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

1. The Governing Body failed to ensure that the facility (hospital) did not allow the contracted clinic (Clinic utilized by the facility to screen [preliminary evaluation of patients] and provide medical clearance for patients) to house patients who are not yet admitted as inpatient in the hospital beds dedicated for admitted patients. There was no proper accountability of the clinic on who will take care of the patients who are not yet admitted. The clinic patients occupied hospital beds for admitted patients while awaiting medical clearance by the Clinic, from 6/1/2023 to 10/16/2023.

This deficient practice resulted in the facility housing five of thirty sampled Clinic patients (Patients 1, 2, 3, 4, 5) in hospital beds, under observation, without a service agreement to ensure patient safety from 6/1/2023 to 10/16/2023. This deficient practice also had the potential for the facility not to be able to provide the treatment of patients with an emergency medical condition requiring a higher level of care and a delay of treatment while the facility arranged for patients to be transferred to another facility or to call 911. (Refer to A - 0083)

2. The Governing Body failed to ensure that patient care and services rendered under contract with an outside entity (clinic) were provided in a safe and effective manner, by accepting two of 30 sampled patients (Patients 14 and 24) who may be presenting with potential emergency medical conditions (EMC, example heart attack etc.) to the Observation area (an extension of emergency care to observe patients for an additional 24 to 48 hours before hospital admissions) of the facility, and allowing them (the patients) to be managed by outpatient practitioners, and after-hours clinicians available on-call only, while the hospital lacked the capability to provide safe and adequate initial emergency treatment. The hospital had no emergency department, and for several months, no intensive care unit (ICU, a unit that handles severe potentially life-threatening cases) where patients with EMCs (Emergency Medical Conditions such as heart attack, etc.) could be appropriately managed; it (the facility) relied on transfers to other facilities that can provide higher level of care when patients were found to have EMCs such as acute myocardial infarction (MI, heart attack) or cerebrovascular accident (CVA, stroke-when blood flow to the brain is blocked or there is sudden bleeding in the brain).

This deficient practice placed patients' health and safety at risk due to delay in treatment of emergency medical conditions that may be identified while the patients were being kept and evaluated in the facility's Observation area. (Refer to A - 0084)

The cumulative effect of these deficient practices placed the patients' health and safety at risk due to the potential delay of treatment of emergency medical conditions that may be identified while Clinic patients were kept in the hospital's observation area, pending medical clearance.

Based on observation, interview, and record review, the governing body failed to ensure that the facility (hospital) did not allow the contracted clinic (Clinic utilized by the facility to screen [preliminary assessment of patients that is completed prior to admission] and provide medical clearance for patients) to house patients who are not yet admitted as inpatient (patients formally admitted to the hospital) in the hospital beds dedicated for admitted patients. There was no proper accountability of the clinic on who will take care of the patients who are not yet admitted. The clinic patients occupied hospital beds for admitted patients while awaiting medical clearance by the Clinic, from 6/1/2023 to 10/16/2023.

This deficient practice resulted in the facility housing five of thirty sampled Clinic patients (Patients 1, 2, 3, 4, 5) in hospital beds, under observation (when patients are temporarily housed while the doctor decides to admit as an inpatient [patients formally admitted to the hospital], transfer to another facility, or discharge a patient), without a service agreement to ensure patient safety from 6/1/2023 to 10/16/2023. This deficient practice also had the potential for the facility not to be able to provide the treatment of patients with an emergency medical condition requiring a higher level of care and a delay of treatment while the facility arranged for patients to be transferred to another facility or to call 911.

Findings:

During an observation on the Seventh (7th) floor inpatient unit, on 10/16/2023 at 3:34 p.m., Patients 1, 2, and 3, were observed in patient rooms designated for "observation (when patients are temporarily housed while the doctor decides to admit as an inpatient [patients formally admitted to the hospital], transfer to another facility, or discharge a patient) to." Mental health worker (MHW) 1 was performing rounds (monitoring and reassessment to ensure patient safety) on Patients 1, 2, and 3.

During an observation on the 7th floor inpatient unit, on 10/17/2023 at 3:49 p.m., Patients 4 and 5 were observed in "Observation" rooms.

During a concurrent interview, on 10/17/2023 at 3:49 p.m., with Registered Nurse (RN) 6, RN 6 stated the following.: Patients in "observation" beds belonged to an outside Clinic (located on the facility's 3rd floor) and were either bed-bound (confined to bed) or had behavior issues and so patients were held in the "Observation" beds because the Clinic was not able to accommodate those patients. RN 6 worked for the hospital and was assigned to care for the Clinic's patients (Patient 4 and 5) located in the "Observation" rooms. Patients 4 and 5 were pending medical clearance, by the Clinic, to see if the patients met the criteria for admission to the hospital, to be discharged home, or transferred to an outside hospital for a higher level of care. In the meantime, while in the "Observation" room, the patients undergo a medical evaluation by the Clinic's physician and await laboratory results such as blood work-up, EKG (Electrocardiogram- a test that records the electrical signal from the heart to check for different heart conditions, it can detect irregular heart rhythms and heart attack) and X-ray (imaging) results. After all the results were in, the Clinic physician determines whether the patients will be admitted to the hospital, discharged home, or are transferred to another hospital for higher level of care.

During an interview on 10/18/2023 at 8:30 a.m., with Nurse Manager (NM) 1 and the Compliance Officer (CO), NM 1 and CO stated the following: Since 6/1/2023, when the facility closed its Urgent Care (a department that assists patients with illnesses that are not life-threatening), patients from an outside clinic (Clinic, located on the 3rd floor of the building) were brought to observation beds (located in the hospital's 7th floor) for up to 23 hours, pending medical clearance consisting of a medical evaluation, and awaiting laboratory, electrocardiogram (EKG, a test that records the electrical signal from the heart to check for different heart conditions, it can detect irregular heart rhythms and heart attacks), and radiology results.

NM 1 and CO verified that the original contract provided by the facility, on 10/17/2023 at 9:11 a.m., did not indicate that Clinic patients waiting for medical clearance would be housed in observation rooms located on the 7th floor of the hospital (which remains under the hospital's license) and that the facility's own staff (Registered Nurses employed by the hospital) assumes the care of the clinic patients while in the observation area. NM 1 and CO stated that the second agreement the facility provided, on 10/17/2023 at 4:45 p.m., included addendum added on 10/17/2023 to include the use of designated hospital beds for Clinic patients for potential hospital admissions, after proper medical clearance.

During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 10/16/2023, the "H&P" indicated that Patient 1 was admitted to a skilled nursing facility (a clinical facility where patients can receive medical care and rehabilitation services from trained professionals) with multiple comorbidities (more than two illnesses or diseases occurring in the same person at the same time). The H&P further stated that Patient 1 has grown increasingly confused, has not been eating as well as he used to, is refusing medications, and has a decreased intake of both food and water. As a result, Patient 1 was temporarily housed under observation (when patients are temporarily housed while the doctor decides to admit as an inpatient [patients formally admitted to the hospital], transfer to another facility, or discharge a patient) to the facility for additional evaluation. Patient 1 was admitted due to adult failure to thrive (syndrome of weight loss, decreased appetite, poor nutrition, and inactivity), dehydration, and increased blood sugar, although Patient 1 had no history of diabetes mellitus, which is a disease of inadequate control of blood sugar levels.

During a concurrent interview and record review on 10/19/2023 at 2:15 p.m. with Registered Nurse (RN) 2, Patient 1's electronic medical record titled "Observation" on 10/16/2023 was reviewed. The electronic medical record indicated Patient 1 was brought to the observation area on 10/16/2023 at 12:02 p.m. and was admitted to the facility as an inpatient on 10/16/2023 at 2:06 p.m. RN 2 stated, "The patient is admitted to the 7th floor, the observation area, because we are waiting for lab results."

During a review of Patient 2's note titled "Observation, Inpatient Medical Clearance," dated 10/16/2023 at 12 p.m., the note indicated the following. "Patient 2 was admitted under observation for episodes of vomiting. Medical history includes hypertension (high blood pressure) ...seizures (uncontrolled electrical activity in the brain cells), dementia (a group of conditions that affect memory and judgment) ..."

