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Based on interview and record review, the facility failed to provide Abuse (intentional maltreatment of an individual that may cause physical or psychological injury) Training for two of six sampled staff members (Registered Nurses (RN) 5, and RN 6), in accordance with the facility ' s policies and procedures regarding abuse training.

This deficient practice had the potential for staff not to be informed of abuse, neglect, related reporting requirements, including prevention, intervention, and detection, which could potentially compromise patient safety.

Findings:

During a concurrent interview and record review on 11/2/2023 at 10:32 a.m., with the Human Resources Director (HRD), the Director of Education (DOED), and the Regional Director of Accreditation, Regulatory and Licensing (RDARL), the staff personnel files were reviewed. The HRD, DOED, and the RDARL verified that RN 5 did not have current Abuse training and RN 6 did not receive Abuse training upon hire. The RDARL stated the facility ' s policy regarding Abuse training required staff to receive Abuse training upon hire and every two years thereafter. The DOED stated staff were required to have the Abuse training because the staff were mandated reporters, in addition, staff needed to be able to recognize signs and symptoms of abuse and neglect in patients. The personnel files indicated the following:

Registered Nurse (RN) 5 was hired on 6/2014. RN 5 ' s last "Abuse Assessment and Reporting," training was completed on 3/30/2021.

RN 6 was hired on 8/2023. RN 6 did not have evidence of completing the facility ' s Abuse training in the personnel file. This was confirmed by the HRD, DOED, and the RDARL.

During a review of the facility ' s policy and procedure (P&P) titled, "Patient Rights: Protection from Abuse, Exploitation, Neglect & Harassment," dated 5/24/2023, the P&P indicated the following: "Train: All employees receive abuse training upon hire and ongoing education at least every two years. The training/education provides all employees with information regarding abuse and neglect, and related reporting requirements, including prevention, intervention, and detection."

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

The facility failed to ensure that one of 30 sampled patients (Patient 1) was assessed and reassessed for change of condition including response to interventions in accordance with accepted standards of nursing practice and the facility ' s policy regarding assessment, reassessment, and coordination of care within the healthcare team to address a patient ' s care needs.

This deficient practice resulted in delay of care provided to Patient 1 by failing to assess and evaluate Patient 1 ' s immediate care needs, worsening health condition, and intervene on an on-going basis. This deficient practice also had the potential to contribute to Patient 1 ' s negative outcomes such as continued decline in health condition requiring life-saving intervention. (Refer to A-0395)

2. The facility failed to ensure that a comprehensive care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) was developed and implemented for two of 30 sampled patients (Patient 1 and Patient 2) in accordance with the facility ' s policy and procedure regarding care plan development and implementation when:

2a. Patient 1 who was admitted with Renal (kidney) failure and Congestive Heart Failure (CHF, a long-term condition in which the heart can't pump blood well enough to meet the body's needs) did not have a care plan to address fluid volume and respiratory (breathing) issues.

2b. Patient 2 who was admitted with acute hypoxemic respiratory failure (occurs when the respiratory system cannot adequately provide oxygen to the body due to low levels of oxygen in the body) did not have a care plan to address respiratory (breathing) issues.

These deficient practices had the potential to delay provision of care to Patient 1 and Patient 2 by not identifying the patients ' needs and risk, which may result in patient harm or death. (Refer to A-0396)

3. The facility failed to ensure one of thirty sampled patients ' (Patient 1) vital signs (VS, temperature, blood pressure, respiratory rate, heart rate that indicates the state of a patient's essential body functions) was monitored, assessed, reassessed and recorded in accordance with the facility ' s policies and procedures regarding assessment, reassessment, and documentation.

This deficient practice had the potential to result in Patient 1 ' s medical issues or change of condition not properly monitored and goes undetected, which may negatively affect the patient ' s health and safety. (Refer to A-0398)

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

Based on interview and record review, the facility failed to ensure that one of 30 sampled patients (Patient 1) was assessed and reassessed for change of condition including response to interventions in accordance with accepted standards of nursing practice and the facility ' s policy regarding assessment, reassessment, and coordination of care within the healthcare team to address a patient ' s care needs.

This deficient practice resulted in delay of care provided to Patient 1 by failing to assess and evaluate Patient 1 ' s immediate care needs, worsening health condition, and intervene on an on-going basis. This deficient practice also had the potential to contribute to Patient 1 ' s negative outcomes such as continued decline in health condition requiring life-saving intervention.

