated, Patient 23 was admitted to the facility with diagnoses of congestive heart failure (CHF, a chronic condition in which a weakness of the heart leads to a buildup of fluid in the lungs) exacerbation (worsening), acute (new onset) hypoxic (deficiency in the amount of oxygen reaching the tissues) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), and acute on chronic kidney disease (CKD, longstanding disease of the kidneys leading to renal failure).

During a review of Patient 23's physician order (orders written by physicians to direct care and treatment), dated 4/27/2024, the physician order indicated Patient 23 had bilateral wrists restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body).

During a concurrent interview and record review with the intensive care unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) registered nurse (RN) 1, Patient 23's care plan (provides a framework for evaluating and providing patient care needs related to the nursing process), was reviewed. The care plan did not address Patient 23 was on restraints. RN 1 stated care plan related to restraints should have been developed for Patient 23 to indicate assessment and intervention needed, and to set goals while Patient 23 was restrained. RN 1 stated without the restraints care plan, restraints use could not be evaluated correctly.

During a review of the facility's policy and procedure (P&P) titled, "Restraints and Immobilization of Patients," dated 3/2023, the P&P indicated, "[the facility] recognizes the need to guarantee all patients their human and civil rights, and that restraints are used only as a last resort when less restrictive interventions have been proven ineffective ... the patient's written plan of care shall address the use of restraint."

During a review of the facility's policy and procedure (P&P) titled, "Care Plan, Patient Multi-Disciplinary," dated 10/2022, the P&P indicated, "the purpose is to provide quality patient care based on the unique needs and diagnosis of patients at [the facility] ... the plan of care will be based on the assessed unique needs and diagnosis of the patient and will include patient problems, expected outcomes/realistic goals and interventions."

Based on interview and record review, the facility failed to ensure restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) were applied safely on one of 30 sampled patients (Patient 25) when there was no documentation on the restraints location being applied, in accordance with the facility's policy and procedure regarding restraints use.

This deficient practice resulted in Patient 25 self-extubating (prematurely removal of the endotracheal tube [a tube placed into the windpipe through the mouth to help patient breathing] by the patient) and put Patient 25 at risk for respiratory distress (difficulty breathing).

Findings:

During a review of Patient 25's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 3/7/2024, the H&P indicated, Patient 25 was admitted to the facility's intensive care unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) with diagnoses of sepsis (a body's overwhelming and life-threatening response to infection), pneumonia (lung infection), chronic obstructive pulmonary disease (COPD, a lung disease characterized by long-term poor airflow), and thrombocytopenia (low platelets [blood cells that help your body form clots to stop bleeding]).

During a review of Patient 25's physician order (orders written by physicians to direct care and treatment), dated 3/12/2024, the physician order indicated, "bilateral wrists restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) for safety" was ordered for Patient 25.

During a review of Patient 25's pulmonary progress notes (physician progress notes written by pulmonologist [a physician who specializes in lung condition]), dated 3/18/2024, the progress notes indicated patient (Patient 25) was intubated (a process when physician inserts a tube through a person's mouth then down into their windpipe to keep airway open, the tube can connect to a machine that delivers oxygen to the patient) on 3/15/2024.

During a concurrent interview and record review on 5/2/2024 at 2:24 p.m. with the Performance Improvement Coordinator (PIC), Patient 25's "Non-Violent Restraint Initiation" (restraints flowsheet, nursing document on indication of restraints, what type of restraints applied, assessment and intervention done for restrained patient) from 3/12/2024 to 3/17/2024 was reviewed. The restraints flowsheet indicated "physical restraint bilateral (both)" was used on Patient 25. PIC stated the documentation was unclear on which body part restraints were applied on for Patient 25. PIC stated nursing staff should have documented the specific location where restraints were applied to reflect physician order was followed.

During a concurrent interview and record review on 5/3/2024 at 2 p.m. with the ICU registered nurse (RN) 1, Patient 25's restraints flowsheet dated 3/17/2024 was reviewed. The restraints flowsheet indicated on 3/17/2024 at 7:47 a.m. "physical restraints bilateral" and "[Patient 25] self-extubated (prematurely removal of the ET tube by the patient) at 7:25 a.m." RN 1 was unable to verify if restraints were applied to bilateral wrists per physician order because it was not documented clearly. RN 1 confirmed that the restraints document could not reflect restraints was safely and appropriately applied since the location of restraints was unclear. RN 1 stated Patient 25 could potentially aspirate (the accidental breathing in of food or fluid into the lungs can cause serious problem such as pneumonia or other lung problems) and go into respiratory distress from self-extubating.

During a review of the facility's policy and procedure (P&P) titled, "Restraints and Immobilization of Patients," dated 3/2023, the P&P indicated, "[the facility] recognizes the need to guarantee all patients their human and civil rights, and that restraints are used only as a last resort when less restrictive interventions have been proven ineffective ... application: the choice of safe, effective, and least restrictive methods are determined by the patient's assessed needs and the effective or ineffective methods previously used on the patients. These attempts are to be documented."

Based on interview and record review the facility failed to set priorities for the performance improvement activities (PIA, a method for analyzing performance issues and establishing systems to ensure good performance) that focused on changes that would lead to improvement in delivery of quality of care in patients with identified sepsis and septic shock diagnoses (sepsis is a serious condition in which the body responds improperly to an infection and may progress to septic shock which is a life-threatening condition).

This deficient practice had the potential to negatively affect health outcomes and safety of all patients in the facility and compromise the quality of care delivered to patients with identified sepsis/septic shock medical diagnosis.

Findings:

During a record review of the facility ' s Severe Sepsis (life-threatening organ dysfunction caused by a dysregulated host response to infection) and Septic Shock (Sepsis may progress to septic shock. This is a dramatic drop in blood pressure that can damage the lungs, kidneys, liver and other organs) Core Measures (evidence-based process that measures to reduce morbidity [the amount of disease within a population] and mortality (death rate) goals, dated 2022 and 2023, the data (information such as facts and numbers used to analyze something or make decisions and presented in a numerical form) indicated the following:

In 2022, the facility ' s reported compliance with sepsis best practice treatment was 46%

In 2023, the facility ' s reported compliance with sepsis best practice treatment rate was at 42 %.

The most recent data indicated, the facility ' s reported compliance with sepsis best practice treatment was 45% in the first quarter (Q1) of year 2024 (the standard calendar quarters that make up the year are as follows: January, February, and March [Q1]).

During an interview on 5/2/2024 at 9:37 a.m., with critical care specialist (MD 2), MD 2 stated, sepsis protocol (a set of guidelines that healthcare providers can use to identify and treat patients with septic shock and severe sepsis) was not implemented until recently.

During an interview on 5/2/2024, at 9:45 a.m., with registered nurse (RN 1), RN 1 stated, patients are typically screened/assessed for sepsis and septic shock in the emergency department (ED) and screening is documented in the electronic medical records. RN 1 also stated all patients that are admitted to the facility are also screened/assessed for sepsis and septic shock once per shift and as needed. RN 1 stated, if a patient is identified to be septic, sepsis protocol is activated (Sepsis protocol consists of sepsis bundles, a series of responses that a medical team takes to treat sepsis. There is a three-hour bundle and six-hour bundle, both of which include different steps, including specific testing, and administering IV [intravenous, delivered through a vein] fluids and antibiotics [medication that destroys germs]).

During an interview on 5/3/2024 at 10:08 a.m. with RN 1, RN 1 stated, if a patient screens positive for sepsis, the physician needs to be informed, and nurses follow sepsis protocol. Screening is important, because it is critical, and time sensitive and early initiation of sepsis protocol (sepsis bundles) helps to improve patients ' outcomes (bundles have been associated with reduced mortality in severe sepsis and septic shock patients).

During an interview on 5/3/2024 at 1:46 p.m., with performance improvement coordinator (PIC), PIC stated, facility performs systematic monitoring of sepsis cases and data analysis (helps organizations harness the power of data, enabling them to make decisions and optimize [improve] processes) is performed regularly. PIC further stated the facility ' s trends [performance] in sepsis best practice treatment and bundles implementation are analyzed and fall-outs (non-compliance with sepsis protocol core elements) are regularly recognized by auditing [the process of reviewing] medical records of patients with identified sepsis and septic shock diagnoses.

During a concurrent interview and record review on 5/3/2024, at 1:46 p.m., with performance improvement coordinator (PIC) and director of quality and performance improvement (DQPI), the facility ' s Severe Sepsis /Septic Shock Core Measures, dated 2022 and 2023 were reviewed. The rates indicated the facility ' s reported compliance with sepsis best practice treatment was 46% in year 2022 and 42 % in year 2023. The most recent data indicated, the facility ' s reported compliance with sepsis best practice treatment was 45% in the first quarter (Q1) of year 2024. DQIP stated, the CMS (the Centers for Medicare and Medicaid Services [CMS], nation ' s health care system) requires the Sepsis Core Measures (minimum sets of actions required by 3-hour and 6-hour time points after a patient reaches severe sepsis or septic shock), which demonstrates adherence to sepsis protocol core elements to be collected and reported to the CMS (sepsis/septic shock are associated with patients ' high morbidity and mortality; therefore processes designed to reduce morbidity and mortality associated with sepsis and septic shock are required to be reported to the CMS to demonstrate facility ' s performance efforts in adhering to sepsis protocol core elements proven to improve patients ' management and outcomes of sepsis). DQIP stated, in the last two years (2022-2023), the facility ' s sepsis compliance rates with the sepsis protocol core elements were bad.