During a review of Patient 2's provider note titled "Observation, Medical Clearance by Provider," dated 10/18/2023 at 12:26 a.m., the note indicated the following: Patient 2 was brought to the facility for "vomiting ...Medical history included hypertension ...seizure, dementia ...Physical exam indicated Patient 2 was lethargic (a state of feeling drowsy, unusually tired, or not alert) and responsive to voice. Clinical impression: 1. Vomit. 2. Abnormal liver function test (blood test that provide information about the state of the liver) 3. Dehydration (loss of water at a rate greater than the body can replace it) 4. Elevated white blood count ...Plan of care: "Okay to admit to doctor per admitting."

During a concurrent interview and record review on 10/18/2023 at 2 p.m., with the Nurse Manager (NM) 1, NM 1 stated the following: Patient 2 was "still a clinic patient" and was admitted to the observation area, under the care of hospital staff and not the clinic staff, on 10/16/2023 for complaints of vomiting and pending medical clearance, a medical evaluation, lab and EKG results. After all the results were in, the physician admitted the patient as an inpatient to the facility.

During a review of Patient 3's history and physical (H&P), dated 10/16/2023, the H&P indicated, Patient 3 was admitted for observation on 10/16/2023, at 12:26 p.m. for psychiatric (mental, emotional, and behavioral conditions) evaluation and medical clearance. The H&P further indicated, Patient 3 was highly delusional (false beliefs or judgements about external reality) and had auditory hallucinations (hearing noises or voices without an external stimulus).

During a review of Patient 4's Face sheet, the Face sheet indicated Patient 4 was admitted to an observation bed on 10/17/2023 for urosepsis (a life-threatening response to a urinary tract infection) and hypertension (high blood pressure).

During a review of Patient 4's "Medical Clearance by Provider," while in Observation area, dated 10/17/2023 at 12:35 p.m., the Medical Clearance by Provider note indicated Patient 4 was an 84 year old female brought from a skilled nursing facility for abnormal urinalysis (UA, a test that detects a urinary tract infection, kidney disease or diabetes) and to rule out a urinary tract infection. Medical history included "chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), hyperlipidemia (too much fat or cholesterol in the blood) ... hypertension, diabetes (high blood sugar), cardiomegaly (enlarged heart, is usually a sign of a heart valve problem or heart disease, may also signal a prior heart attack) ..."

During a review of Patient 5's history and physical (H&P), dated 10/17/2023, the H&P indicated, Patient 5 was admitted for observation on 9/17/2023 with a chief complaint of right hip pain. The H&P further indicated Patient 5 had past medical history (PMH, the total sum of a patient's health status prior to the presenting problem) of psychosis (mental condition in which thoughts and emotions are so affected that contact is lost with reality), open angle glaucoma (progressive irreversible loss of side vision), hypertension (increased blood pressure), hyperlipidemia, and hypothyroidism (thyroid gland does not produce enough thyroid hormones).

On 10/17/2023 at 9:11 a.m., the facility provided an agreement between the facility (hospital) and the outside clinic (Clinic or Company). During the review of the "Service Agreement," dated 6/1/2023, the agreement indicated the following: "Services included: Medical Clearance and Code Blue (indicates a patient requiring immediate medical attention such as heart attack)/RRT (Rapid Response Team, a group of clinicians who responds to the patient's bedside when a patient demonstrates signs of imminent clinical deterioration)/Face to Face Consultations including telehealth (a variety of communication technology and tactics to provide health services remotely or from a distance) and medication refills." The Agreement did not indicate that Clinic patients would be housed in designated beds under observation in the hospital during the medical clearance.

On 10/17/2023 at 4:45 p.m., after the facility was questioned for not having a service agreement indicating that patients of the clinic will be housed in the facility's 7th floor hospital beds and being cared for by the facility's Registered Nurses instead of the clinic's staff, the facility provided another "Service Agreement," between the hospital and the Clinic, dated 6/1/2023, with an addendum dated 10/17/2023. The agreement indicated that "designated hospital beds were used for potential admission(s) and will be jointly managed by the facility (hospital) and the Clinic (or Company) ..."

Based on interview and record review, the facility failed to ensure patient care and services rendered under contract with an outside entity (Clinic) were provided in a safe and effective manner, for two of 30 sampled patients (Patients 24 and 14), by accepting patients who may be presenting with potential emergency medical conditions (EMC, example: heart attack) to the Observation area (an area where patients are held in the facility to wait for medical clearance, such as lab results and diagnostic testing of the facility), and allowing them (the patients) to be managed by outpatient practitioners, and after-hours clinicians available on-call only, while the hospital lacked the capability to provide safe and adequate initial emergency treatment. The hospital had no emergency department (ED-responsible for the provision of medical care for patients arriving at the hospital in need of immediate care), and for several months, no intensive care unit (ICU, a unit that handles severe potentially life-threatening cases) where patients with EMCs could be appropriately managed; it (the facility) relied on transfers to other facilities that can provide higher level of care when patients are found to have EMCs such as acute myocardial infarction (MI, heart attack) or cerebrovascular accident (CVA, stroke, when blood flow to the brain is blocked or there is sudden bleeding in the brain).

This deficient practice placed patients' health and safety at risk due to delay in treatment of emergency medical conditions that may be identified while the patients are being kept and evaluated in the facility's Observation area.

Findings:

During an interview with the facility's Nurse Manager (NM) 1 of Medical-Surgical Services (a specific area of the hospital that cares for patients with a variety of health issues that are not life threatening) and the Compliance Officer (CO) on 10/18/2023 at 9 a.m., the NM 1 stated the hospital had closed its ICU (Intensive Care Unit, a unit that handles severe potentially life-threatening cases) in November 2022 and subsequently also closed its Urgent Care (UC, a department that assists patients with illness that are not life-threatening) department at the end of May 2023. The NM 1 added that following the UC closure, the facility entered into an agreement with a group of outpatient providers (operating a clinic within the facility's building on the 3rd floor) to perform medical clearance, or "screening (preliminary assessment of patients that is completed prior to admission)," of all patients presenting to the hospital.

According to the NM 1, patients may be kept on the Observation area (located in the facility's 7th floor which is dedicated for admitted patients to the hospital) for up to 23 hours while they (the clinic patients) complete their medical evaluation, including laboratory tests, chest x-ray (an imaging test to detect problems in the heart or lungs), and EKG (or ECG, electrocardiogram: a recording of the heart's electrical activity), and await their final disposition. The NM 1 stated that depending on the findings from laboratory and diagnostic testing, patients may be admitted to the hospital, discharged, or if an EMC (emergency medical condition) is identified, transferred to one of the higher-level-of-care facilities with which the hospital maintains a transfer agreement.

The NM 1 stated that when an "inquiry" (notification from outside entity indicating that it plans to send a patient to the hospital) is received, for instance from the Department of Mental Health, physician's office, skilled nursing facility, or assisted living facility, for potential patient admission to the hospital, the House Supervisor (HS) reviews the inquiry packet containing the relevant patient medical information, including the chief complaint, past medical history, and current medications. Based on this information and the acuity level (severity of a patient's illness) of the patient's clinical presentation, the HS then determines whether to accept the patient to the Observation area for possible admission to the hospital. The NM added that the HS uses a screening form called the "Admission Screening Questionnaire" to make this determination, and only those patients deemed "low acuity (patients requiring minimal care due to mild illness)" based on the information derived from the questionnaire are accepted to the Observation area for medical clearance by the outpatient clinic physicians with whom the hospital contracts to provide this service.

A review of the "Admission Screening Questionnaire" indicated the information considered in the determination of patient acceptance to the hospital included: patient's ambulatory status (ability to walk), mobility (bed or wheelchair bound), need for 1:1 monitoring (a patient assigned one staff member for continuous monitoring), presence of wounds or ulcers, need for dialysis (a treatment to remove extra fluid and waste products from the blood when the kidneys are not able to), developmental delay (patients manifesting signs of abnormal motor [specific movements of the body's muscles to perform a certain task], cognitive [intellectual activity] and social skills), fall (unintentional event resulting in a person coming to rest on the ground or another lower level) risk, isolation precautions (interventions to reduce the transmission of microorganisms [such as bacteria] in the healthcare setting. The Questionnaire also included the use of gloves, masks, etc.), HIV (Human Immunodeficiency virus, a virus that attacks the body's immune system [helps the body defend against infection]) status, conservatorship (when a judge appoints another person to act or make decisions for the person who needs help), suicide history, elopement (when a patient leaves the hospital against medical advice and poses an imminent threat to patient's health and safety) history, assaultive or violent behavior, presence of any indwelling catheters and tubes, female of child-bearing age, and any known medical problems.