Findings:

During a review of Patient 1 ' s Emergency Department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care) provider note, dated 8/19/2017 at 2:06 a.m., the ED note indicated, on 8/19/2017 at 1:19 a.m. Patient 1 was seen in the ED for progressive weakness, inability to walk due to weakness, and inability to eat. The ED note further indicated, Patient 1 ' s blood pressure (BP) was 66/32 (abnormally low blood pressure, lower than 90/60 millimeters of mercury [mm Hg, measuring unit]), pulse (P) 58 (low, normal is between 60 to 100) beats per minute (bpm), respirations (R) 14, and oxygen saturation rate (SpO2, measured to demonstrate how well lungs are working) was 85% (oxygen saturation levels below 95% are considered abnormal).

The ED note also indicated, Patient 1 was placed on a cardiac monitoring (a machine that watches the electrical activity of the heart to ensure it is working normally) and an electrocardiogram (EKG, a simple test that can be used to check your heart's rhythm [the pattern and amount of time that passes in between each heartbeat] and electrical activity) was ordered.

During a concurrent interview and record review on 11/1/2023, at 9:58 a.m. with Clinical Informatics Specialist (CSI 1), Patient 1 ' s EKG results, dated 8/19/2017, at 1:50 a.m., was reviewed. The EKG strip indicated, Patient 1 had Atrial Fibrillation with Rapid Ventricular Response (A-fib with RVR, In A-fib with RVR, the heart ' s lower chambers beat too quickly and irregularly, resulting in a rapid heart rate. RVR can develop in people with A-fib, disrupting the regular supply of blood to the body's organs). The CIS 1 confirmed, the EKG strip was not signed by the provider, and it was not recorded in Patient 1 ' s chart as reviewed.

During a review of Patient 1 ' s ED provider note, dated 8/19/2017, at 4:36 a.m., the ED note indicated, Patient 1 was diagnosed with acute-on-chronic renal failure (decline in renal [kidney] function in patients with known kidney disease often caused by hypovolemia [low fluid volume] due to an episode of concurrent illness such as infection) and elevated troponin I (protein found in the muscles of the heart, even a slight increase in the troponin level may indicate damage to the heart muscle). The ED provider note had no documentation of Patient 1 ' s EKG results obtained on 8/19/2017 at 1:50 a.m.

During a review of Patient 1 ' s Vital Signs (VS, temperature, blood pressure, respiratory rate, heart rate) record in the ED, dated 8/19/2017, the ED VS record indicated the following:

On 8/19/2017, at 2:19 a.m. Patient 1 ' s BP was 66/32 (low, normal is 120/80), Temperature was 98.2 (Fahrenheit, a unit of measurement), Pulse was 58 (low, normal is between 60 to 100), Respiratory rate was 14.

On 8/19/2017, at 1:32 a.m., Patient 1 ' s BP was 113/84, Temperature not recorded, Pulse 92, Respiratory rate 20, SpO2 (oxygen saturation rate, measured to determine how well the lungs are working) 94%;

On 8/19/2017, at 4:00 a.m., Patient 1 ' s BP was 114/73, Pulse 105, Respiratory rate 26 (high, normal is 12-18 breaths per minute), no SpO2 documented, no Temperature recorded.

The ED VS record further indicated, on 8/19/2017 at 4:30 a.m., Patient 1 ' s BP was 94/77, Pulse 85, Respiratory rate 26 (high, normal is 12-18 breaths per minute), SpO2 98%.

Patient 1 ' s last ED documented VS indicated, on 8/19/2017, at 5:01 a.m., BP was 108/64, Pulse 90, no Temperature recorded, Respiratory rate 34 (high, normal is 12-18 breaths per minute), no SpO2 documented, cardiac rhythm AFib (Atrial Fibrillation). The ED VS record did not indicate if Patient 1 ' s oxygen saturation rate was measured while Patient 1 was on room air (RA) or on supplemental oxygen.

During a review of Patient 1 ' s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 8/19/2017, the H&P indicated, on 8/19/2017, Patient 1 was admitted to the Observation Unit (area where patients are monitored and evaluated) on a medical surgical floor (a specific area of the hospital that cares for patient with a variety of health issues that are not life threatening) with no cardiac monitoring and with a principal problem of acute-on-chronic renal failure, accompanied by generalized weakness, not eating much at home for two days, with concerns for congestive heart failure (CHF, a long-term condition in which the heart can't pump blood well enough to meet the body's needs) worsening, and one episode of nausea (the feeling of uneasiness in the stomach before vomiting) and vomiting.

During a review of Patient 1 ' s physician ' s note titled, "Progress Note," dated 8/19/2017 at 10:21 a.m., the Progress note indicated, Patient 1 ' s treatment plan included IV (intravenous, through the vein) hydration, monitoring renal (kidney) functions, and monitoring for signs and symptoms of congestive heart failure (such as fatigue and weakness, rapid and irregular heartbeat, etc.).