During an interview on 5/3/2024, at 2: 03 with director of quality and performance improvement (DQPI), DQPI stated, the facility only recently (in February 2024) added Sepsis Bundle compliance rates to the Quality Improvement Activities (QIA, systematic processes that review, evaluate, and improve the quality of work) to achieve 80% compliance rate, but no action plan for improvement in the identified sepsis underperformance Core Measures was proposed yet. The DQPI stated, underperformance indicators (below national average goal of 59% and the facility ' s goal of 80%) in achieving sepsis best practice treatment rates and bundle compliance for the last two years (2022 and 2023) were only recently presented to the facility ' s representatives during the monthly Quality Improvement/Utilization Review/Risk Management Committee meeting on February, 2024 but the action plan to improve sepsis indicators yet need to be formulated.

During a review of the facility ' s policy and procedure (P&P) titled, "Performance Improvement Plan (a Performance Improvement Plan is a systematic effort to address a specific issue in a facility or across the facility. The Quality Assurance Performance Improvement (QAPI) program is a requirement for healthcare providers, including to improve their care quality and safety)," dated 4/2023, the P&P indicated, " PIP is designed to outline a coordinated and integrated process in improving organizational performance and provides a framework for systematic monitoring and evaluation of the quality and appropriateness of care, treatment and services and prioritization of improvement opportunities to enhance patient care, organizational processes and resolve identified problems at the facility."

During further review of the facility ' s policy and procedure (P&P) titled, "Performance Improvement Plan," dated 4/2024, the P&P indicated, "The organization will prioritize those performance improvement activities that address processes that are high risk-put patients at risk of serious consequences of deprivation of substantial benefit if care is not provided correctly or not provided as indicated. The organization will select performance measures for processes that are known to jeopardize the safety of the individuals served or associated with sentinel events and when detects significant underperformance, it will initiate best to focus changes for improvement."

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 provide supervision of a certified nursing assistant (CNA), who did not adhere to infection control precautions (standard recommendations to reduce the risk of transmission of infectious agents) when providing care for one of thirty sampled patients (Patient 14), who was placed in contact isolation precaution (utilized when direct or indirect contact with contaminated body fluids, equipment, or the environment is anticipated. Example: use of gloves and gowns). The CNA did not wear a gown while providing patient care inside a contact isolation precaution room occupied by Patient 14, in accordance with the facility's policy and procedure regarding infection control precautions.

This deficient practice had the potential to increase the likelihood of multidrug-resistant bacteria spread and could potentially increase the risk of outbreaks in the facility compromising health and well-being of other patients and staff. (Refer to A-0395)

2. The facility failed to initiate and develop individualized nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for three of thirty sampled patients (Patient 20, Patient 23 and Patient 27) in accordance with the facility's policy and procedure regarding care planning when:

2.a. The facility failed to initiate and update a care plan for infection prevention and control for Patient 20. This deficient practice had the potential to result in the spread of infectious agents among other patients and the staff. (Refer to A-0396)

2.b. The facility failed to initiate and update a care plan for hemodialysis (process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) for Patient 23. This deficient practice had the potential to result in Patient 23's delay in receiving education regarding hemodialysis treatment and management including a lack of understanding regarding the hemodialysis treatment which may affect patient's involvement in her (Patient 23) own care and recovery. (Refer to A-0396)

2.c. The facility failed to initiate and update a care plan to address sepsis (a body's overwhelming and life-threatening response to infection) and pneumonia (lung infection) for Patient 27. This deficient practice had the potential to result in Patient 27's needs and risks not being met which may result in Patient 27's condition to worsen including prolonged hospitalization. (Refer to A-0396)

3. The facility failed to screen (a method of assessment to identify early sepsis) six of 30 sampled patients (Patient 1, Patient 12, Patient 13, Patient 16, Patient 23, and Patient 27) for sepsis (a life-threatening complication of infection) and septic shock (a widespread infection causing organ failure and dangerously low blood pressure), and failed to follow through with interventions required for the management of sepsis for patients who identified to meet the criteria for sepsis and septic shock, in accordance with the facility's policy and procedure regarding "Sepsis Identification & Management Checklist."

This deficient practice had the potential for patients experiencing sepsis or septic shock to not be identified and proper interventions to be implemented, which had the potential to cause harm, or death. (Refer to A-0398)

4. The facility failed to ensure antibiotics (Zosyn and Linezolid, medications to fight infections) were given in a timely manner (every 8 hours for Zosyn and every 12 hours for Linezolid) for one of 30 sampled patients (Patient 1) in accordance with the physician order and the facility's policy and procedure regarding medication administration.

This deficient practice resulted in a delay in treatment and had the potential for the antibiotic to be ineffective. (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 observation, interview and record review, the facility failed to provide supervision of a certified nursing assistant (CNA), who did not adhere to infection control precautions (standard recommendations to reduce the risk of transmission of infectious agents) when providing care for one of thirty sampled patients (Patient 14), who was placed in contact isolation precaution (utilized when direct or indirect contact with contaminated body fluids, equipment, or the environment is anticipated. Example: use of gloves and gowns). The CNA did not wear a gown while providing patient care inside a contact isolation precaution room occupied by Patient 14, in accordance with the facility's policy and procedure regarding infection control precautions.

This deficient practice had the potential to increase the likelihood of multidrug-resistant bacteria spread and could potentially increase the risk of outbreaks in the facility compromising health and well-being of other patients and staff.

Findings:

During a review of Patient 14's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 3/11/2024, the H&P indicated, Patient 14 was admitted on 3/11/2024, due to common bile duct obstruction (a blockage in the tubes that carry bile [fluid released by the liver that aids with digestion] from the liver to the gallbladder and small intestine), and needed to have endoscopic retrograde cholangiopancreatography (ERCP, a procedure used to identify the presence of stones, tumors, or narrowing in the biliary and pancreatic ducts).

During a review of Patient 14's medical record (MR) titled, "Internal Medicine Progress Note," dated 4/29/2024, the MR indicated, Patient 14 had duodenal perforation (occurs when bowel contents spill freely into the abdomen) and underwent exploratory laparotomy (a surgery to open up the belly, with a placement of a new bile duct stent [a tubular device used to relief blockage and open the duct that carries bile]), cholecystectomy (surgical removal of the gallbladder) and feeding Jejunal tube placement (J-tube, a tube inserted through the belly that brings nutrition directly to the stomach).

During a review of Patient 14's medical record (MR) titled, "Internal Medicine Progress Note," dated 4/29/2024, the MR indicated, on 4/20/24, Patient 14 was tested positive for the presence of vancomycin resistant (VRE, occurs when germs no longer respond to the vancomycin antibiotic, designed to kill them) Enterococcus faecium bacteria (bacteria typically present in the human intestines).

During a concurrent observation and interview on 4/29/2024, at 2:18 p.m., on a medical surgical floor (Med/Surg floor, designed to provide care to patients with broad range of conditions), with charge nurse (CN 1), Patient 14 was observed in room, resting in a wheelchair (W/C), while a certified nursing assistant (CNA) was changing Patient 14's bed linens. The CNA was not wearing a gown (a personal protective equipment [PPE] worn to minimize exposure to and prevent the spread of infection or illness). CN 1 stated, Patient 14 had contact isolation precautions (utilized when direct or indirect contact with contaminated body fluids, equipment, or the environment is anticipated. Example: use of gloves and gowns) in place due to VRE present in bile (fluid released by the liver that aids with digestion) and the CNA should wear a gown when inside the patient's (Patient 14) room.

During an interview on 4/29/2024, at 2:23 p.m., with Patient 14's primary nurse (RN 7), RN 7 stated, Patient 14 was on contact isolation precautions which require to wear gloves, facial mask, and a gown upon entering the room. RN 7 stated, the CNA in Patient 14's room should wear a gown to prevent spread of infection (infection can be spread by cross-contamination which is transfer of harmful bacteria from one person, object, or place to another). RN 7 was not aware that the CNA in Patient 14's room did not use proper PPEs and had no gown worn inside the room.

During a review of the facility's policy and procedure (P&P) titled, "Multiple Drug Resistant Organisms Isolation," dated, 11/2019, "Patients with identified multi-organism infections such as vancomycin resistant Group D enterococci (VRE). Isolation can be initiated by nursing or Infection Control, but an order should be obtained from the primary care physician prior to placing the patient in isolation or as soon as possible after. Gowns and gloves should be worn to prevent direct contact with the patient or articles potentially contaminated with the patient's body substances. Contact isolation protocol requires wearing gloves, a mask, and a gown upon entering room."

Based on interview and record review, the facility failed to initiate and develop individualized nursing care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for three of thirty sampled patients (Patient 20, Patient 23 and Patient 27) in accordance with the facility's policy and procedure regarding care planning as evidenced by:

1. Failure to initiate and update a care plan for infection prevention and control for Patient 20. This deficient practice had the potential to result in the spread of infectious agents among other patients and the staff.

2. Failure to initiate and update a care plan for hemodialysis (process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) for Patient 23. This deficient practice had the potential to result in Patient 23's delay in receiving education regarding hemodialysis treatment and management including a lack of understanding regarding the hemodialysis treatment which may affect patient's involvement in her (Patient 23) own care and recovery.