A review of the facility document called "Patient List Report," that lists the patients seen and evaluated in the Observation area from May 31, 2023 to October 17, 2023, indicated that on August 4, 2023, a patient (Patient 24) presented with a chief complaint of elevated troponin (can indicate a recent heart attack or other injuries and conditions that affect the heart). A review of Patient 24 ' s medical records indicated this was an 84-year-old individual with a documented history of hypertension (high blood pressure), diabetes mellitus (metabolic disease that results in high blood sugar), and coronary artery disease (disease caused by plaque buildup in the arteries that supply the heart, limiting blood flow to the heart), who was sent from a skilled nursing facility (a facility that provides medical care and rehabilitations services for patients who do not require immediate medical attention) because of elevated blood pressure and altered mental status (a change in mental function such as confusion that stems from illnesses, disorders, and injuries affecting the brain). According to the records, the patient (Patient 24) was found to have an elevated troponin I (protein found in the muscles of the heart, used to aid in diagnosing acute (severe and sudden in onset) myocardial infarction [heart attack]) level of 522.40 (reference range: 51.4, unit not specified in the patient records) on screening laboratory testing. Upon identification of this significant laboratory abnormality which raised concern for an acute MI (myocardial infarction), the physician ordered the patient (Patient 24) to be transferred out to a facility that can adequately manage patients having an acute (severe and sudden in onset) cardiac event. The records showed Patient 24 arrived at 11:41 a.m. and remained in the Observation area until 4:30 p.m. when the patient was taken to another facility by transportation service.

During a review of Patient 14's vital signs (temperature, blood pressure, heart rate, respiratory rate, and pain) record upon arrival to the observation area, dated 10/13/2023 at 11 a.m., the vital signs record indicated the following: Temperature (T) was 98.1 Fahrenheit (F, normal), blood pressure (BP) was 195/115 (high, normal is 120/80), heart rate (HR) was 85 (normal), respiratory rate was 18 (normal), and left-sided chest pain rated at 4/10 (moderate pain).

During a review of a document for Patient 14 titled "Medical Clearance by Provider," dated 10/13/2023 at 12:07 p.m., the document indicated the following: Patient 14 was placed in observation area. Patient 14 ' s chief complaint was chest discomfort. History of present illness indicated Patient 14 had Type 2 Diabetes (high blood sugar), hypertension, coronary artery disease (CAD, most common type of heart disease), coronary artery bypass graft (CABG, a surgical procedure used to treat CAD, it diverts blood around narrowed or clogged arteries to improved blood flow and oxygen to the heart) and schizophrenia (a disorder that affects a person ' s ability to think, feel, and behave clearly). Patient 14 was referred from extended care facility, for medical clearance as Patient 14 was exhibiting aggressive behavior.

On arrival to the observation area, on 10/13/2023 at 11 a.m., Patient 14 had elevated blood pressure, and left-sided chest pain. In addition, at 11: 10 a.m., Patient 14's Troponin level (can indicate a recent heart attack or other injuries and conditions that affect the heart) was 767.10 (high, normal range is between 0 and 0.04 ng/ml). At 6:40 p.m., Patient 14's Troponin level was 707.20 (high). EKG results indicated ...first degree atrioventricular (AV) block (a condition of abnormally slow conduction through the AV node [atrioventricular node, controls the passage of the heart's electrical signal], considered benign. However, it is associated with increased risk of all-cause mortality in the general population). "Patient 14 requires a higher level of care given the history of CAD and active chest pain. Observation Discharge Disposition: Another hospital for a higher level of care."

A review of Patient 14's EKG results dated 10/13/2023 at 11:15 a.m., indicated the results were abnormal. The results indicated sinus rhythm (normal rhythm of the heart) with first degree AV block (a condition of abnormally slow conduction through the AV node [atrioventricular node, controls the passage of the heart's electrical signal], considered benign. However, it is associated with increased risk of all-cause mortality in the general population).

During a review of a nurses' progress note titled "Interdisciplinary Team Progress Note Nursing," dated 10/13/2023 at 11 a.m., the progress note indicated that Patient 14 complained of "chest pain with blood pressure of 195/115 (high). Physician notified. Patient (Patient 14) was given aspirin (a blood thinner that can reduce the risk of heart attack) and nitroglycerin (treats chest pain). Patient (Patient 14) reported a history of open-heart surgery and stroke (brain attack, when something blocks blood supply to part of the brain or when a blood vessel in the brain burst) ...Rechecked patient's (Patient 14) BP 182/102 (high) ... At 2:30 p.m., the BP was 197/107 (high). At 5 p.m., the BP was 195/102 (high)."

During a review of Patient 14's "Physician's Order," dated 10/13/2023 at 12:12 p.m., the physician ' s order indicated, "Transfer to higher level of care when bed available or as soon as possible. Dx (diagnosis): elevated Troponin, abnormal EKG and h/o (history of) chest pain."

During a review of a nurses' progress note titled "Interdisciplinary Team Progress Note Nursing," dated 10/13/2023 at 8:35 p.m., the progress note indicated " Patient (Patient 14) reported left-sided chest pain, vital signs ...BP was 172 /92 (high) ...orders for transfer of patient (Patient 14) to higher level of care ...At 10:45 p.m., report given to an RN in the ICU of an outside hospital. On 10/14/2023 at 12:18 a.m., Patient 14 was transported to an outside hospital ..."

During a concurrent interview and record review on 10/19/20203 at 3:40 p.m., with Nurse Manager (NM) 1, Patient 14's medical record was reviewed. NM 1 stated the following: Patient 14 was placed in an observation room on 10/13/2023 at 11 a.m. Upon placement in the observation area, Patient 14 had an elevated blood pressure and complained of chest pain. Aspirin and nitroglycerin (medication for chest pain) and other medications were given to treat the elevated blood pressure and chest pain. The blood pressure remained elevated while under observation. NM 1 verified that the EKG was abnormal, and the Troponin level was elevated. NM 1 stated Patient 14's symptoms could be related to a heart attack or stroke. NM 1 stated Patient 14 did not require cardiac monitoring, and it was not ordered by the physician. The physician ordered for Patient 14 to be transferred to another facility for a higher level of care. NM 1 verified that the facility took 12 to 13 hours to transfer Patient 14 to another hospital.

A review of the minutes of the July 2023 meeting of the facility's Governing Board (responsible for developing and reviewing the hospital's overall mission and strategy) indicated that the Urgent Care department of the hospital had closed, effective June 1, 2023. According to the minutes, physicians from the Clinic, "a third-party run primary care clinic available to walk-ins on the 3rd floor of the hospital) that is not part of the hospital (not part of the hospital ' s license)" would evaluate patients and give clearance for admission to the hospital's BHU (Behavioral Health Unit, area of the hospital designed to stabilize a patient with a mental health emergency) or Medical unit.

A review of the Services Agreement established between the facility and the health foundation (operating the clinic located in the facility's 3rd floor) as of June 1, 2023 indicated that the services the latter would provide at the hospital consisted of: medical clearance, participation in code blue (hospital code used for a patient in need of immediate resuscitation) and rapid response team (RRT: interdisciplinary medical team dispatched in anticipation of significant medical deterioration of patient that could lead to cardiopulmonary arrest), face-to-face consultation including telehealth (delivery of health care services via information and communication technologies such as video-conferencing), and managing medication refills.

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 a safe environment when the facility housed clinic Patients (that belonged to an outside Clinic utilized by the facility to screen and provide medical clearance to patients and is located in the facility's 3rd floor) under observation (when patients are temporarily housed while the doctor decides to admit as an inpatient [patients formally admitted to the hospital], transfer to another facility, or discharge a patient), pending medical clearance, in the facility's 7th floor (designated for admitted inpatients) without having the capacity to treat patients who required a higher level of care. Seven of 30 sampled patients (Patients 1, 2, 3, 4, 5, 12, and 14) were held in observation rooms while waiting to be medically cleared of potentially unknown or emergent medical conditions (example: heart attack), to be either admitted to the facility, discharged home, or transferred to another facility for higher level of care (a hospital capable of providing diagnostic, interventional, or specialized care beyond the capacity from which it originates). This deficient practice had the potential for the facility not to be able to treat patients with an emergency medical condition requiring a higher level of care and a delay of treatment, while the facility arranged for patients to be transferred to another facility or called 911, which can result in patient harm or death. (Refer to A - 0144)

The deficient practice resulted in the facility's inability to provide a safe environment by accepting patients from an outside Clinic who may be presenting with potential emergency medical conditions, on hold and not admitted to the hospital, and placing these patients in the observation area (an area where patients are held in the facility to wait for medical clearance, such as lab results and diagnostic testing of the facility), while the observation area lacked the capability to provide emergency treatment and a higher level of care.