During a review of Patient 1 ' s physical therapy (PT, helps injured or ill people improve movement and manage pain) initial assessment note, dated 8/19/2017 at 2:02 p.m., the PT note indicated, on 8/19/2017 at 12:15 p.m., Patient 1 ' s SpO2 on room air was 72% (oxygen saturation levels below 95% are considered abnormal). The PT note further indicated, Patient 1 required supplemental oxygen (O2) via nasal cannula (NC, device that delivers oxygen through a tube into a patient ' s nose) up to 3 Liters (L, measurement unit for oxygen delivery) and was saturating (amount of oxygen measurement) 87-91% on supplemental O2 via NC.

During a review of Patient 1 ' s Vital Signs (VS, temperature, blood pressure, respiratory rate, heart rate) record, dated 8/19/2017, from 6:00 a.m. to 3:35 p.m., no documentation of supplemental oxygen use was recorded.

During further review of Patient 1 ' s VS record, dated 8/19/2017, at 3:36 p.m., the record indicated, Patient 1 was on supplemental oxygen via NC, no rate documented.

During a concurrent interview and record review, on 11/1/2023 at 10:00 a.m., with Chief Nursing Executive (CNE) and the Clinical Informatics Specialist (CIS 1), Patient 1 ' s nursing notes, dated 8/19/2017-8/20/2017 were reviewed. The CIS 1 confirmed, primary nurse did not document notification to physician about Patient 1 requiring supplemental oxygen on 8/19/2017 at 3:36 p.m.

During an interview on 11/1/2023 at 12:23 p.m., with Respiratory Manager (RM 1), the RM 1 stated, if oxygen saturation rate measurement is below 90% and patient requires supplemental oxygen, a physician ' s order for oxygen needs to be obtained.

During a review of Patient 1 ' s EKG record, dated 8/19/2017, at 5:16 p.m., the EKG results indicated, Patient 1 ' s heart rate was 112 beats per minute, and the EKG indicated the following results, "Afib (Atrial fibrillation) with RVR (Rapid Ventricular Rate, In A-fib with RVR, the heart ' s lower chambers beat too quickly and irregularly, resulting in a rapid heart rate. RVR can develop in people with A-fib, disrupting the regular supply of blood to the body's organs) with a competing junctional pacemaker (when the heart ' s natural pacemaker [generates an electrical impulse that spreads to the heart and results to a heartbeat] is not working). Inferior Infarct (occlusion in a heart artery resulting to a decreased blood flow), age undetermined. Abnormal EKG."

During further review of Patient 1 ' s nursing note, dated 8/19/2017, the note indicated, on 8/19/2017, at 6:46 p.m., the nursing note indicated, "Patient (Patient 1) complaining of heartburn, 12 lead EKG done. Primary physician notified of findings. Patient given Tylenol for chronic left shoulder pain."

During a concurrent interview and record review, on 11/1/2023 at 12:26 p.m., with Chief Nursing Executive (CNE), the Clinical Informatics Specialist (CIS 1), and the ICU Manager (M1), Patient 1 ' s EKG results, dated 8/19/2017, at 5:16 p.m., and Patient 1 ' s nursing note, dated 8/19/2017 at 6:46 p.m., were reviewed. The CNE stated, the primary nurse documented Patient 1 ' s EKG results notification to primary care physician and the physician was informed, but physician did not order cardiac monitoring (a machine that watches the electrical activity of the heart to ensure it is working normally) for Patient 1, and the Primary Nurse did not also clarify with the physician if Patient 1 should be on a cardiac monitor so that Patient 1 could be transferred from a Medical Surgical unit to a unit with a cardiac monitor. The CNE further stated, nurses are expected to clarify orders and advocate for interventions by escalating issues utilizing the chain of command because a nurse ' s role in patient care is to advocate for patient ' s safety per established standards of care. The CIS 1 further confirmed, no documentation of heart rate of 112 bpm was recorded in Patient 1 ' s VS at 5:16 p.m. The CIS 1 then confirmed, no documentation of follow up assessment and plan of care for Patient 1 ' s identified change in EKG and cardiac rhythm was documented by primary nurse in Patient 1 ' s chart.

During a concurrent interview and record review on 11/1/2023 at 12:25 p.m. with Chief Nursing Executive (CNE), the Clinical Informatics Specialist (CIS 1), and the ICU Manager (M1), Patient 1 ' s primary nurse ' s note, dated 8/20/2017, at 5:52 a.m., was reviewed. The note indicated, "Patient 1 verbalized dizziness when standing up, course crackles (may indicate a condition such as heart failure due to accumulation of fluids in the lungs) observed with breathing, coughing up phlegm (sputum produced by the lungs)." The note further indicated, primary nurse discontinued IV fluids (IVF, intravenous fluids administered through the vein) after obtaining a physician ' s order and Primary Nurse further documented, "Physician ' s note to stop IVF (intravenous fluids) when patient develops signs and symptoms of heart failure was noted." The CNE and the M1 stated, the primary nurse followed up with the physician, as was indicated by the note. However, the CIS 1 confirmed, no other actions, no further reassessment, no documentation of VS such as oxygen saturation level, and no changes to care plan specific to Patient 1 ' s newly identified health issues were recorded by the primary nurse in Patient 1 ' s chart after the primary nurse made a note about Patient 1 ' s worsening condition on 8/20/2017 at 5.52 a.m.