3. Failure to initiate and update a care plan to address sepsis (a body's overwhelming and life-threatening response to infection) and pneumonia (lung infection) for Patient 27. This deficient practice had the potential to result in Patient 27's needs and risks not being met which may result in Patient 27's condition to worsen including prolonged hospitalization.

Findings:

1. During a review of Patient 20's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 4/27/2024, the H&P indicated, Patient 20 had past medical history (PMH, records of information about the patient's medical, personal and family history) of hypertension (a condition in which the blood vessels have persistently raised pressure), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and percutaneous endoscopic gastrostomy (PEG) placement ( a surgery to place a feeding tube [PEG tube] into the stomach to deliver nutrition through the tube). The H&P further indicated, Patient 20 was admitted on 4/26/2024 due to atrial fibrillation (Afib, an irregular and very rapid heart rhythm).

During a review of Patient 20's medical record (MR) titled, "Internal Medicine Progress Note," dated 4/29/2024, the MR indicated, on 4/26/2024, Patient 20 tested positive for Escherichia coli (E.coli) ESBL in urine (E. coli bacteria have started to produce small proteins (enzymes) called extended-spectrum beta-lactamases [ESBLs] that are antibiotic resistant), and on 4/27/2024, Patient 20 tested positive for Methicillin Resistant Staph Aureus (MRSA, a type of bacteria that's become resistant to many of the antibiotics).

During a concurrent observation and interview on 4/29/2024 at 2:26 p.m. with charge nurse (CN 2), Patient 20 was observed in room, resting in bed. No infection precaution sign was posted outside the door (Patient 20's room). RN 2 stated, Patient 20 tested positive for ESBL in urine and should be in isolation room to prevent the spread of infection, but no sign for infection precaution (standard recommendations to reduce the risk of transmission of infectious agents) was posted outside Patient 20's room.

During a concurrent interview and record review on 5/2/2024 at 4:05 p.m. with informatics technology nurse (RN 6), Patient 20's medical record titled, "Care Plan (provides a framework for evaluating and providing patient care needs related to the nursing process)," dated 4/26/2024 through 4/29/2024 was reviewed. RN 6 verified, there was no "Infection related," care plan initiated for Patient 20.

During a concurrent interview and record review on 5/2/2024 at 4:06 p.m. with informatics technology nurse (RN 6), Patient 20's medical record titled, "Care Assessments," dated 4/26/2024 through 4/29/2024 was reviewed. RN 6 verified, there was no isolation precautions assessment recorded in Patient 20's medical chart.

During an interview on 5/2/2024 at 10:51 a.m. with the director of intensive care unit (DICU), DICU stated, nursing should initiate care plan for infection because care planning would provide guidance on what to monitor for and what interventions can be done to meet patient needs, as well as what education hads to be provided to the patient.

During a review of the facility's policy and procedure (P&P) titled, "Care Plan, Patient Multi-Disciplinary," dated 10/2022, the P&P indicated, "Care plan shall be developed to provide quality patient care based on the unique needs and diagnosis of patients at [the facility] ... The plan of care will be based on the assessed unique needs and diagnosis of the patient and will include patient problems, expected outcomes/realistic goals and interventions ... The plan will be evaluated and updated as needed based on assessment of patient's response to interventions and/or new needs."

2. During a review of Patient 23's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/26/2024, the H&P indicated, Patient 23 was admitted to the facility with diagnoses of congestive heart failure (CHF, a chronic condition in which a weakness of the heart leads to a buildup of fluid in the lungs) exacerbation (worsening), acute (new onset) hypoxic (deficiency in the amount of oxygen reaching the tissues) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), and acute on chronic kidney disease (CKD, longstanding disease of the kidneys leading to renal failure).

During a review of Patient 23's nephrology progress notes (physician progress notes written by nephrologist [a physician who specializes in kidneys condition]), dated 4/28/2024, the nephrology progress notes indicated, Patient 23 had acute kidney injury secondary to acute tubular necrosis (damage to the tubule cells of the kidney). The notes also indicated Patient 23 was oliguric (severe reduction in urine production) and needed hemodialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly).

During a concurrent interview and record review on 5/2/2024 at 1:39 p.m. with the Performance Improvement Coordinator (PIC), Patient 23's care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) was reviewed. PIC confirmed there was no care plan initiated relating to Patient 23's hemodialysis to address care and management.

During an interview on 5/3/2024 at 1:34 p.m. with the intensive care unit (ICU, specialist hospital wards that provide treatment and monitoring for people who are very ill) registered nurse (RN) 1, RN 1 stated nursing staff should have added care plan for hemodialysis when Patient 23 received first hemodialysis on 4/28/2024. RN 1 stated the care plan would provide guidance on what to monitor during hemodialysis and intervention including providing Patient 23 with education on hemodialysis care and management. RN 1 stated Patient 23 might not know how to deal with hemodialysis if nursing staff did not educate her (Patient 23).

During a review of the facility's policy and procedure (P&P) titled, "Care Plan, Patient Multi-Disciplinary," dated 10/2022, the P&P indicated, "the purpose is to provide quality patient care based on the unique needs and diagnosis of patients at [the facility] ... the plan of care will be based on the assessed unique needs and diagnosis of the patient and will include patient problems, expected outcomes/realistic goals and interventions ... the plan will be evaluated and updated as needed based on assessment of patient's response to interventions and/or new needs"

3. During a review of Patient 27's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/19/2024, the H&P indicated, Patient 27 was admitted to the facility with diagnoses of pneumonia (lung infection), sepsis (a body's overwhelming and life-threatening response to infection), chronic obstructive pulmonary disease (COPD, a lung disease characterized by long-term poor airflow) exacerbation (worsening) and acute (new onset) on chronic respiratory failure (condition in which not enough oxygen passes from the lungs into the blood).

During a concurrent interview and record review on 5/2/2024 at 3:41 p.m. with the Performance Improvement Coordinator (PIC), Patient 27's care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) was reviewed. PIC confirmed there was missing care plan to address Patient 27's diagnoses of sepsis and pneumonia. PIC stated the care plan for pneumonia would address problems associated with pneumonia including impaired gas exchange, ineffective breathing pattern, ineffective airway clearance (inability to clear secretions or obstructions in the air passages), pain, infection and activity tolerance. PIC stated care plan should be individualized and problem specific, without proper care plan, nurses would not know what to monitor.

During an interview on 5/3/2024 at 2:51 p.m. with the Director of ICU (DICU), DICU stated care plan should be individualized to each patient so that certain condition can be managed properly in order to facilitate healing and discharge.

During a review of the facility's policy and procedure (P&P) titled, "Care Plan, Patient Multi-Disciplinary," dated 10/2022, the P&P indicated, "the purpose is to provide quality patient care based on the unique needs and diagnosis of patients at [the facility] ... the plan of care will be based on the assessed unique needs and diagnosis of the patient and will include patient problems, expected outcomes/realistic goals and interventions ... the plan will be evaluated and updated as needed based on assessment of patient's response to interventions and/or new needs."

Based on interview and record review, the facility failed to screen (a method of assessment to identify early sepsis) six of 30 sampled patients (Patient 1, Patient 12, Patient 13, Patient 16, Patient 23, and Patient 27) for sepsis (a life-threatening complication of infection) and septic shock (a widespread infection causing organ failure and dangerously low blood pressure) and failed to follow through with interventions required for the management of sepsis for patients who identified to meet the criteria for sepsis and septic shock, in accordance with the facility's policy and procedure regarding "Sepsis Identification & Management Checklist."

This deficient practice had the potential for patients experiencing sepsis or septic shock to not be identified and proper interventions to be implemented, which had the potential to cause harm, or death.

Findings:

1. During a concurrent interview and record review on 5/1/2024 at 9:29 a.m. with the Director of Intensive Care Unit (DICU) and the Clinical Shift Supervisor (CSS) 1, the DICU and CSS 1 stated the following:
Patient 1 had spine surgery as an outpatient on 6/28/2021 at 12:37 p.m. At 6:40 p.m., Patient 1 was transferred to the Intensive Care Unit (ICU, provides treatment and monitoring for people who are very ill) in critical condition.
Patient 1 was intubated (a tube is inserted through the nose or mouth into the airway, so air can get through) and had an estimated blood loss of over 2000 milliliters (ml, a unit of measurement). At 7 p.m., Patient 1 had an elevated heart rate and respiratory rate, was on a ventilator (machine that helps one breathe). At 7:10 p.m., Patient 1's white blood count (WBC) was 39. 6 (high, may indicate infection, inflammation, or injury; Normal range is from 4.5 to 11). Patient 1 was already receiving intravenous (IV, in the vein) fluids and started on Levophed (medication to support the blood pressure) and Neosynephrine (help support blood pressure) and received blood transfusions (a procedure in which blood or blood components are administered through an intravenous line). The DICU and the CSS 1 also stated that Patient 1 met the criteria for Sepsis (a life-threatening complication of infection). However, the Sepsis screening (a screening tool used as a decision support mechanism for early detection of sepsis) has not been done by the admitting nurse in the ICU or every shift. The Sepsis screen was only done starting on 6/30/2021 at 6 p.m., two days later. The Sepsis screening should be done upon admission to the unit, every shift, and with change of condition to help identify early signs of sepsis and to implement interventions to reduce downhill spiral of a patient's condition and reduce mortality (death) rates.