On 10/19/2023 at 11:40 a.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Nurse Manager (NM 1), Chief Nursing Officer (CNO), Director of Quality (DOQ), and the Chief Executive Officer (CEO). Starting 6/1/2023, patients, with unknown and potentially emergent medical conditions, were brought up from an outside clinic (Clinic located in the facility's 3rd floor which is being utilized by the facility to screen and provide medical clearance for patients) into observations rooms (located in the facility's 7th floor dedicated for admitted patients) pending medical clearance and waiting on a medical evaluation, and pending blood test results, electrocardiogram (EKG, a test that records the electrical signal from the heart to check for different heart conditions, it can detect irregular heart rhythms and heart attacks) and radiology (imaging) results. Seven of thirty sampled patients (1, 2, 3, 4, 5, 12, and 14) were held in the observation area for up to 23 hours until a determination was made as to whether the patients were medically cleared to be admitted to the facility, discharged home, or transferred to another facility for a higher level of care (a hospital capable of providing diagnostic, interventional, or specialized care beyond the capacity from which it originates). The facility did not have the capacity to provide a higher level of care to patients with a high acuity level (condition is severe and imminently dangerous) since the facility closed its Intensive Care Unit (ICU, a unit that handles severe potentially life-threatening cases) on 11/2022 and the Urgent Care on 6/1/2023 and did not have an Emergency Department (ED-responsible for the provision of medical care for patients arriving at the hospital in need of immediate care). This had the potential for the facility not to be able to treat patients with an emergency medical condition (such as heart attack etc.) requiring a higher level of care and a delay of treatment while the facility arranged for patients to be transferred to another facility or to call 911.

On 10/20/2023 at 7:01 p.m., the IJ was removed in the presence of the Administrator (ADM), NM 1, CNO, DOQ, CEO, the Compliance Officer (CO), and the Case Manager (CM) after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record review. The IJ Removal Plan indicated hospital beds will only be used for admitted patients, who have been medically cleared and meet the hospital's admission criteria. The patients will remain in the clinic until they are medically cleared for admission. The hospital will not admit patient with certain conditions, such as acute (severe and sudden in onset) cardiac conditions, suspected or actual head injuries, grossly infected wounds, and patients who are immediately post-operative from major surgical procedures.

Based on observation, interview, and record review, the facility failed to provide a safe environment when the facility housed clinic Patients (that belonged to an outside Clinic utilized by the facility to screen and provide medical clearance to patients and is located in the facility's 3rd floor) under observation (when patients are temporarily housed while the doctor decides to admit as an inpatient [patients formally admitted to the hospital], transfer to another facility, or discharge a patient), pending medical clearance, in the facility's 7th floor (designated for admitted inpatients) without having the capacity to treat patients who required a higher level of care. Seven of 30 sampled patients (Patients 1, 2, 3, 4, 5, 12, and 14) were held in observation rooms while waiting to be medically cleared of potentially unknown or emergent medical conditions (example: heart attack), to be either admitted to the facility, discharged home, or transferred to another facility for higher level of care (a hospital capable of providing diagnostic, interventional, or specialized care beyond the capacity from which it originates).

This deficient practice had the potential for the facility not to be able to treat patients with an emergency medical condition requiring a higher level of care and a delay of treatment, while the facility arranged for patients to be transferred to another facility or called 911, which can result in patient harm or death.

On 10/19/2023 at 11:40 a.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Nurse Manager (NM 1), Chief Nursing Officer (CNO), Director of Quality (DOQ), and the Chief Executive Officer (CEO). Starting 6/1/2023, patients, with unknown and potentially emergent medical conditions, were brought up from an outside clinic (Clinic located in the facility's 3rd floor which is being utilized by the facility to screen and provide medical clearance for patients) into observations rooms (located in the facility's 7th floor dedicated for admitted patients) pending medical clearance and waiting on a medical evaluation, and pending blood test results, electrocardiogram (EKG, a test that records the electrical signal from the heart to check for different heart conditions, it can detect irregular heart rhythms and heart attacks) and radiology (imaging) results. Seven of thirty sampled patients (1, 2, 3, 4, 5, 12, and 14) were held in the observation area for up to 23 hours until a determination was made as to whether the patients were medically cleared to be admitted to the facility, discharged home, or transferred to another facility for a higher level of care (a hospital capable of providing diagnostic, interventional, or specialized care beyond the capacity from which it originates). The facility did not have the capacity to provide a higher level of care to patients with a high acuity level (condition is severe and imminently dangerous) since the facility closed its Intensive Care Unit (ICU, a unit that handles severe potentially life-threatening cases) on 11/2022 and the Urgent Care on 6/1/2023 and did not have an Emergency Department (ED-responsible for the provision of medical care for patients arriving at the hospital in need of immediate care). This had the potential for the facility not to be able to treat patients with an emergency medical condition (such as heart attack etc.) requiring a higher level of care and a delay of treatment while the facility arranged for patients to be transferred to another facility or to call 911.

On 10/20/2023 at 7:01 p.m., the IJ was removed in the presence of the Administrator (ADM), NM 1, CNO, DOQ, CEO, the Compliance Officer (CO), and the Case Manager (CM) after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record review. The IJ Removal Plan indicated hospital beds will only be used for admitted patients, who have been medically cleared and meet the hospital's admission criteria. The patients will remain in the clinic until they are medically cleared for admission. The hospital will not admit patient with certain conditions, such as acute (severe and sudden in onset) cardiac conditions, suspected or actual head injuries, grossly infected wounds, and patients who are immediately post-operative from major surgical procedures.

Findings:

During an interview on 10/16/2023 at 1:11 p.m. with Nurse Manager (NM) 1, NM 1 stated the following: The Hospital closed the Intensive Care Unit (ICU, a unit that handles severe potentially life-threatening cases) on 11/2022 and the Urgent Care (a department that assists patients with illnesses that are not life-threatening) on 6/1/2023. The Hospital never had an Emergency Department (ED- responsible for the provision of medical care for patients arriving at the hospital in need of immediate care). The hospital did not have the capacity to take care of high acuity (condition is severe and imminently dangerous) patients or patients with cardiac (heart) issues. The patients with a high acuity would need to be transferred to another hospital and if needed, the facility would call 911.

During an observation on the Seventh (7th) floor inpatient unit, on 10/16/2023 at 3:34 p.m., Patients 1, 2, and 3, were observed in patient rooms designated for "observation." Mental health worker (MHW) 1 was performing rounds (monitoring and reassessment to ensure patient safety) on Patients 1, 2, and 3. The observation rooms did not have any monitoring equipment, such as cardiac monitors (a machine that watches the electrical activity of the heart to ensure it is working normally).

During an observation on the 7th floor inpatient unit, on 10/17/2023 at 3:49 p.m., Patients 4 and 5 were observed in "Observation (when patients are temporarily housed while the doctor decides to admit as an inpatient [patients formally admitted to the hospital], transfer to another facility, or discharge a patient)," rooms.

During a concurrent interview on 10/17/2023 at 3:49 p.m. with Registered Nurse (RN) 6, RN 6 stated the following: Patients in "observation" beds belonged to an outside Clinic (located on the facility's 3rd floor) and were either bedbound or had behavior issues and so patients were held in the "Observation" beds because the Clinic was not able to accommodate those patients. RN 6 worked for the hospital and was assigned to care for the Clinic's patients (Patient 4 and 5) located in the "Observation" rooms. RN 6 reported abnormalities to the Clinic physicians. Patients 4 and 5 were pending medical clearance, by the Clinic's physicians, to see if the patients met the criteria for admission to the hospital, to be discharged home, or transferred to an outside hospital for a higher level of care. In the meantime, while in the "Observation" room, the patients undergo a medical evaluation by the Clinic's physician and await laboratory results or blood work-up, EKG (Electrocardiogram, ECG, a test that records the electrical signal from the heart to check for different heart conditions, it can detect irregular heart rhythms and heart attacks) and X-ray (imaging) results. After all the results are in, the Clinic physician determines whether the patients are admitted to the hospital, discharged home, or are transferred to another hospital for higher level of care.