During further review of Patient 1 ' s primary nurses note, dated 8/20/2017, at 8:05 a.m., the primary nurse ' s note indicated, Patient 1 was found tachypneic (rapid respirations) with RR (respiratory rate) of 40 breaths per minute (bpm, normal range for respirations is 12-18 bpm) and notified the attending physician of findings.

During a concurrent interview and record review on 11/1/2023 at 12:25 a.m., with CIS 1, Patient 1 ' s medical record, dated 8/20/2017 from 8:05 a.m. to 8:41 a.m., was reviewed. The CIS 1 confirmed, no documentation of VS on 8/20/2017 from 8.05 a.m. to 8:41 a.m., was recorded in Patient 1 ' s chart. The CIS 1 further confirmed, primary nurse did not document focused assessment in Patient 1 ' s chart, and did not document any interventions implemented specific to Patient 1 ' s worsening of breathing on 8/20/2017 from 8:05 a.m. to 8:41 a.m. when Patient 1 was still in the Medical Surgical floor.

During a review of Patient 1 ' s Vital Signs (VS, temperature, blood pressure, respiratory rate, heart rate) record, dated 8/20/2017, the record indicated, on 8/20/17 at 8:41 a.m., Patient 1 ' s respirations were 48 bpm (high, normal is 12-18 bpm), BP 90/58, SpO2 78% (oxygen saturation levels below 95% are considered abnormal), no documentation of heart rate was recorded. The record further indicated, on 8/20/2017 at 8:51 a.m., no heart rate recorded, no respirations recorded, BP was 128/59, no SpO2 recorded; and on 8/20/2017 at 9:22 a.m., Patient 1 ' s heart rate was 131 bpm (high, normal is 60-100 bpm), no respirations recorded, BP 115/56, no SpO2 recorded.

During further review of Patient 1 ' s medication administration record (MAR), dated 8/20/2017, at 9:30 a.m., the MAR indicated, Patient 1 received 40 milligrams (mg, measurement unit) of Lasix IV (diuretic) and 2 mg of Morphine IV (an opioid that can affect breathing rate).

During a review of Patient 1 ' s medical record on 11/1/2023 at 12:30 p.m., the medical record indicated no documentation of reassessment after administration of 2 mg of Morphine IV administered on 8/20/2017 at 9:30 a.m. This finding was validated with the M1 and the CIS 1 during an interview and record review on 11/1/2023.

During a concurrent interview and record review on 11/1/2023, at 12:25 p.m.., with CNE, the M1 and the CIS 1, Patient 1 ' s cardiac technician ' s note, dated 8/20/2017, at 9:54 a.m. was reviewed. The note indicated, Patient 1 was tachycardic (fast heart rate), with heart rate ranging 150-180 bpm (high, normal is between 60 to 100 bpm) throughout exam (EKG [electrocardiogram] test, a simple test that can be used to check your heart's rhythm [the pattern and amount of time that passes in between each heartbeat] and electrical activity). The note further indicated, Patient 1 was on oxygen and very short of breath. The CNE stated, based on cardiac technician ' s note, Patient 1 ' s condition needed immediate evaluation and intervention. The CIS 1 confirmed, there was no documentation of Patient 1 being on cardiac monitor on 8/20/2017 at 9:54 a.m. and there was no record of nursing intervention recorded for increased heart rate and shortness of breath on 8/20/2017 at 9:54 a.m.

During further review of Patient 1 ' s physician ' s progress note, dated 8/20/2017 at 9:49 a.m., the physician ' s progress note indicated, Patient 1 became very short of breath, was hypoxic (low level of oxygen in the body), tachypneic (rapid breathing) and needed to be transferred to a higher level of care (capable of providing diagnostic, interventional, or specialized care beyond the capacity from which it originates).