During a review of Patient 1's "Pulmonary Consultation Note," dated 6/29/2021 at 1:40 p.m., the note indicated the following:
Patient 1 was admitted on 6/28/2021 at 8:56 a.m., ...Patient 1, 35-year-old woman with history of morbid obesity (more than 100 pounds [lbs, a unit of measurement] over ideal body weight), hypertension (high blood pressure), diabetes mellitus (too much sugar in the blood) came to hospital for outpatient surgery for spine yesterday (6/28/2021). Admitted to Intensive Care Unit (provides critical care and life support for acutely ill and injured patients) after symptoms for shock (acute medical condition caused by such events as loss of blood, bacterial infection, marked by irregular breathing and rapid pulse), hypoxia (not enough oxygen in the blood) and respiratory failure (inability to breathe on your own) ...Noticed to have DIC (disseminated intravascular coagulation, condition that affects the body's ability to clot and stop bleeding) as well as renal shut down (kidneys unable to remove waste and balance fluids), and severe metabolic acidosis (too much acid in the body). Patient 1 also had a cardiac arrest (when the heart stops beating) this morning and left groin HD (hemodialysis, process to remove waste from the blood) catheter was placed. Patient 1 is on multiple pressors (medications to support blood pressure), bicarb drip (Sodium Bicarbonate, treats metabolic acidosis [when acid builds up in the body]), insulin drip (medication to treat diabetes), transfusions(blood transfusion administered through an intravenous line) with packed red blood cells (PRBC, prepared from whole blood by removing plasma) as well as frozen fresh plasma (FFP, fluid portion of a unit of whole blood frozen in a designed time frame, usually within 8 hours) ...

During a review of Patient 1's Nursing "Admission Assessment Report," dated 6/28/2021 through 8/07/2021, indicated the following:
Assessment time 6/29/2021 at 7 p.m., (but documented on 6/29/2021 at 8:03 a.m.): Patient 1 arrived to the Intensive Care Unit (ICU, provides treatment and monitoring for people who are very ill) on 6/28/2024 at 7 p.m., Patient 1 was lethargic (lack of energy), non-verbal (unable to speak) ...intubated (a tube placed in a person's mouth or nose, then down into the airway, to keep open so air can get through) and on a ventilator (breathing machines that help keep the lungs working) ...Heart sounds were regular, Rhythm was Sinus Tachycardia (faster than normal heart rate), respiratory effort was Tachypnea (breathing more than 20 breaths per minute) on a ventilator ...

During a review of Patient 1's white blood count (WBC, component of complete blood count, that fight infection) level, indicated the following:
On 6/28/2021 at 7:11 p.m., the WBC was 39.6 (high, can indicate infection, inflammation or injury, reference range is between 4.8 - 10.8).
On 6/28/2021 at 10:25 p.m., the WBC was 46.3 (high).
On 6/29/2021 at 4:10 a.m., the WBC was 43.8 (high).

During a review of Patient 1's "Vital Signs (Temperature, Heart rate, respiratory rate, and blood pressure) Report," dated 6/28/2021 through 8/7/2021, the report included the following:
On 6/28/2021 at 7:50 p.m., the heart rate (HR, normal range is 60 - 100) was 155, Respiratory rate (RR, normal range is 12 - 18) was 34, oxygen saturation (O2 sat, normal is 95 % to 100 %) was 97 % on a ventilator.
On 6/28/2021 at 9:15 p.m., Blood pressure (BP, normal range is 120/80) was 98/33, BP Mean (pressure of blood pushing against the walls of the artery) was 37 (less than 65 indicates inability to perfuse vital organs) HR was 159 (high), RR 39 (high).
On 6/28/2021 at 9:45 p.m., BP was 46/33 (low), BP Mean was 41 (inability to perfuse vital organs) HR was 154 (high), RR 34 (high).
On 6/28/2021 at 10:45 p.m., BP was 46/33 (low), HR was 154 (high), RR was 37 (high)
Notes: On 6/28/2021 at 9:45 p.m., BP: Levophed (or Norepinephrine, treats low blood pressure) at 26 MCG/MIN.
On 6/28/2021 at 10:30 p.m., Neosynephrine (a vasopressor [constricts blood vessels] used to maintain blood pressure) 100 MCG (microgram, a unit of measurement)/MIN.

During a review of Patient 1's Lactic Acid levels (produced by the body when sugar in the blood is broken down to produce energy) indicated that Lactic Acid levels were as follows: Lactic Acid level collected on 6/29/2021 at 4:10 a.m., was 10.1 (high, normal range is less than 2). Lactic Acid level collected on 6/29/2021 at 7:55 a.m., was 10.1.

During a review of Patient 1's "Sepsis Identification & Management Checklist," dated 6/30/2021 at 6 p.m., the Checklist indicated the following: A check mark was present in the box indicating: There is Physician documentation of Sepsis, rule out (R/O) Sepsis or Septic Shock, R/O Septic Shock. No nurse screening needed. Physician documentation date and time was blank.
Nursing Sepsis Screening:
1. Infection 1 or more present: Check mark present on correlating box (indicating infection criteria is met). Descriptions, check marks present for: physician diagnosis of infection, nursing assessment or suspected infection, on antibiotic treatment for infection.
2. SIRS (Systemic inflammatory response syndrome, exaggerated defense response of the body to a noxious stressor, such as infection, trauma, surgery etc.) 2 more present: Check mark present on correlating box (indicating SIRS criteria met. Descriptions, check marks on the following: Heart rate over 90 per minute, white blood count (WBC, park of the complete blood count, help fight infections) under 4,000 or over 12,000. Creatinine over 2.0 (may indicate impaired kidney function), Acute respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood) on a ventilator.
3. Organ Dysfunction/Failure: Check mark present on correlating box (indicating organ dysfunction/failure criteria met. Descriptions, check marks on the following: Hypotension (SBP of less than 90 or MAP [mean arterial blood pressure, less than 65 which may indicate there is not enough pressure to perfuse vital organs])
The Sepsis date and time were not documented on the Checklist. Check marks were in boxes indicating: to monitor and document blood pressure for 6 hours, every 30 minutes if SBP is less than 90 or MAP is less than 65 or Lactic Acid is less than 4 to monitor for Septic Shock.
Complete within 3 hours of onset. STAT (immediately) Lactic Acid, STAT blood culture (a laboratory test to check for bacteria or other germs in the blood sample), Broad Spectrum Antibiotics (a class of antibiotics that act against an extensive range of disease-causing bacteria), Crystalloid Fluid Administration (used for sustaining maintenance fluid requirements), there were no check marks, no dates, no times, as to if and when these interventions were implemented.
Nursing Notes: Indicated "TX (treatment) in progress."

During a review of the facility's policy and procedure (P&P) titled, "Sepsis/Septic Shock Assessment and Management," dated 10/2019, the P&P indicated the following: Protocol: Screening/Assessment: I. Nurse must screen/assess all patients over or equal to age 18 years old for sepsis and septic shock following the criteria outlined in section II. Upon arrival to the Emergency Department and inpatient unit, every shift, and anytime during the hospital stay when there is a change in the patient's condition.
II. Criteria: Sepsis must meet all three (3) criteria.
1. SIRS, 2 or more: Temperature: over 100.9 Fahrenheit (F, a unit of temperature measurement) or less then 96.8 F, HR over 90, RR over 20, WBC over 12,000 ...
2. Infection, Suspected infection or confirmed.
3. New Onset Organ Dysfunction/Failure (not chronic condition), at least 1 of the following: Lactate over 2, Systolic BP less than 90, MAP less than 65, ...Acute respiratory failure, on ventilator.
Inpatient Unit: Per this policy, when a patient is positive for SIRS and Infection, a licensed nurse is authorized and shall do the following: a. Order the following labs immediately even without a specific order ...i. Lactic Acid x (times 2). ii. Blood culture times 2 ...call attending physician for antibiotic order ...

2. During a review of Patient 12's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 4/29/2024, the H&P indicated, Patient 12 had diagnosis of acute sepsis and had past medical history (PMH, records information about the patient's medical, personal and family history that might be relevant to the presenting illness) of end-stage renal disease (ESRD, final, permanent stage of chronic kidney disease when kidneys can no longer function on their own), congestive heart failure (CHF, weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), diabetes (a serious condition where your blood sugar level is too high), coronary artery disease (CAD, a condition that affects heart and heart arteries), and pacemaker (a device used to control an irregular heart rhythm).

During a review of Patient 12's medical record (MR) titled, "Triage Nursing Assessment," dated 4/29/2024, the MR indicated, Patient 12 was triaged (the prioritization of injured or sick patients based on their need for emergency treatment) on 4/29/2024 at 5:58 p.m.

During a review of Patient 12's medical record (MR) titled, "Sepsis Screening," dated 4/29/2024, the MR indicated, initial sepsis (a life-threatening complication of infection) screening/assessment (a screening tool used as a decision support mechanism for early detection of sepsis) was recorded at 8:43 p.m.