During an interview on 10/17/2023 at 4:30 p.m. with Nurse Manager (NM) 1, NM 1 and the Compliance Officer (CO) stated the following: Starting 6/1/2023, patients were brought up from an outside clinic (Clinic utilized to screen (preliminary assessment of patients that is completed prior to admission) and provide medical clearance to patients prior to admission as an inpatient) into observations rooms (located in the facility's 7th floor dedicated for admitted patients to the hospital) for up to 23 hours, pending medical clearance and waiting on medical evaluation, pending blood work results, EKG and radiology (imaging tests) results. The facility housed the Clinic's patients, in licensed hospital beds, pending medical clearance to either admit as an inpatient or transfer out as unable or discharged home. The clinic patients brought to the facility's 7th floor for observation were monitored by the facility's own staff (Registered Nurses). NM 1 and CO stated patients brought to the observation area had to be low acuity patients (patients who are more independent, require minimal nursing care, and have a mild illness or injury) and must meet screening criteria (patients are not placed in observation if they require total care, have pressure injuries [damage to the skin] on the skin, require dialysis [purification of blood], are developmentally delayed [slower than normal development of motor, cognitive, social, and emotional skills] or are females of child-bearing age [18 - 55 years old]).

During an interview on 10/18/2023 at 8:30 a.m. with NM 1 and the CO, the NM 1 and CO stated the following: The Clinic referred Patients who were bedbound and/or with behavior problems to the observation rooms (located in the facility ' s 7th floor and designated as inpatient hospital beds), pending the medical evaluation, laboratory work-up, EKG, and radiology results. The NM 1 and the CO further said there was a possibility that the patients in observation beds may have unknown medical complications that may require emergency medical intervention. The facility did not have cardiac monitoring equipment in the observation rooms. The facility did not have the capacity to care for these patients, nor will the facility try to take care of these patients. If patients were not medically cleared and required an intervention that the facility was not capable of treating, the facility would arrange for transfer to another hospital for higher level of care or call 911.

During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 10/16/2023, the "H&P" indicated that Patient 1 was admitted to a skilled nursing facility (a clinical facility where patients can receive medical care and rehabilitation services from trained professionals) with multiple comorbidities (more than two illnesses or diseases occurring in the same person at the same time). The H&P further stated that Patient 1 has grown increasingly confused, has not been eating as well as he used to, is refusing medications, and has a decreased intake of both food and water. As a result, Patient 1 was admitted to the facility for additional evaluation. Patient 1 was admitted due to adult failure to thrive (syndrome of weight loss, decreased appetite, poor nutrition, and inactivity), dehydration, and increased blood sugar, although Patient 1 had no history of diabetes mellitus, which is a disease of inadequate control of blood sugar levels.

During a concurrent interview and record review on 10/19/2023 at 2:15 p.m. with Registered Nurse (RN) 2, Patient 1's electronic medical record titled "Observation" dated 10/16/2023 was reviewed. The electronic medical record indicated Patient 1 was brought to the observation area on 10/16/2023 at 12:02 p.m. and was admitted to the facility on 10/16/2023 at 2:06 p.m. RN 2 stated, "The patient is admitted to the 7th floor, the observation area, because we are waiting for lab results."

During an interview on 10/17/2023 at 3:25 p.m. with Compliance Officer (CO), the CO stated all patients will be screened by the clinic (an outpatient clinic that is contracted with the facility to provide medical clearance services) and will be placed in an observation area while waiting for all testing to be completed by the clinic. Patients will be cared for by a hospital nurse and a mental health worker will do rounding (monitoring and reassessment to ensure patient safety) on patients every 15 minutes. The CO further stated, "patients that the facility placed in the observation area are not admitted to the facility." The CO stated that these patients held in the 7th floor observation area are not part of the facility census. The CO also stated, "Technically, the patients in the observation area are not facility patients until they have all testing completed."

During a review of Patient 2's note titled "Observation, Inpatient Medical Clearance," dated 10/16/2023 at 12 p.m., the note indicated the following. Patient 2 was admitted under observation "for episodes of vomiting. Medical history included hypertension (high blood pressure) ... seizures (uncontrolled electrical activity in the brain cells), dementia (a group of conditions that affect memory and judgment)."

During a review of Patient 2's provider note titled "Observation, Medical Clearance by Provider," dated 10/18/2023 at 12:26 a.m., the note indicated the following: Patient 2 was brought to the facility for "vomiting ...Medical history included hypertension ...seizure, dementia ...Physical exam indicated Patient 2 was lethargic (a state of feeling drowsy, unusually tired, or not alert) and responsive to voice. Clinical impression: 1. Vomit. 2. Abnormal liver function test (blood test that provide information about the state of the liver) 3. Dehydration (loss of water at a rate greater than the body can replace it) 4. Elevated white blood count ...Plan of care: "Okay to admit to doctor per admitting."

During a concurrent interview and record review on 10/18/2023 at 2 p.m. with the Nurse Manager (NM) 1, NM 1 stated the following: Patient 2 was "still a clinic patient" and was admitted to the observation on 10/16/2023 for complaints of vomiting and pending medical clearance, a medical evaluation, laboratory work-up and EKG results. After all the results were in, the physician admitted the patient to the facility.

During a review of Patient 3's history and physical (H&P), dated 10/16/2023, the H&P indicated, Patient 3 was admitted for observation on 10/16/2023, at 12:26 p.m. for psychiatric (mental, emotional, and behavioral conditions) evaluation and medical clearance. The H&P further indicated, Patient 3 was highly delusional (false beliefs or judgements about external reality) and had auditory hallucinations (hearing noises or voices without an external stimulus).

During further review of Patient 3's H&P, dated 10/16/2023, the H&P indicated Patient 3 had past medical history (PMH) of bipolar disorder (mental condition that causes extreme mood swings), schizophrenia (mental condition involving a breakdown in the relation between thought, emotion, and behavior, leading to inappropriate actions, feelings, and withdrawal from reality), psychosis (mental condition in which thought and emotions are so affected that contact is lost with reality), and schizoaffective disorder (mental illness that can affect thoughts, mood, and behavior).

A review of Patient 4's Face sheet indicated Patient 4 was admitted to an observation bed on 10/17/2023 for urosepsis (a life-threatening response to a urinary tract infection) and hypertension (high blood pressure).

A review of Patient 4's "Medical Clearance by Provider," in Observation, dated 10/17/2023 at 12:35 p.m., indicated Patient 4 was an 84-year-old female brought from a skilled nursing facility for abnormal urinalysis (UA, a test that detects a urinary tract infection, kidney disease or diabetes) and to rule out a urinary tract infection. Medical history includes chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), hyperlipidemia (too much fat or cholesterol in the blood) ... hypertension, diabetes (high blood sugar), cardiomegaly (enlarged heart, is usually a sign of a heart valve problem or heart disease, may also signal a prior heart attack).

During a concurrent interview and record review on 10/17/2023 at 3:49 p.m., with Registered Nurse (RN) 6, RN 6 stated she (RN 6) administered two intravenous (IV-through the vein) medications to Patient 4. RN 6 administered a Rocephin (an antibiotic to treat infection) IV to treat a urinary tract infection, and a Hydralazine (a medication to treat high blood pressure) injection to treat the elevated blood pressure of 178/80 (normal is 120/80).

During a review of Patient 5's history and physical (H&P), dated 10/17/2023, the H&P indicated, Patient 5 was admitted for observation on 9/17/2023 with a chief complaint of right hip pain. The H&P further indicated Patient 5 had past medical history (PMH) of psychosis (mental condition in which thoughts and emotions are so affected that contact is lost with reality), open angle glaucoma (progressive irreversible loss of side vision), hypertension (increased blood pressure), hyperlipidemia (abnormally high concentration of facts in the body), and hypothyroidism (thyroid gland does not produce enough thyroid hormones).