During further review of Patient 1 ' s "Physician Progress Note," dated 8/20/2017, at 11:15 a.m., the Physician Progress Note indicated, on 8/20/2017, at 11:08 a.m., Rapid Response Team (RRT, RRT ' s purpose is to provide patient stability, reduce the incidence of Code Blue [called when a patient requires resuscitation (methods to start the heart and lungs when they stop working) or otherwise in need of immediate medical attention, most often as the result of a respiratory or cardiac arrest or heart attack], reduce unplanned transfers to critical care (a unit that handles severe potentially life-threatening cases) and decrease mortalities (death) through early evaluation and management of adult patients whose condition may be deteriorating) was called for Patient 1, and Patient 1 was placed on BiPAP ( a type of ventilator—a device that helps with breathing) for having more difficulty breathing, and required administration of 0.4 mg (milligram, unit of measurement) of Narcan (a medication administered to reverse the effect of opioids [medication to relieve pain but can negatively affect respiration] such as Morphine [pain medicine]) for being unresponsive (does not respond to voice, command, or deep stimulation like pinching). The note further indicated, Patient 1 was found apneic (cessation of breathing), and Code Blue was then called. The note also indicated, Patient 1 was found to be in A-fib with RVR with heart rate in 150s-160s bpm (high, normal is between 60-100 bpm) and elevated systolic blood pressure (indicates how much pressure the blood is exerting against the walls of the heart, anything higher than 130 systolic pressure is considered abnormal) in 200s (severe increase in blood pressure and a medical emergency).

During a review of Patient 1 ' s physician progress note titled "Progress Note-Intensive Care Unit," dated 8/20/2017, at 2:40 p.m., the note indicated, Patient 1 had two Code Blue (called when a patient requires resuscitation [methods to start the heart and lungs when they stop working] or otherwise in need of immediate medical attention, most often as the result of a respiratory or cardiac arrest or heart attack) activations, and (Patient 1) was intubated (insertion of a thin plastic tube into a patient ' s airway to assist with breathing) and transferred to ICU (Intensive Care Unit, a unit that handles severe potentially life-threatening cases) for further care.

During a review of Patient 1 ' s medical record titled "Death Note," dated 8/20/2017, at 7:47 p.m., the note indicated, Patient 1 was pronounced expired (dead) on 8/20/2017 at 7:30 p.m.

During an interview on 11/2/2023 at 12:50 p.m. with Assistant Medical Center Administrator of Hospital Quality Program (AMCAHQP), the AMCAHQP stated, the facility expects nurses to act according to their scope of practice and nurses are expected to act upon an immediate change and recognize changes in patient ' s condition and intervene accordingly. The AMCAHQP further stated nurses must be able to practice safe medication administration and should know if assessment or reassessment is required after certain medication administration. The AMCAHQP then stated, nurses play an important role in patient safety and should act as patient advocates and whenever there is a concern nurses may have about any changes in a patient ' s condition, the facility ' s expectation for nursing is to act in accordance with standards of practice and provide professional nursing care as established by regulatory standards of care and facility ' s policies and procedures.

During a review of the facility ' s policy and procedure (P&P) titled "Patient Assessment and Reassessment," dated 3/2022, the P&P indicated, "Upon completion of the assessment, a plan of care will be developed by a registered nurse (RN). The RN will develop and document a plan of care that will best meet the individualized health care needs of the patient. Based on the initial and ongoing assessment of the patient, an appropriate problem and intervention list will be developed. The plan of care reflects the individualized needs identified by assessments performed by each discipline as indicated. The registered nurse is responsible for coordination of care within the healthcare team and the patient ' s plan of care reflects the status of the patient ' s needs."

During a review of the facility ' s policy and procedure (P&P) titled, "Rapid Response Team (RRT)," dated 9/2022, the P&P indicated, "RRT ' s purpose is to provide patient stability, reduce the incidence of Code Blue, reduce unplanned transfers to critical care and decrease mortalities through early evaluation and management of adult patients whose condition may be deteriorating. RRT was established to respond to critical events, whenever there is a concern about acute changes in the patient ' s condition and the need for immediate evaluation and intervention. RRT is a clinical resource available for patient assessment and intervention. Any staff who recognizes acute changes in a patient such as respiratory factors or cardiovascular factors may initiate an RRT."

During a review of the facility ' s standards of practice for staff Registered Nurse (RN) titled, "Professional Standards Requirements for Licensed Nursing Personnel," dated 11/01/2021, the standards of practice for staff RN indicated, "Registered Nurse (RN) is a provider of professional nursing care, utilizes the nursing process in accordance with established standards of care, policies, and procedures. An RN is expected to demonstrate proficiency by complying with regulatory requirements, policies, procedures, and standards of nursing practice; develops and contributes to the individualized plan of care that reflects assessment, planning, implementation and evaluation of the outcome of that plan; utilizes communication strategies including chain of command and issue escalation; makes comprehensive nursing decisions based on interpretation data, assessment, and evaluations of patient outcomes; and ensures care meets standards of practice."