During a concurrent interview and record review on 5/3/2024 at 10:39 a.m. with registered nurse (RN 1), Patient 12's medical record titled, "Sepsis Screening," dated 4/29/2024, was reviewed. RN 1 confirmed, sepsis screening/assessment was not recorded in triage on 4/29/2024, when Patient 12 was triaged at 5:58 p.m.

During an interview on 5/3/2024 at 10:08 a.m. with registered nurse (RN 8), RN 8 stated, sepsis screening/assessment initially is done in triage. RN 8 stated, nurses shall do the assessment and document the findings in the electronic medical record. RN 6 further stated, if a patient screens positive for sepsis, the physician is informed right away, and the protocol for sepsis care and management is initiated. RN 8 stated, screening for sepsis is important because it is very critical to identify sepsis as early as possible, as it may improve patient's outcomes (results from care and treatment provided to patient).

During a review of the facility's policy and procedure (P&P) titled, Sepsis/Septic Shock Assessment and Management Protocol," dated 3/2023, the P&P indicated, "Nurse must screen/assess all patients over or equal to age 18 years old for sepsis and septic shock upon arrival in the ED (Emergency Department, responsible for providing medical care to patients arriving in the hospital in need of immediate care) and inpatient unit, every shift, and anytime during the hospital stay when there is a change in the patient's condition.

3. During a review of Patient 13's History and Physical (H&P, the most formal and complete assessment of the patient and the problem), dated 4/25/2024, the H&P indicated, Patient 13 had past medical history (PMH, records information about the patient's medical, personal and family history that might be relevant to the presenting illness) of diabetes (a serious condition where your blood glucose level is too high) hypertension (a condition in which the blood vessels have persistently raised pressure), paraplegia (a form of paralysis that mostly affects the movement of the lower body) and several wounds on right hip, right thigh, sacrum (a shield-shaped bony structure that is located at the base of the spine), and right 4th toe. The H&P further indicated Patient 13 was admitted due to an infected pressure ulcer (Damage to an area of the skin caused by constant pressure on the area for a long time).

During further review of Patient 13's medical record titled, "Triage Nursing Assessment," dated 4/24/2024, the MR indicated, Patient 13 was triaged (the prioritization of injured or sick patients based on their need for emergency treatment) on 4/24/2024, at 4:40 p.m.

During a concurrent interview and record review on 5/2/2024 at 10:39 a.m. with informatics technology nurse (RN 6), Patient 13's medical record titled, "Sepsis Screening," dated 4/24/2024, was reviewed. RN 6 confirmed, sepsis (a life-threatening complication of infection) screening/assessment (a screening tool used as a decision support mechanism for early detection of sepsis) was not recorded in triage on 4/24/2024, when Patient 13 was triaged at 4:40 p.m.

During an interview on 5/3/2024 at 10:08 a.m., with registered nurse (RN 8), RN 8 stated, sepsis screening/assessment initially is done in triage. RN 8 stated, nurses shall do the assessment and document the findings in the electronic medical record. RN 6 further stated, if a patient screens positive for sepsis, the physician is informed right away, and the protocol for sepsis care and management is initiated. RN 8 stated, screening for sepsis is important because it is very critical to identify sepsis as early as possible, as it may improve patient's outcomes (results from care and treatment provided to patient).
.
During a review of the facility's policy and procedure (P&P) titled, Sepsis/Septic Shock Assessment and Management Protocol," dated 3/2023, the P&P indicated, "Nurse must screen/assess all patients over or equal to age 18 years old for sepsis and septic shock upon arrival in the ED (Emergency Department, responsible for providing medical care to patients arriving in the hospital in need of immediate care) and inpatient unit, every shift, and anytime during the hospital stay when there is a change in the patient's condition.

4. During a review of Patient 16's medical record (MR) titled, "Emergency Department (ED) Note," dated 4/25/2024, the MR indicated, Patient 16 arrived with multiple complaints and was seen by the physician immediately. The MR further indicated, Patient 16 was noted to have a possible or confirmed severe sepsis (a life-threatening complication of infection) and time of suspected sepsis was 3:30 p.m.

During a review of Patient 16's medical record (MR), dated 4/25/2024, the MR indicated, Patient 16 arrived at the ED on 4/25/2024 and was triaged (the prioritization of injured or sick patients based on their need for emergency treatment) at 1:52 p.m., with a complaint of back pain after sustaining a fall (an unintentional event that results in the person coming to rest on the ground or another lower level) at home. The H&P indicated, Patient 16 reported pain and was confused.

During a concurrent interview and record review on 5/2/2024 at 10:25 a.m. with informatics technology nurse (RN 6) Patient 16's medical record (MR) titled, "Sepsis Screening," dated 4/25/2024, at 5.45 p.m. and Patient 16's triage nursing documentation was reviewed. The MR indicated, Patient 16's initial sepsis screening/assessment was not done until 5:45 p.m., which was a few hours after Patient 16 was triaged by the Emergency Department (ED) nurse and suspected sepsis time called. RN 6 stated, initial sepsis screening/assessment was not recorded upon patient's arrival to the ED on 4/25/2024 at 1:52 a.m.

During an interview on 5/3/2024 at 8:00 a.m. with registered nurse (RN 1), RN 1 stated, sepsis screening/assessment shall be done when patients arrive to ED, and inpatient upon admission, and every shift thereafter.

During an interview on 5/3/2024 at 10:08 a.m. with registered nurse (RN 8), RN 8 stated, sepsis screening/assessment initially is done in triage. RN 8 stated, nurses shall do the assessment and document the findings in the electronic medical record. RN 6 further stated, if a patient screens positive for sepsis, the physician is informed right away, and the protocol for sepsis care and management is initiated. RN 8 stated, screening for sepsis is important because it is very critical to identify sepsis as early as possible, as it may improve patient's outcomes (results from care and treatment provided to patient).

During a review of the facility's policy and procedure (P&P) titled, Sepsis/Septic Shock Assessment and Management Protocol," dated 3/2023, the P&P indicated, "Nurse must screen/assess all patients over or equal to age 18 years old for sepsis and septic shock upon arrival in the ED and inpatient unit, every shift, and anytime during the hospital stay when there is a change in the patient's condition.

5. During a review of Patient 23's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/26/2024, the H&P indicated, Patient 23 was admitted to the facility with diagnoses of congestive heart failure (CHF, a chronic condition in which a weakness of the heart leads to a buildup of fluid in the lungs) exacerbation (worsening), acute (new onset) hypoxic (deficiency in the amount of oxygen reaching the tissues) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood), and acute on chronic kidney disease (CKD, longstanding disease of the kidneys leading to renal failure).

During an interview on 5/1/2024 at 11 a.m. with the Director of Intensive Care Unit (ICU, provides treatment and monitoring for people who are very ill) (DICU), DICU stated the following: the facility had set policy and procedure of sepsis (a life-threatening complication of infection) for nursing staff to follow. All nursing staff will perform sepsis screening (a screening tool used as a decision support mechanism for early detection of sepsis) on all patients once a shift. Once patient has met the systemic inflammatory response syndrome (SIRS, an exaggerated defense response of the body to a noxious stressor such as infection, trauma, surgery, acute inflammation and ischemia [less than normal amount of blood flow to a body part]) criteria for sepsis, the nursing staff should follow the protocol to order specific blood tests and notify physician. It is important to identify sepsis in early stage and follow the protocol in order to reduce mortality (death) otherwise patient could deteriorate and go into shock (critical condition brought on by the sudden drop in blood flow through the body, may result from trauma, blood loss or infection).

During a concurrent interview and record review on 5/2/2024 at 1:39 p.m. with the Performance Improvement Coordinator (PIC), Patient 23's "Sepsis Screening" dated 4/29/2024 at 8 a.m. was reviewed. The sepsis screening indicated the following:

Level 1 - Infection: documented infection

Level 2 - SIRS (sepsis SIRS x 2 criteria present): respiratory rate over 20 breath per minute (bpm), white blood cells (WBC, part of body's immune system help the body to fight infection and other diseases) below 4,000 or above 12,000 or bands (type of white blood cell, increase band cell count may indicate infection or inflammation of body) above 10%

Level 3 - organ dysfunction: acute respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood)

PIC stated the sepsis screening had indicated Patient 23 met all three criteria for sepsis screening and nursing staff should have ordered blood tests including lactic acid (produced by the body when sugar in the blood is broken down to produce energy) and blood culture (a laboratory test to check for bacteria or other germs in the blood sample), and to notify physician for additional intervention including antibiotics (medicine to treat infection) and fluid administration within three (3) hours per the facility's sepsis policy. PIC stated the lactic acid and blood culture were not ordered for Patient 23 at all. PIC stated the nursing staff did not follow the facility's sepsis policy and procedure.

During a review of the facility's policy and procedure (P&P) titled, "Sepsis/Septic Shock Assessment and Management," dated 10/2019, the P&P indicated the following: Protocol: Screening/Assessment: I. Nurse must screen/assess all patients over or equal to age 18 years old for sepsis and septic shock following the criteria outlined in section II. Upon arrival to the Emergency Department and inpatient unit, every shift, and anytime during the hospital stay when there is a change in the patient's condition.
II. Criteria: Sepsis must meet all three (3) criteria.
1. SIRS, 2 or more: Temperature: over 100.9 Fahrenheit (F, a unit of temperature measurement) or less than 96.8 F, HR over 90, RR over 20, WBC over 12,000 ...