During a review of Patient 12's observation nurses' progress note titled "Interdisciplinary Team Progress Note Nursing," dated 7/27/2023 at 9:48 a.m., the Interdisciplinary Team Progress Note Nursing indicated the following. Patient 12 was an 88-year-old female, placed in observation. Patient 12 was on a 5150 Hold (a law which allows an adult who is experiencing a mental health crisis to be involuntarily detained in the hospital for 72 hours when evaluated to be a danger to others or self) for being a danger to others (DTO) and had increased aggression. Patient 12 had a medical history of "metabolic encephalopathy (a problem in the brain caused by a chemical imbalance), transient ischemic attack (TIA or mini stroke, a temporary disruption in the blood supply to part of the brain), atrial fibrillation (a-fib, an irregular, often rapid heart rate that commonly causes poor blood flow), hyperlipidemia (blood has too much fat and cholesterol), hypertension (high blood pressure), Alzheimer ' s Disease (a progressive disease that destroys memory and other important mental functions), dementia (a condition that affects impairment of memory and judgment), and psychosis (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality) ...At 12 p.m., Patient 12 had a blood pressure of 195/79 (high, normal is 120/80) and heart rate (HR) of 58 (low, normal is between 60 to 100 beats per minute) ...At 12:50 p.m., rechecked BP 191/73 (high), HR was 77."

During a concurrent interview and record review on 10/19/2023 at 3:40 p.m., with NM 1, Patient 12's medical record was reviewed. NM 1 stated the following: Patient 12 was placed under observation on 7/27/2023 at 9:48 a.m., for aggressive behavior and placed on a 5150 hold. At 10:29 a.m., Patient 12's blood pressure was high (172/80) and heart rate (HR) was 67 (normal). At 12 p.m., Patient 12's blood pressure was 195/79 (high) and heart rate was 58 (normal is between 60 and 100). NM 1 stated that high blood pressure could be a complication of a heart attack or stroke (patient may be having a heart attack or stroke).

A review of Patient 14's vital signs (temperature, blood pressure, heart rate, respiratory rate, and pain) record upon arrival to the observation bed, dated 10/13/2023 at 11 a.m., indicated the following. Temperature (T) was 98.1 Fahrenheit (F, normal), blood pressure (BP) was 195/115 (high, normal is 120/80), heart rate (HR) was 85 (normal), respiratory rate was 18 (normal), and left-sided chest pain rated at 4/10 (moderate pain).

During a review of a document for Patient 14 titled "Medical Clearance by Provider," dated 10/13/2023 at 12:07 p.m., the document indicated the following: Patient 14 was placed in observation. Patient 14's chief complaint was chest discomfort. History of present illness indicated Patient 14 had Type 2 Diabetes (high blood sugar), hypertension, coronary artery disease (CAD, disease caused by plaque buildup in the arteries that supply the heart, limiting blood flow to the heart), coronary artery bypass graft (CABG, a surgical procedure used to treat CAD, it diverts blood around narrowed or clogged arteries to improve blood flow and oxygen to the heart) and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Patient 14 was referred from an extended care facility, for medical clearance as Patient 14 was exhibiting aggressive behavior. On arrival, Patient 14 had elevated blood pressure, and left-sided chest pain ...In addition, at 11: 10 a.m., Patient 14's Troponin level (can indicate a recent heart attack or other injuries and conditions that affect the heart) was 767.10 (high, normal range is between 0 and 0.04 ng/ml). At 6:40 p.m., Patient 14's Troponin level was 707.20 (high). EKG results indicated ...first degree atrioventricular (AV) block (a condition of abnormally slow conduction through the AV node [atrioventricular node, controls the passage of the heart ' s electrical signal], considered benign, however it is associated with increased risk of all-cause mortality in the general population). The document further indicated, Patient 14 "requires a higher level of care given the history of CAD and active chest pain. Observation Discharge Disposition: Another hospital for a higher level of care."

A review of Patient 14's EKG results dated 10/13/2023 at 11:15 a.m., indicated the results were abnormal. The results indicated sinus rhythm (normal rhythm of the heart) with first degree AV block (a condition of abnormally slow conduction through the AV node, considered benign, however it is associated with increased risk of all-cause mortality in the general population).

During a review of a nurses' progress note titled "Interdisciplinary Team Progress Note Nursing," dated 10/13/2023 at 11 a.m., the progress note indicated that "patient (Patient 14) complained of chest pain with blood pressure of 195/115 (high). Physician notified. Patient (Patient 14) was given aspirin (a blood thinner that can reduce the risk of heart attack) and nitroglycerin (treats chest pain). Patient (Patient 14) reported a history of open-heart surgery (a surgical procedure performed to treat heart problems by directly accessing the heart through an opening in the chest) and stroke (brain attack, when something blocks blood supply to part of the brain or when a blood vessel in the brain burst) ... Rechecked Patient 14's BP 182/102 ... At 2:30 p.m., the BP was 197/107 (high). At 5 p.m., the BP was 195/102 (high)."

During a review of Patient 14's "Physician's Order," dated 10/13/2023 at 12:12 p.m., the physician's order indicated "Transfer to higher level of care when bed available or as soon as possible. Dx (diagnosis): elevated Troponin, abnormal EKG and h/o (history of) chest pain."

During a review of a nurses' progress note titled "Interdisciplinary Team Progress Note Nursing," dated 10/13/2023 at 8:35 p.m., the progress note indicated Patient 14 reported "left-sided chest pain, vital signs ...BP was 172 /92 (high) ...orders for transfer of Patient 14 to higher level of care ...At 10:45 p.m., report given to an RN in the ICU of an outside hospital. On 10/14/2023 at 12:18 a.m., Patient 14 was transported to an outside hospital ..."

During a concurrent interview and record review on 10/19/20203 at 3:40 p.m., with NM 1, Patient 14's medical record was reviewed. NM 1 stated the following: Patient 14 was admitted to the observation area on 10/13/2023 at 11 a.m. Upon admission, Patient 14's blood pressure was elevated and complained of chest pain. Aspirin and nitroglycerin and other medications were given to treat the blood pressure and chest pain. The blood pressure remained elevated while under observation. The physician ordered for Patient 14 to be transferred to another facility for a higher level of care. NM 1 verified that the facility took 12 to 13 hours to transfer Patient 14 to another hospital.

During a review of the facility's policy and procedure (P&P) titled, "Patient's Rights," dated 3/2019, the P&P indicated the following. "B. Rights Which May Not be Limited ...To safe and sanitary housing."

Based on observation, interview and record review, the facility failed to ensure that physicians sign verbal and telephone orders communicated to licensed staff, within 48 hours, for two of thirty sampled patients (Patients 12, and 14) in accordance with the facility ' s rules and regulation for medical staff regarding signing of orders.

This deficient practice had the potential to result in negatively affecting Patient 12 and 14 ' s health and well-being by placing the patients at risk for medication errors and other potential adverse incidents.

Findings:

1. During a review of Patient 12 ' s "History and Physical" (H&P, a formal and complete assessment of the patient and the problem), dated 7/28/2023 at 8:20 a.m., the H&P indicated Patient 12 was admitted to the facility on a 5150 hold (a law which allows an adult who is experiencing a mental health crisis to be involuntarily detained in the hospital for 72 hours when evaluated to be a danger to others or self) for danger to self and had increased aggression. Patient 12 had a past medical history of transient ischemic attack (TIA or mini stroke, a temporary disruption in the blood supply to part of the brain), atrial fibrillation (a-fib, an irregular, often rapid heart rate that commonly causes poor blood flow), hyperlipidemia (blood has too much fat and cholesterol), hypertension (high blood pressure), dementia (a condition that affects impairment of memory and judgment) with behavior disturbances.

During a review of Patient 12 ' s "Telephone Order," entered on 7/28/2023 at 9 p.m., the order indicated "Depakene 250 MG / 5 ML Syrup (Valproic Acid, used to treat seizures and mood disorders), (oral) 2 times a day for 30 days. The order was signed by the physician on 8/19/2023.

During a concurrent interview and record review on 10/19/2023 at 3:40 p.m., with Nurse Manager (NM) 1, NM 1 stated the verified Patient 12 ' s Telephone order for Depakene entered on 7/28/2023 at 9 p.m., was signed by the physician on 8/19/2023. NM 1 said telephone orders should be signed by the physician within 48 hours.

During a review of the facility ' s rules and regulations (R&R) for medical staff, dated 10/19/2022, the R&R indicated, "6.5-3, "Telephone orders shall be entered on behalf of the providers and shall be countersigned within forty-eight (48) hours."