Based on interview, and record review, the facility failed to ensure that a comprehensive care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) was developed and implemented for two of 30 sampled patients (Patient 1 and Patient 2) in accordance with the facility ' s policy and procedure regarding care plan development and implementation when:

Patient 1 who was admitted with Renal (kidney) failure and Congestive Heart Failure (CHF, a long-term condition in which the heart can't pump blood well enough to meet the body's needs) did not have a care plan to address fluid volume and respiratory (breathing) issues.

Patient 2 who was admitted with acute hypoxemic respiratory failure (occurs when the respiratory system cannot adequately provide oxygen to the body due to low levels of oxygen in the body) did not have a care plan to address respiratory (breathing) issues.

These deficient practices had the potential to delay provision of care to Patient 1 and Patient 2 by not identifying the patients ' needs and risk, which may result in patient harm or death.

Findings:

1a. During a review of Patient 1 ' s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 8/19/2017, the H&P indicated, on 8/19/2017, Patient 1 was admitted to the Observation Unit (area where patients are monitored and evaluated) on a medical surgical floor (a specific area of the hospital that cares for patient with a variety of health issues that are not life threatening) with no cardiac monitoring (a machine that watches the electrical activity of the heart to ensure it is working normally) with a principal problem of acute-on-chronic renal failure (decline in renal [kidney] function in patients with known kidney disease), accompanied by generalized weakness, not eating much at home for two days, with concerns for congestive heart failure (CHF, a long-term condition in which the heart can't pump blood well enough to meet the body's needs) worsening, and one episode of nausea and vomiting. The H&P further indicated, Patient 1 ' s plan of treatment included gentle hydration (replacement or adding fluid to a body by administering fluid through the veins).

During a review of Patient 1 ' s physician ' s note titled, "Progress Note," dated 8/19/2017 at 10:21 a.m., the Progress Note indicated, Patient 1 ' s treatment plan included intravenous (IV, administered through the veins) hydration (fluids delivered though a catheter placed into a vein), monitoring renal (kidney) functions, and monitoring for signs and symptoms of congestive heart failure (CHF) such as fatigue or weakness, rapid or irregular heartbeat, etc.

During a concurrent interview and record review on 11/1/2023, at 9:42 a.m., with the Chief Nurse Executive (CNE) and the Clinic Informatics Specialist (CIS 1), Patient 1 ' s nursing care plan (NCP), dated 8/19/2017-8/20/2017 was reviewed. Patient 1 ' s NCP indicated, no care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) was developed for congestive heart failure, renal failure, and respiratory issues. The CNE stated, nursing has the responsibility to develop plan of care for each patient based on presenting and identified patient ' s health issues because the CP serves as a guide for patient care and development of appropriate interventions, and aids in monitoring toward patient progress in response to interventions implemented.

During a review of the facility ' s policy and procedure (P&P) titled "Patient Assessment and Reassessment," dated 3/2022, the P&P indicated, "Upon completion of the assessment, a plan of care will be developed by a registered nurse (RN). The RN will develop and document a plan of care that will best meet the individualized health care needs of the patient. Based on the initial and ongoing assessment of the patient, an appropriate problem and intervention list will be developed. The plan of care reflects the individualized needs identified by assessments performed by each discipline as indicated. The registered nurse is responsible for coordination of care within the healthcare team and the patient ' s plan of care reflects the status of the patient ' s needs."

According to the Centers for Medicare & Medicaid Services (CMS, a government agency dedicated to improving patient health outcomes) guidelines and regulations, nursing care planning starts upon admission and includes planning the patient ' s nursing care to meet the patient needs and interventions toward meeting patient treatment goals while in the hospital. A nursing care plan is based on assessing the patient ' s nursing care needs (not solely those needs related to the admitting diagnosis).

1b. During a review of Patient 2 ' s history and physical (H&P a formal and complete assessment of the patient and the problem), dated 10/30/2023, the H&P indicated, Patient 2 was admitted to the facility for acute hypoxemic respiratory failure (occurs when the respiratory system cannot adequately provide oxygen to the body due to low levels of oxygen in the body) and low hemoglobin (not having enough red blood cells to carry oxygen to body tissues).The H&P further indicated, Patient 2 ' s past medical history included end-stage renal disease (ESRD, a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis [a treatment to remove wastes and excess water from the blood when the kidneys cease functioning) and coronary artery disease (CAD, caused by plaque buildup in the wall of the arteries that supply blood to the heart) and atrial fibrillation (an irregular and often very rapid heart rhythm).

During a further review of Patient 2 ' s H&P, dated 10/30/2023, the H&P indicated, Patient 2 ' s treatment plan included a blood transfusion ( a routine medical procedure in which donated blood is provided to a patient through a narrow tube placed within a vein in the arm), inpatient hemodialysis (HD, a treatment to remove wastes and excess water from the blood when the kidneys cease functioning), and monitoring of respiratory (breathing) status.