2. Infection, Suspected infection or confirmed.
3. New Onset Organ Dysfunction/Failure (not chronic condition), at least 1 of the following: Lactate over 2, Systolic BP less than 90, MAP (mean arterial blood pressure, less than 65 [may indicate there is not enough pressure to perfuse vital organs]) less than 65, ...Acute respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood), on ventilator.
Inpatient Unit: Per this policy, when a patient is positive for SIRS and Infection, a licensed nurse is authorized and shall do the following: a. Order the following labs immediately even without a specific order ...i. Lactic Acid x (times 2). ii. Blood culture times 2 ...call attending physician for antibiotic order ...

6. During a review of Patient 27's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/19/2024, the H&P indicated, Patient 27 was admitted to the facility with diagnoses of pneumonia (lung infection), sepsis (a life-threatening complication of infection), chronic obstructive pulmonary disease (COPD, a lung disease characterized by long-term poor airflow) exacerbation (worsening) and acute (new onset) on chronic respiratory failure (condition in which not enough oxygen passes from the lungs into the blood).

During an interview on 5/1/2024 at 11 a.m. with the Director of ICU (DICU), DICU stated the following: the facility had set policy and procedure of sepsis for nursing staff to follow. All nursing staff will perform sepsis screening (a screening tool used as a decision support mechanism for early detection of sepsis) on all patients once a shift. Once patient has met the systemic inflammatory response syndrome (SIRS, an exaggerated defense response of the body to a noxious stressor such as infection, trauma, surgery, acute inflammation and ischemia) criteria for sepsis, the nursing staff should follow the protocol to order specific blood tests and notify physician. It is important to identify sepsis in early stage and follow the protocol in order to reduce mortality otherwise patient could deteriorate and go into shock.

During a concurrent interview and record review on 5/2/2024 at 3:41 p.m. with the Performance Improvement Coordinator (PIC), Patient 27's "Sepsis Screening" dated 4/19/2024 at 6:26 p.m. was reviewed. The sepsis screening indicated the following:
Level 1 - Infection: suspected new infection
Level 2 - SIRS (sepsis SIRS x 2 criteria present): respiratory rate over 20 breath per minute (bpm), white blood cells (WBC, part of body's immune system help the body to fight infection and other diseases) below 4,000 or above 12,000 or bands (type of white blood cell, increase band cell count may indicate infection or inflammation of body) above 10%
Level 3 - organ dysfunction: acute respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood)
PIC stated the sepsis screening had indicated Patient 27 met all three criteria for sepsis screening and nursing staff should have ordered blood tests including lactic acid (produced by the body when sugar in the blood is broken down to produce energy) and blood culture (a laboratory test to check for bacteria or other germs in the blood sample), and to notify physician for additional intervention including antibiotics and fluid administration within three (3) hours per the facility's sepsis policy. PIC stated Patient 27's lactic acid test was collected on 4/20/2024 at 4 a.m., which was not within three (3) hours from the time Patient 27 met all three criteria for sepsis screening. PIC stated the nursing staff did not follow the facility's sepsis policy and procedure.

During a review of the facility's policy and procedure (P&P) titled, "Sepsis/Septic Shock Assessment and Management," dated 10/2019, the P&P indicated the following: Protocol: Screening/Assessment: I. Nurse must screen/assess all patients over or equal to age 18 years old for sepsis and septic shock following the criteria outlined in section II. Upon arrival to the Emergency Department and inpatient unit, every shift, and anytime during the hospital stay when there is a change in the patient's condition.
II. Criteria: Sepsis must meet all three (3) criteria.
1. SIRS, 2 or more: Temperature: over 100.9 Fahrenheit (F, a unit of temperature measurement) or less than 96.8 F, HR over 90, RR over 20, WBC over 12,000 ...
2. Infection, Suspected infection or confirmed.
3. New Onset Organ Dysfunction/Failure (not chronic condition), at least 1 of the following: Lactate over 2, Systolic BP less than 90, MAP less than 65, ...Acute respiratory failure, on ventilator.
Inpatient Unit: Per this policy, when a patient is positive for SIRS and Infection, a licensed nurse is authorized and shall do the following: a. Order the following labs immediately even without a specific order ...i. Lactic Acid x (times 2). ii. Blood culture times 2 ...call attending physician for antibiotic order ...

Based on interview and record review, the facility failed to ensure antibiotics (Zosyn and Linezolid, medications to fight infections) were given in a timely manner (every 8 hours for Zosyn and every 12 hours for Linezolid) for one of 30 sampled patients (Patient 1) in accordance with the physician order and the facility's policy and procedure regarding medication administration.

This deficient practice resulted in a delay in treatment and had the potential for the antibiotic to be ineffective.

Findings:

During a concurrent interview and record review on 5/1/2024 at 2:30 p.m. with the Director of Intensive Care Unit (DICU) and the Director of Pharmacy (DOP), the DICU and the DOP stated the following: Patient 1 had an order for Zosyn (antibiotic to treat infection) on 6/29/2021 at 5:11 a.m., to be given every eight (8) hours and to start at 8 a.m., on 6/29/2024. The first dose should have been given at 8 a.m., it was not given, and there was no reason documented as to why it had not been given. The first dose was given almost four (4) hours later, at 10:56 a.m. The next dose of Zosyn was given on 6/29/2021 at 7:42 p.m. The third dose was given on 6/30/2021 at 11:57 a.m., almost sixteen (16) hours later. The DICU and DOP stated the Zosyn had been started almost 4 hours late and the third dose was given almost 16 hours after the second dose. Both the DICU and the DOP verified the Zosyn had not been given as ordered by the physician.
In addition, the DOP verified that Linezolid should have been given on 6/30/2021 at 9 a.m., but instead, it was given at 1:13 p.m. The DOP stated it was very important to give the antibiotics on time for the medications to be effective.

During a review of Patient 1's "Pulmonary Consultation Note," dated 6/29/2021 at 1:40 p.m., the note indicated the following: Patient 1 was admitted on 6/28/2021 at 8:56 a.m., ...Patient 1, 35-year-old woman with history of morbid obesity (more than 100 pounds [lbs, a unit of measurement] over ideal body weight), hypertension (high blood pressure), diabetes mellitus (too much sugar in the blood) came to hospital for outpatient surgery for spine yesterday (6/28/2021). Admitted to Intensive Care Unit (ICU, provides treatment and monitoring for people who are very ill) after symptoms for shock (acute medical condition caused by such events as loss of blood, bacterial infection, marked by irregular breathing and rapid pulse), hypoxia (not enough oxygen in the blood) and respiratory failure (inability to breathe on your own) ...Noticed to have DIC (disseminated intravascular coagulation, condition that affects the body's ability to clot and stop bleeding) as well as renal shut down (kidneys unable to remove waste and balance fluids), and severe metabolic acidosis (too much acid in the body) ...

During a review of Patient 1's physician's order dated 6/29/2021 at 5:11 a.m., the order indicated to give Zosyn (piperacillin tazobactam, an antibiotic, fights infections) 3.375 GM (gram, a unit of measurement) ...IVPB (IV [in the vein] piggyback) every eight (8) hours, start: Next scheduled time (8 a.m.).

During a review of Patient 1's "Medication Administration Record (MAR)," the MAR indicated the following:
On 6/29/2021 at 8 a.m., Zosyn was not given.
On 6/29/2021 at 10:56 a.m., Zosyn was given (late administration- 3 hours late).
On 6/29/2021 at 8:42 p.m., Zosyn was given.
On 6/30/2021 at 11:57 a.m., Zosyn was given (late administration- 16 hours late).

During a review of Patient 1's physician's order dated 6/29/2021 at 9 p.m., the order indicated to give Linezolid 600 mg every twelve (12) hours (at 9 p.m., and 9 a.m.,) IVPB.

During a review of Patient 1's "Medication Administration Record (MAR)," the MAR indicated the following: Linezolid 600 mg was given on 6/30/2021 at 1:13 p.m. (4 hours late).

During a review of the facility's policy and procedure (P&P) titled, "Medication Administration," reviewed date 10/2023, the P&P indicated the following: Medication will be administered to the patient: Within 4 hours for new medication orders ...Schedule to Administration Frequency ...Every 8 hours: 8 a.m., 4 p.m., and 12 a.m. (midnight).

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

1. Mark/Label the date and time on the enteral feeding formula (a liquid food composed of essential nutrients and fluid which enters the body through a tube in the nose or stomach) with the date and time the formula was started for one of 30 sampled patients (Patient 20), in accordance with the facility's policy and procedure regarding enteral and oral (by mouth) feeding.

This deficient practice had the potential to compromise Patient 20's health and wellbeing by exceeding product hang time that could lead to bacterial contamination.

2. Initiate contact isolation precautions (intended to prevent transmission of infectious agents) and obtain a physician's order for isolation for one of thirty sampled patients (Patient 20) in accordance with the facility's policy and procedure regarding isolation precautions.

This deficient practice had the potential to place other patients, visitors and staff at an increased risk for spreading and contracting an infection.

3. Discard an opened single-use bottle of sodium chloride that was used for irrigation of a wound for one of 30 sampled patients (Patient 3) in accordance with the manufacturer's label instructions. This deficient practice had the potential to cause infection for Patient 3.