2. During a review of a document for Patient 14 titled "Medical Clearance by Provider," dated 10/13/2023 at 12:07 p.m., the document indicated the following: Patient 14 was placed in observation. Patient 14 ' s chief complaint was chest discomfort. History of present illness indicated Patient 14 had Type 2 Diabetes (high blood sugar), hypertension, coronary artery disease (CAD, disease caused by plaque buildup in the arteries that supply the heart, limiting blood flow to the heart), coronary artery bypass graft (CABG, a surgical procedure used to treat CAD, it diverts blood around narrowed or clogged arteries to improved blood flow and oxygen to the heart) and schizophrenia (a disorder that affects a person ' s ability to think, feel, and behave clearly). Patient 14 was referred from extended care facility, for medical clearance as Patient 14 was exhibiting aggressive behavior.

During a review of Patient 14 ' s "Telephone Order," entered on 10/13/2023 at 12:16 p.m., the order indicated to give Ativan (Lorazepam, relieves anxiety) 1 MG, intramuscular [in the muscle] STAT (immediately) only once, as needed for anxiety. The order indicated it was "Pending Signature."

During a concurrent interview and record review on 10/19/20203 at 3:40 p.m., with Nurse Manager (NM) 1, NM 1 reviewed Patient 14 ' s Ativan order and stated telephone orders should be signed by the physician within 48 hours. NM 1 verified the telephone order for Ativan (lorazepam) injection (INJ) 1 MG, (STAT) ordered on 10/13/2023 at 12:16 p.m., had not yet been signed by the physician.

During a review of the facility ' s rules and regulations (R&R) for medical staff, dated 10/19/2022, the R&R indicated, "6.5-3, "Telephone orders shall be entered on behalf of the providers and shall be countersigned within forty-eight (48) hours."

Based on interview and record review, the facility failed to ensure physicians prepare a complete and legible History and Physical (H&P, a formal complete assessment of the patient and the problem) within 24 hours prior to surgery for two of 30 sampled patients (Patient 6 and 11) in accordance with the facility ' s policies and procedures regarding H&Ps.

This deficient practice had the potential to result in poor quality of care received by Patient 6 and Patient 11 due to inadequate or delayed management/treatment plan based on the H&P that is used to guide later diagnostic and treatment decisions.

Findings:

1. During a concurrent interview and record review on 10/18/2023 at 4:35 p.m., with case manager (CM), Patient 6 ' s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 08/02/2023, was reviewed. The H&P was handwritten, incomplete, and not legible. The CM stated, the H&P was not readable.

During a concurrent interview and record review on 10/20/2023 at 10:39 a.m., with the Nurse Supervisor (Sup 2), Patient 6 ' s H&P, dated 8/2/2023, was reviewed. The H&P was handwritten and not legible. The Sup 2 attempted to read Patient 6 ' s H&P, but stated the H&P is not readable.

During a review of Patient 6 ' s operative report (OR), dated 08/02/2023, the OR indicated Patient 6 underwent left leg percutaneous (done though skin) angioplasty (PTA, an invasive procedure used to open a blocked artery). The OR further indicated, Patient 6 had past medical history (PMH) of multiple medical problems, including peripheral vascular disease (PVD, a systemic disorder that involves the narrowing of peripheral blood vessels), hypertension (elevated blood pressure), and history of multiple bilateral (both) lower legs angioplasties.

During a review of the facility ' s rules and regulations (R&R) for medical staff, dated 10/19/2022, the R&R indicated, " 6.2. The attending staff member shall be responsible for the preparation of a complete and legible medical record for each patient. The contents of the record shall be pertinent and current. 6.3." A complete history and physical (H&P) examination shall be completed and signed within 24 hours of the patient admission. The attending physician must validate and sign this report within 24 hours of admission."

The Code of Federal Regulations indicates that the purpose of a medical history and physical examination is to determine whether there is anything in the patient's overall condition that would affect the planned course of the patient's treatment, such as a medication allergy, or a new or existing co-morbid condition that requires additional interventions to reduce risk to the patient.

2. During a review of Patient 11 ' s History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 10/11/2023, the H&P indicated Patient 11 was admitted on 10/11/2023 for severe weakness and confusion, failure to thrive (insufficient weight gain), weight loss, and dysphagia (difficulty swallowing).

During an interview, on 10/19/2023, at 3:15 p.m., with Nurse Manager (NM 1), the NM 1 stated, H&P must be completed within forty-eight (hours), but the NM 1 further stated the NM 1 was not sure and had to check the facility ' s policy. The NM 1 stated, attending physicians are required to compete H&P on newly admitted patients to provide a plan of care and treatment based on the assessed medical, psychological, social, family and medication history and overall condition of the patient.

During a concurrent interview and record review, on 10/19/2023, at 4:45 p.m., with case manager (CM), Patient 11 ' s H&P, dated 10/11/2023, was reviewed. The H&P indicated date of service was 10/11/2023. The H&P further indicated, the attending physician dictated Patient 11 ' s H&P on 10/14/2023 at 8:37 p.m. and signed off on Patient 11 ' s H&P on 10/15/2023 at 11:05 a.m. The CM stated a complete H&P shall be completed and signed twenty-four (24) hours of the patient admission, but the attending physician did not.

During a review of the facility ' s rules and regulations (R&R) for medical staff, dated 10/19/2022, the R&R indicated, " 6.2. The attending staff member shall be responsible for the preparation of a complete and legible medical record for each patient. The contents of the record shall be pertinent and current. 6.3." A complete history and physical (H&P) examination shall be completed and signed within 24 hours of the patient admission. The attending physician must validate and sign this report within 24 hours of admission."

The Code of Federal Regulations indicates that the purpose of a medical history and physical examination is to determine whether there is anything in the patient's overall condition that would affect the planned course of the patient's treatment, such as a medication allergy, or a new or existing co-morbid condition that requires additional interventions to reduce risk to the patient.

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 follow State and Federal staffing regulatory standards regarding safe patient care assignments for five of five sampled charge nurses (CN 1, 2, 3, 4, and 5) by assigning the charge nurses to multiple units on different floors and assigning the charge nurses to perform individual patient care. This deficient practice had the potential to result in patient needs not being met to assure patient safety especially when there is an emergency situation, and the charge nurse is not readily available to assist the staff. (Refer to A-0392)

2. The facility failed to communicate to the physician one of thirty sampled patients' (Patient 28) blood sugar result. Patient 28 had a blood sugar result of 59 mg/dL (milligrams per deciliter, a unit of measurement of substance in fluid. Normal is between 70 mg/dl to 100 mg/dl). This deficient practice had the potential to compromise Patient 28's health and safety by failing to communicate the abnormal blood sugar result to the physician, which can delay treatment and may result in further health complications for Patient 28 due to untreated low blood sugar level. (Refer to A-0395)

3. The facility failed to develop and implement a care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for post-operative (after surgery/procedure) care for one of thirty (30) sampled patients (Patient 6) in accordance with the facility's policy and procedures regarding care plan development. This deficient practice had the potential to result in Patient 6's treatment and care goals not being met by not identifying the patient ' s needs and risks. (Refer to A-0396)

4. The facility failed to ensure two of the thirty sampled patients (Patient 25 and Patient 28) had complete documentation for medications that were administered in accordance with the facility ' s policies and procedures regarding medication documentation. Patient 28 was administered with Levophed (norepinephrine, an intravenous medication used in critical care settings to treat severe low blood pressure), and Patient 25 was administered with Epinephrine (a hormone used as a medication for life-threatening conditions).

This deficient practice had the potential to compromise Patient 25 and Patient 28's health and safety when medications administered were not completely and accurately documented, which increased the risk of medication administration errors and may create a challenge for healthcare providers to make informed decisions based on incomplete documentation. (Refer to A-0398)

5. The facility failed to perform rounds (monitoring and reassessment to ensure patient safety) every fifteen (15) minutes for one of thirty sampled patients (Patient 15), who was located in a combined medical surgical (serves the general population of patients with a variety of illnesses that are not life threatening) and behavioral health unit (area of the hospital designed to stabilize a patient with a mental health emergency) in accordance with the facility's policies and procedures regarding patient monitoring for patient's behavior, respiratory (breathing) status and location. This deficient practice had the potential to result in lack of assessment of Patient 15's behavior, respiratory status, and location, which may result in delayed treatment/interventions for Patient 15. (Refer to A-0398)

6. The facility failed to ensure one of thirty sampled patients (Patient 28) blood pressure medications (Metoprolol administered oral and intravenously [through the vein]) were administered following a physician's order and that Patient 28's blood pressure was reassessed after administration of a blood pressure medication.