During a review of Patient 2 ' s care plan (CP, provides a framework for evaluating and providing patient care needs related to the nursing process), dated 10/30/2023-11/1/2023, the CP indicated, nursing did not develop a care plan for monitoring Patient 2 ' s respiratory function.

During an interview on 11/1/2023, at 9:42 a.m. with the Chief Nurse Executive (CNE), the CNE stated, nursing should develop a plan of care for each admitted patient based on identified patient ' s health issues to develop appropriate interventions and to ensure monitoring and consistency of patient care.

During a review of the facility ' s policy and procedure (P&P) titled "Patient Assessment and Reassessment," dated 3/2022, the P&P indicated, "Upon completion of the assessment, a plan of care will be developed by a registered nurse (RN). The RN will develop and document a plan of care that will best meet the individualized health care needs of the patient. Based on the initial and ongoing assessment of the patient, an appropriate problem and intervention list will be developed. The plan of care reflects the individualized needs identified by assessments performed by each discipline as indicated. The registered nurse is responsible for coordination of care within the healthcare team and the patient ' s plan of care reflects the status of the patient ' s needs."

According to the Centers for Medicare & Medicaid Services (CMS, a government agency dedicated to improving patient health outcomes) guidelines and regulations, nursing care planning starts upon admission and includes planning the patient ' s nursing care to meet the patient needs and interventions toward meeting patient treatment goals while in the hospital. A nursing care plan is based on assessing the patient ' s nursing care needs (not solely those needs related to the admitting diagnosis.

Based on interview and record review, the facility failed to ensure one of thirty sampled patients (Patient 1) vital signs (VS, temperature, blood pressure, respiratory rate, heart rate that indicates the state of a patient's essential body functions) was monitored, assessed, reassessed and recorded in accordance with the facility ' s policies and procedures regarding assessment, reassessment, and documentation.

This deficient practice had the potential to result in Patient 1 ' s medical issues or change of condition not properly monitored and undetected, which may negatively affect the patient ' s health and safety.

Findings:

During a review of Patient 1 ' s Emergency Department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care) provider note, dated 8/19/2017 at 2:06 a.m., the ED note indicated, on 8/19/2017 at 1:19 a.m., Patient 1 Patient 1 was seen in the ED for progressive weakness, inability to walk due to weakness, and inability to eat. The ED note further indicated, Patient 1 ' s blood pressure (BP) was 66/32 (abnormally low blood pressure, lower than 90/60 millimeters of mercury [mm Hg, measuring unit]), pulse (P) 58 (low, normal is between 60 to 100) beats per minute (bpm), respirations (R) 14, and oxygen saturation rate (SpO2, measured to demonstrate how well lungs are working) was 85% (oxygen saturation levels below 95% are considered abnormal).

During a review of Patient 1 ' s ED summary report titled "ED Care Timeline," dated 8/19/2017, the ED summary report indicated, on 8/19/2017 at 2:06 a.m., Patient 1 received 1000 milliliters (ml, measurement unit) Sodium Chloride 0.9% (a solution containing sodium and chloride given to replenish lost water and salt in the body due to certain conditions) Intravenous (IV, though a vein). The ED summary report further indicated, on 8/19/2017 between 1:32 a.m. and 4:00 a.m., Patient 1 ' s Vital Signs (VS) were not reassessed after receiving 1000 ml Sodium Chloride 0.9% IV bolus (a single large dose of medication given in a short amount of time to achieve favorable results).

During a review of Patient 1 ' s Vital Sign (VS, temperature, blood pressure, respiratory rate, heart rate that indicates the state of a patient's essential body functions) record in the ED, dated 8/19/2017, the ED VS record indicated the following:

On 8/19/2017 at 2:19 a.m., Patient 1 ' s BP was 66/32 (abnormally low blood pressure, lower than 90/60 millimeters of mercury [mm Hg, measuring unit]), Temperature 98.2 (F), Pulse 58, Respiration 14;

On 8/19/2017 at 1:32 a.m., Patient 1 ' s BP was 113/84, Temperature not recorded, Pulse 92, Respiration 20, SpO2 94%;

on 8/19/2017, at 4:00 a.m., Patient 1 ' s BP was 114/73, Pulse 105, Respiration 26 (high, normal is 12 to 18 breaths per minute), no SpO2 documented, no Temperature recorded;

The ED VS record further indicated, on 8/19/2017 at 4:30 a.m., Patient 1 ' s BP was 94/77, Pulse 85, Respiration 26 (high, normal is 12-18 breaths per minute), SpO2 98%;

The last documented ED VS record for Patient 1 indicated, on 8/19/2017, at 5:01 a.m., BP was 108/64, Pulse 90, no Temperature recorded, Respiration 34 (high, normal is 12-18 breaths per minute), no SpO2 documented. The ED VS record did not indicate if Patient 1 ' s oxygen saturation rate was measured while Patient 1 was on room air (RA) or on supplemental oxygen. The ED VS record did not indicate consistent documentation of cardiac rhythm for Patient 1 with each Vital Sign recordings while Patient 1 was on a continuous cardiac monitor.