4. Ensure one of 30 sampled patient's (Patient 4) urinary collection bag was hung properly, without touching the floor in accordance with the facility's policy and procedure regarding catheter care and collection bag maintenance. This deficient practice had the potential for bacterial contamination of the catheter bag and infection of the urinary tract (the body's drainage system for removing urine).

5. Discard expired sterile supplies and remove all tape and tape residue from the Operating Room (OR, where surgical procedures are performed) table's mattress for one of one sampled OR suite (OR #3).

This deficient practice had the potential for contamination of the sterile supplies and spreading infection to the patients undergoing a procedure.

Findings:

1. During a review of Patient 20's History and Physical, (H&P, the most formal and complete assessment of the patient and the problem), dated 4/27/2024, the H&P indicated, Patient 20 had past medical history (PMH, records of information about the patient's medical, personal and family history) of hypertension (a condition in which the blood vessels have persistently raised pressure), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and percutaneous endoscopic gastrostomy (PEG placement, a surgery to place a feeding tube [PEG tube] into the stomach to deliver nutrition through the tube). The H&P further indicated, Patient 20 was admitted on 4/26/2024 due to atrial fibrillation (AFib, an irregular and very rapid heart rhythm).

During a concurrent observation and interview on 4/29/2024 at 2:26 p.m., with charge nurse (CN 2), Patient 20's enteral feeding (the process of the delivery of nutritional needs and fluids directly into the stomach through a tube) was observed. Enteral feeding formula was running at 35 milliliters (ml, measuring unit) per hour. The feeding formula bottle had no label that would indicate the time and date of administration. CN 2 stated, the feeding formula had to be dated, timed, and initialed by the person administering the formula. CN 2 further stated, enteral feeding formula hang time should not exceed 24 hours due to a risk of bacterial contamination.

During an interview on 5/2/2024 at 3:59 p.m. with director of Intensive Care Unit (DICU), DICU stated, all feeding bottles when hung should have a label, that contains a date, time, and initial of the person initiating feeding formula.

During a review of the facility's policy and procedure (P&P) titled, "Enteral and Oral Feeding," dated 5/2023, the P&P indicated, "Nursing staff is responsible for administration of enteral feeding following nursing enteral tube feeding policy and procedures. Policy will include a product hanging time of no more than 24 hours for closed-system and 8-12 hours for open-system with date and time initialed. Licensed nurse should mark the hanging time and date of ready to hang formula or enteral bag using permanent waterproof ink."

2. During a review of Patient 20's History and Physical, (H&P, the most formal and complete assessment of the patient and the problem), dated 4/27/2024, the H&P indicated, Patient 20 had past medical history (PMH, records of information about the patient's medical, personal and family history) of hypertension (a condition in which the blood vessels have persistently raised pressure), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and percutaneous endoscopic gastrostomy (PEG placement, a surgery to place a feeding tube [PEG tube] into the stomach to deliver nutrition through the tube). The H&P further indicated, Patient 20 was admitted on 4/26/2024 due to atrial fibrillation (AFib, an irregular and very rapid heart rhythm).

During a review of Patient 20's medical record (MR) titled, "Internal Medicine Progress Note," dated 4/29/2024, the MR indicated, on 4/26/2024 Patient 20 tested positive for Escherichia coli (E.coli) ESBL in urine (E. coli bacteria producing small proteins (enzymes) called extended-spectrum beta-lactamases [ESBLs] that are antibiotic resistant), and on 4/27/2024, Patient 20 tested positive for Methicillin Resistant Staph Aureus (MSRA, a type of bacteria that's become resistant to many of the antibiotics).

During a concurrent observation and interview on 4/29/2024 at 2:26 p.m., with charge nurse (CN 2), Patient 20 was observed in the room, resting in bed. No isolation sign (isolation precaution sign to indicate the need to implement measures to protect other patients, staff and visitors from contact with infectious agents) was posted outside the door (Patient 20's door). RN 2 stated, Patient 20 tested positive for ESBL in urine and should be on isolation precautions, but no sign for "Contact Isolation" (requires anyone entering the room to wear gloves, mask, and a gown to prevent the spread of germs in the facility) was posted outside Patient 20's room.

During a concurrent interview and record review on 5/2/2024, at 4:05 p.m. with informatics technology nurse (RN 6), Patient 20's medical record titled, "Physician's orders," dated 4/26/2024-4/29/2024 was reviewed. RN 6 verified, no there was no isolation precautions order placed in Patient 20's medical chart.

During a review of the facility's policy and procedure (P&P) titled, "Multiple Drug Resistant Organisms Isolation," dated, 11/2019, "Patients with identified multi-organism infections such as vancomycin resistant Group D enterococci (VRE). Isolation can be initiated by nursing or Infection Control, but an order should be obtained from the primary care physician prior to placing the patient in isolation or as soon as possible after. Gowns and gloves should be worn to prevent direct contact with the patient or articles potentially contaminated with the patient's body substances. Contact isolation protocol requires wearing gloves, a mask, and a gown upon entering room."

3. During a review of Patient 3's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/14/2024, the H&P indicated Patient 3 was admitted to the facility with a chief complaint of cholecystitis (inflammation of the gallbladder), anemia (deficiency of red blood cells in the blood), and gangrene toe (localized death and decomposition of body tissue, resulting from either obstructed circulation or bacterial infection).

During an observation on 4/29/2024 at 2:55 p.m. in the Telemetry (a floor in the hospital where patients undergo continuous heart monitoring) Unit, there was one opened bottle of 0.9 % Sodium Chloride (an irrigation solution to wash and clean body cavities and wounds) 250 ml (milliliter, a unit of measurement) on top of Patient 3's bedside table. Patient 3 was in bed and had a dressing to the left toes.

Concurrently, during an interview on 4/29/2024 at 2:55 p.m. with the Director of the Telemetry Unit (DOT), the DOT stated the Sodium Chloride was used to clean Patient 3's toe, that had gangrene (localized death and decomposition of body tissue, resulting from either obstructed circulation or bacterial infection). The DOT stated she (DOT) did not know when the bottle of Sodium Chloride was opened, and that it was good for 72 hours after opening. The DOT said that since the date of when the bottle of solution was opened was unknown, then the bottle should be discarded, to prevent infection.

During a review of the bottle of 0.9 % Sodium Chloride label, the label indicated the following: Indications: For moistening of a wound dressing, wound debridement (removal of dead or infected skin tissue) and device irrigation. Not for injection. No antimicrobial or other substance added. Sterile ...Single use. Discard unused portion.

4. During a review of Patient 4's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 4/28/2024, the H&P indicated Patient 4's chief complaint was acute urinary tract infection (UTI, a common infection that happens when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract) with obstructive (blockage that prevents urine flow) kidney stone.

During an observation on 4/29/2024 at 3:10 p.m., in the Telemetry Unit (a floor in the hospital where patients undergo continuous heart monitoring), Patient 4 was observed awake and alert in bed. Patient 4's urinary collection bag (a bag that collects urine from the bladder) was hanging on the right side of the bed and was touching the floor.

Concurrently, during an interview on 4/19/2024 at 3:10 p.m., the Director of the Telemetry Unit (DOT) stated the urinary collection bag should not be touching the floor because the bag can become contaminated and cause infection.

During a review of the facility's policy and procedure (P&P) titled, "Catheter Care, Foley/Indwelling Urinary," dated 7/2023, the P&P indicated A. Purpose: To prevent catheter-associated urinary tract infection and ensure compliance with evidence-based guidelines for insertion, maintenance, and care of indwelling urinary catheter ....C. Procedure ...Keep the collection bag below the level of the bladder at all times; but do not rest the bag on the floor.

5. During an observation on 4/30/2024 beginning at 10:06 a.m., at the Operating Room (OR) suite, the following was observed: Expired endotracheal tubes (ETT, tubes that are placed through the mouth and into the windpipe to help assist breathing during surgery) size 5, fourteen (14) ETT expired on 11/12/2023 and for size 6, two (2) expired on 3/18/2024). At 10:50 a.m. in OR # 3, two staplers (used to close internal and external wounds) and 1 package of staples (a piece of metal or wire in the shape of a U that is used for attaching things) were expired. The two staplers expired on 1/31/2024 and staples expired 2/29/2024. Likewise, Adhesive tape and tape residue was observed on the Allen Spinal table (a specialty table for complex surgical procedures for patients weighing over 600 pounds [lbs, a unit of measurement]) with 2 padded holders, one holder to hold chest and one to hold abdomen area, on each of the left sides of the padded holders.

Concurrently, during an interview on 4/30/2024 at 10:54 a.m., with the Clinical Shift Supervisor (CCS) 2 and the Director of Peri-Operative Services (DPOS), the CSS 2 stated supplies should be checked for expiration dates every month and expired supplies should be discarded. Expired supplies may lose their sterility and have the potential for infection. In addition, DPOS stated all tape should be removed from the operating tables after each surgery and stated that tape and tape residual could be an infection control issue if not removed.

During an interview on 5/3/3024 at 2:37 p.m., with the Infection Control Practitioner (ICP), the ICP stated the following: Expired supplies were not allowed and should be removed due to possible contamination. In addition, it was not acceptable to have tape and tape residue on the OR table because it collects bugs and can get contaminated. All tape and tape residue should be removed.

During a review of the facility's policy and procedure (P&P) titled, "Supplies: Sterile Supplies, Outdated," dated 3/2023, the P&P indicated ...nursing personnel in each area of the hospital will use sterile supplies in a rotational system, so that the supplies stored first, will be used first. All outdated supplies much be returned to Central Service immediately.

During a review of the facility's policy and procedure (P&P) titled, "Surgery Room Between Case Cleaning," dated 12/2021, the P&P indicated to clean surgical table beginning at the top and work down to base of table. Remove cushions damp clean both sides and table base with cleaning cloth and a disinfectant.

Based on observation, interview and record review, the facility failed to ensure one of 30 sampled patients (Patient 2) had a complete filled out History and Physical examination note (a formal and complete assessment of the patient and the problem) in the medical record, prior to Patient 2's surgical procedure, in accordance with the facility's "Medical Staff Rules and Regulations."

This deficient practice had the potential for the surgical team to be unaware of clinical conditions that may negatively affect Patient 2 during or after the surgical procedure.

Findings:

During an observation on 4/30/2024 at 10:05 a.m., in the recovery room (an area near the operating room where a patient will be monitored after surgery), Patient 2 was observed recovering after surgery.

During a concurrent interview and record review on 5/2/2024 at 3:15 p.m., with the Director of Peri-Operative Services (DPOS), the DPOS stated the following: A History and Physical (H&P, a formal and complete assessment of the patient and the problem) examination was required to be in the patient's (Patient 2) medical record, prior to patient's surgical procedure so the surgical team would be aware of any allergies, co-morbidities (simultaneous presence of two or more medical conditions in a patient), current medications, and past medical history and patient's current condition. The DPOS verified that there were two pages to Patient 2's H&P, one of the pages was titled "Admitting History and Physical Examination," was untimed, undated, and unsigned by a physician. Another page titled, "Physical Examination," was dated 4/30/2024 at 2 p.m., it (Physical Examination page) had been faxed on 4/29/2024 at 2:37 p.m. The DPOS stated the H&P dated 4/30/2024 at 2 p.m., that had been faxed from the doctor's office was incomplete and was missing the first page (included chief complaint, history of present illness, past surgical and medical history, etc.), so the Surgeon (MD 11) filled out a separate form titled "Admitting History and Physical Examination." However, the form was not signed dated, timed, or signed by MD 11. In addition, the DPOS verified that the faxed H&P was dated after the surgical procedure at 2 p.m., and the surgery took place in the morning, around 9 a.m. on 4/30/2024.

During a concurrent interview and record review, on 5/2/2024 at 4 p.m., with registered nurse (RN) 1, RN 1 stated Patient 2 arrived at Pre-op (Pre-operative holding area, where patients wait as they are prepared for surgery) on 4/30/2024 at 6:38 a.m. Patient 2 had surgery between 8 a.m. and 9:46 a.m. After recovering from anesthesia (temporary loss of sensation), Patient 2 was admitted to an inpatient unit (where the patient is admitted overnight whether briefly or for an extended period of time depending on their condition) on 4/30/2024 at 11:05 a.m. RN 1 verified that there were two pages to Patient 2's H&P, one of the pages was titled "Admitting History and Physical Examination, was untimed, undated, and unsigned by a physician. Another page titled, "Physical Examination," was dated 4/30/2024 at 2 p.m., it had been faxed on 4/29/2024 at 2:37 p.m.

During a review of Patient 2's "Operative Note," dated 4/30/2024 at 9:30 a.m., the Operative Note indicated Patient 2 had a surgical procedure for a right ovarian cyst (a fluid-filled sack on the surface of the ovaries) removal.

During a review of a document for Patient 2 titled, "Physical Examination," dated 4/30/2024 at 2 p.m., the Physical Examination document indicated it had been faxed on 4/29/2024 at 2:37 p.m.

During a review of a document for Patient 2 titled, "Admitting History and Physical Examination," the document indicated it was untimed, undated, and unsigned by a physician.

During a review of the facility's "Medical Staff Rules and Regulations," dated 2/2020, the Medical Staff Rules and Regulations indicated that a complete admission history and physical examination must be recorded within twenty-four (24) hours after the admission of all patients ...To be acceptable outside reports should be in form approved by the hospital, or a reasonable facsimile of such format compatible with the current medical record system ...When the history and physical examination are not recorded before an operation ...the procedure shall be cancelled unless the attending practitioner states in writing that the delay would be detrimental to the patient.

Based on interview and record review, the facility failed to ensure its surgeons completed the comprehensive operative report immediately following surgery for two of 30 sampled patients (Patient 24 and Patient 29).

This deficient practice had the potential for healthcare team not being able to identify care needs for Patient 24 and Patient 29 and may delay treatment and care rendered after surgeries.

Findings:

1. During a review of Patient 24's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 5/1/2024, the H&P indicated, Patient 24 was admitted to the facility with diagnoses of small bowel obstruction (a gastrointestinal condition in which digested material is prevented from passing normally through the bowel), and leukocytosis (high white blood cell count).

During a review of Patient 24's "Authorization and Consent to Surgery or Special Diagnostic or Therapeutic Procedures (informed consent, a process in which a health care providers educates a patient about the risks, benefits, and alternatives of a given procedure or intervention)," dated 5/1/2024, the informed consent indicated Patient 24 consented for a surgical procedure of diagnostic laparoscopy (surgical procedure to examine the organs in the abdomen) exploratory laparotomy (general surgical operation where the abdomen was opened and the abdominal organs are examined for injury or disease) possible bowel resection (surgery to remove part of the small intestine, large intestine or both).

During a concurrent interview and record review on 5/3/2024 at 2:28 p.m. with the Director of Peri-Operative (DPOP), Patient 24's "Pre-Operative H&P Update Operative Notes (report completed date of surgery to given information of the surgery performed)," dated 5/2/2024 was reviewed. The operative notes indicated surgeon (MD 11) performed a procedure on Patient 24 on 5/2/2024. The DPOP stated surgeons were required to write the operative notes immediately after surgery in order to communicate with other providers to note what procedure was performed, what was the finding and if there was any tissue removed or any biopsy done. DPOP stated Patient 24's operative notes were handwritten by MD 11 and she (DPOP) was not able to read and understand Surgeon 1's handwriting. DPOP stated there should be a comprehensive operative report to follow immediately after the surgery, but it was not found. DPOP stated without the operative notes, the other providers would not know what was done in surgery and what to look out for after surgery for Patient 24.

During an interview on 5/3/2024 at 3:40 p.m. with the Director of Health Information Management (HIM), HIM stated MD 11 did not complete the comprehensive operative report for Patient 24, immediately after the surgery.

During a review of the facility's "Medical Staff Rules and Regulations (rules and regulations)," dated 6/2020, the rules and regulations indicated, "All diagnostic and therapeutic procedures should be recorded and authenticated in the medical record ... Operative reports: should be dictated or written in the medical record immediately after surgery and should contain a description of the findings, the technical procedures used, the specimens removed, the postoperative diagnosis, and the same of the primary surgeon and assistants. The complete operative report should be authenticated by the surgeon and filed in the medical record as soon as possible after surgery. There shall be a comprehensive operative progress note entered in the medical record immediately after surgery in order to provide pertinent information for use by any practitioner who is required to attending the patient."

2. During a review of Patient 29's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 4/23/2024, the H&P indicated, Patient 29 was admitted to the facility with diagnosis of abscess (a pocket of pus formed any part of the body) of left gluteal (buttock area).

During a review of Patient 29's "Authorization and Consent to Surgery or Special Diagnostic or Therapeutic Procedures (informed consent)," dated 5/1/2024, the informed consent indicated Patient 29 consented for a surgical procedure of incision and drainage (I&D, surgical procedure to release pus or pressure built up under the skin) of left groin and left buttock abscess.

During a concurrent interview and record review on 5/3/2024 at 2:40 p.m. with the Director of Peri-Operative (DPOP), Patient 29's "Pre-Operative H&P Update Operative Notes," dated 4/26/2024 was reviewed. The operative notes indicated surgeon (MD 11) performed a procedure on Patient 29 on 4/26/2024. The DPOP stated surgeons were required to write the operative notes immediately after surgery in order to communicate with other providers to note what procedure was performed, what was the finding and if there was any tissue removed or any biopsy done. DPOP stated Patient 29's operative notes was handwritten by MD 11 and she (DPOP) was not able to read because it was illegible.

During a concurrent interview and record review on 5/3/2024 at 3:40 p.m. with the Director of Health Information Management (HIM), Patient 29's "Operative Note," dated 4/30/2024 was reviewed. The operative note indicated the date of completion on 4/20/2024. HIM stated MD 11 did not follow the medical staff rules and regulation to complete the operative notes immediately after surgery.

During a review of the facility's "Medical Staff Rules and Regulations (rules and regulations)," dated 6/2020, the rules and regulations indicated, "All diagnostic and therapeutic procedures should be recorded and authenticated in the medical record ... Operative reports: should be dictated or written in the medical record immediately after surgery and should contain a description of the findings, the technical procedures used, the specimens removed, the postoperative diagnosis, and the same of the primary surgeon and assistants. The complete operative report should be authenticated by the surgeon and filed in the medical record as soon as possible after surgery. There shall be a comprehensive operative progress note entered in the medical record immediately after surgery in order to provide pertinent information for use by any practitioner who is required to attending the patient."