During a review of Patient 1 ' s VS record, dated 8/20/2017, the VS record indicated, on 8/20/2017 at 8:41 a.m., Patient 1 ' s respiration was 48 (high, normal is 12-18 breaths per minute) bpm, BP 90/58, SpO2 78% (oxygen saturation levels below 95% are considered abnormal), no documentation of heart rate. The record further indicated, on 8/20/2017 at 8:51 a.m., no heart rate recorded, no respirations recorded, BP was 128/59, no SpO2 recorded; and on 8/20/2017 at 9:22 a.m., Patient 1 ' s heart rate was 131 bpm (high, normal is between 60 to 100 bpm), no respirations recorded, BP 115/56, no SpO2 recorded.

During an interview on 11/1/2023 at 11:05 a.m. with the Chief Nurse Executive (CNE), the CNE stated, nurses should document a complete set of Vital Signs, including temperature, respiratory rate, pulse rate, blood pressure and pain assessment as per facility ' s policy.

During an interview, on 11/1/2023 at 2.:22 p.m. with the emergency room clinical educator (CE), the CE stated, nurses should document cardiac rhythm (refers to the pattern and amount of time that passes between each heartbeat) upon initiation of cardiac monitoring in the ED, in addition to VS, and document every 2 hours thereafter.

During a review of Patient 1 ' s medication administration record (MAR), dated 8/20/2017, at 9:30 a.m., the MAR indicated, Patient 1 received 40 milligrams (mg, measurement unit) of Lasix IV (diuretic administered intravenously [through the vein]) and 2 mg of Morphine IV (an opioid that can affect breathing rate).

During a review of Patient 1 ' s medical record on 11/1/2023 at 12:30 p.m., the medical record indicated no documentation of reassessment, and no VS assessment was documented after administration of 2 mg of Morphine IV administered on 8/20/2017 at 9:30 a.m.

During an interview on 11/2/2023 at 11:50 a.m. with the pharmacist (Pharm 1), the Pharm 1 stated, Morphine is an opioid (medications to relieve pain but can negatively affect respiration) often prescribed for moderate to severe pain and can be administered to decrease respiratory rate. The Pharm then stated, the facility does not have a policy on Morphine IV push (a fast form of administering a medication through a catheter directly into bloodstream) administration because nurses should know Morphine can cause respiratory depression and should administer it with caution. Pharm 1 also said RNs should assess and document VS, such as patient ' s respirations, blood pressure, and oxygen saturation rate. The Pharm 1 then stated, reassessment of patient ' s VS after Morphine administration is within nursing scope of practice.

During an interview, on 11/2/2023 at 12:50 p.m. with Assistant Medical Center Administrator of Hospital Quality Program (AMCAHQP), the AMCAHQP stated, nurses play an important role in patient safety and should act as patient advocates and whenever there is a concern nurses may have about any changes in a patient condition, the facility ' s expectation for nursing to act in accordance with standards of practice and provide professional nursing care as established by regulatory standards of care and facility ' s policies and procedures.

During a review of the facility ' s policy and procedure (P&P) titled, "Patient Assessment and Reassessment," dated 3/2022, the P&P indicated, "All patients should have complete set of vital signs done, including temperature, pulse, respiratory rate, and blood pressure."

During a review of the facility ' s policy and procedures (P&P) titled, "Patient Triage and Flow in the Emergency Department," dated 10/2021, the P&P indicated, "Patient care should be delivered in accepted to Nursing Standards of Care. Patients' pain levels must be assessed, reassessed and documented throughout the visit. Patients' response to all treatments and medications must be documented."

During a review of the facility ' s standards of practice for staff Registered Nurse (RN) titled, "Professional Standards Requirements for Licensed Nursing Personnel," dated 11/01/2021, the standards of practice for staff RN, indicated, "Registered Nurse (RN) is a provider of professional nursing care, utilizes the nursing process in accordance with established standards of care, policies, and procedures. An RN is expected to demonstrate proficiency by complying with regulatory requirements, policies, procedures, and standards of nursing practice; develops and contributes to the individualized plan of care that reflects assessment, planning, implementation and evaluation of the outcome of that plan; utilizes communication strategies including chain of command and issue escalation; makes comprehensive nursing decisions based on interpretation data, assessment, and evaluations of patient outcomes; and ensures care meets standards of practice."