This deficient practice had the potential to compromise Patient 28's health and safety, placing Patient 28 at risk for experiencing hypotensive (low blood pressure) or hypertensive (high blood pressure) conditions. (Refer to A-0405)

7. The facility failed to ensure two (2) of thirty (30) sampled patients (Patient 6 and Patient 25) had a physician order or a standing order (an order that continues to be followed until it is changed or canceled) for medications (epinephrine [a hormone used as a medication for life-threatening conditions]) that were administered during a code blue (any patient with an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a hospital-wide alert).

This deficient practice resulted in the unauthorized administration of emergency medication and had the potential to compromise Patient 6 and Patient 25's health and safety. (Refer to A- 0406)

8. The facility failed to ensure telephone orders were kept to a minimum, for one of 30 sampled patients (Patient 15), in accordance with the facility's policy and procedure regarding telephone orders. This deficient practice had the potential for medications not to be prescribed in a safe manner, which can adversely affect the patient ' s health and safety. (Refer to A - 0407)

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 follow State and Federal regulatory standards regarding safe patient care assignments for five of five sampled charge nurses (CN 1, 2, 3, 4, and 5) by assigning the charge nurses to multiple units on different floors and assigning the charge nurses to perform individual patient care.

This deficient practice had the potential to result in patient needs not being met to assure patient safety especially when there is an emergency situation, and the charge nurse is not readily available to assist the staff.

Findings:

During an observation, interview, and record review on 10/16/2023 at 2:22 p.m., on the 8th floor (medical and behavioral health unit [area of the hospital designated to stabilize a patient with a mental health emergency]), Ten (10) patients were observed on the unit. A review of the unit assignment indicated Charge Nurse (CN) 1 was assigned as the charge nurse for the 6th and 8th floors. CN 1 was also assigned to Code Blue Team (a team that responds when a patient is experiencing a cardiac [heart]) or respiratory (breathing) arrest). Concurrently, during an interview with the Compliance Officer (CO) and Nurse Manager (NM) 1, the CO and NM 1 verified that CN 1 was assigned as the charge nurse for the units located on the 6th and 8th floors. In addition, CN 1 was also assigned to the Code Blue Team.

During an interview on 10/17/2023 at 9:33 a.m. with the compliance officer (CO), the CO stated the following: The facility followed staffing ratios (maximum number of patients assigned to a Registered Nurse [RN] during one shift) as per State Regulations. Charge nurse duties included assisting other nurses if their patients were in distress and covering nurses during breaks. The CO verified Charge Nurses were assigned to multiple units on different floors. The CO stated she was not aware that charge nurses could not be assigned to units located on different floors.

During an observation and interview on 10/17/2023 at 11:10 a.m., in the Behavioral Health Unit (BHU, area of the hospital designated to stabilize a patient with a mental health emergency), with Charge Nurse (CN) 2, CN 2 stated the following: CN 2 was assigned as the charge nurse in the BHU. In addition, CN 2 was assigned to seven (7) total patients, including four (4) primary patients (Charge nurse is the designated nurse to carry out all patient tasks for the four patients) and had to develop care plans (provides a framework for evaluating and providing patient care needs related to the nursing process) and sign off nursing assessments for three (3) other patients that belonged to licensed vocational nurse (LVN) 1. CN 2 also stated that she was orienting a registered nurse (RN) trainee. CN 2 also stated that her (CN 2) charge nurse duties included having knowledge of all the 28 patients on the unit to be able to properly endorse the patients to the incoming charge nurse.

During a review of the facility's "Shift Assignment," dated 10/15/2023 Night Shift (7 p.m. to 7 a.m.), the assignment indicated the following: Charge Nurse (CN) 5 was assigned as the charge nurse for the 6th, 7th, and 8th floors (medical and behavioral units). The assignment also indicated there were 19 patients on the 6th floor, 25 patients on the 7th floor, and 10 patients on the 8th floor.

During a review of the facility's "Shift Assignment," dated 10/16/2023 Day Shift (7 a.m. to 7 p.m.), the assignment indicated the following: CN 1 was assigned as the charge nurse for the 6th and 8th floor (medical and behavioral units). The assignment also indicated there were 20 patients on the 6th floor, and 10 patients on the 8th floor.

During a review of the facility's "Shift Assignment," dated 10/17/2023 Day Shift, the assignment indicated the following: Charge Nurse (CN) 4 was assigned as the charge nurse for the 7th and 8th floor. The assignment also indicated there were 22 patients on the 7th floor and 9 patients on the 8th floor.

During a review of the facility's "Shift Assignment," for the 5th floor ' s Behavioral Health Unit, dated 10/17/2023 Day Shift, the assignment indicated the following: CN 2 was assigned as the charge nurse of the unit. In addition, CN 2 was also assigned to take care of four (4) patients, train a registered nurse (RN) orientee who was assigned four (4) patients, and oversee four (4) of licensed vocational nurse (LVN) 1's patients.

During a review of the facility's "Shift Assignment," dated 10/18/2023 Day Shift, the assignment indicated the following: CN 4 was assigned as the charge nurse for the 6th, 7th, and 8th floors. The assignment also indicated there were 18 patients on the 6th floor, 22 patients on the 7th floor, and 8 patients on the 8th floor.

During a review of the facility's "Shift Assignment," dated 10/20/2023 Day Shift, the assignment indicated the following: CN 3 was assigned as the charge nurse for the 6th, 7th, and 8th floors. The assignment also indicated there were 10 patients on the 6th floor, 10 patients on the 7th floor, and 10 patients on the 8th floor.

During a review of the facility's policy and procedure (P&P) titled, "Staffing Guidelines," dated 3/2019, the P&P indicated the following: "The Nursing Department will maintain a staffing level that supports safe, appropriate, and effective care for each patient on each unit in the hospital ... Staff for each unit is commensurate with patient acuity (severity of a patient's illness) levels, regulatory requirements, staff expertise, and the availability of ancillary support systems ... Qualified nursing staff members are assigned to meet the needs of patients based on acuity (severity of a patient's illness) mechanism. Acuity rates individual patient care needs based on patient care hours. These hours are mandated by the State i.e. For med surg (Medical Surgical, serves the general population of patients with a variety of illnesses that are not life threatening) patients 1:5 (1 nurse for 5 patients), behavioral unit is 1:6 (1 nurse for 6 patients), telemetry is 1:4 (1 nurse for 4 patients), under Title 22 (a primary regulatory framework for healthcare facilities), an LVN (licensed vocational nurse) can be utilized to meet the RN (registered nurse) ratio mandate, as long as the number of LVNs does not exceed the number of RNs in the Med surg and behavioral units. Each unit functions with the team approach and is directed by a Registered Nurse. Using the acuity system, the Unit Charge Nurse assigns patient care and directs the overall management of the unit. (Name of the Hospital) has a house Supervisor, Charge Nurses in every shift and a Med Surg (Medical Surgical) RN Manager."

Based on interview and record review, the facility failed to communicate to the physician, one of thirty sampled patients' (Patient 28) blood sugar result. Patient 28 had a blood sugar result of 59 mg/dL (milligrams per deciliter, a unit of measurement of substance in fluid. Normal is between 70 mg/dl to 100 mg/dl).

This deficient practice had the potential to compromise Patient 28's health and safety by failing to communicate the abnormal blood sugar result to the physician, which can delay treatment and may result in further health complications for Patient 28 due to untreated low blood sugar level.

Findings:

During a review of Patient 28's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 6/6/2023, the "H&P" indicated, Patient 28's medical history included diabetes (high blood sugar), epilepsy (is a brain condition that causes sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements, feelings), Osteoarthritis (OA, disease that causes swelling and tenderness of one or more joints), and major depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest). The H&P also indicated Patient 28 was admitted to the facility for further evaluation of poor oral intake and generalized weakness (weak in most areas of your body).

During a concurrent interview and record review on 10/19/2023 at 2:30 p.m. with Registered Nurse (RN) 2, Patient 28's laboratory results, dated 4/14/2023 at 5:55 a.m., were reviewed. The lab results indicated Patient 28 had a glucose (blood sugar) of 59 mg/dL (milligrams per deciliter, a unit of measurement). RN 2 confirmed that the physician was not made aware that Patient 28's blood sugar was 59 mg/dL. The lab results indicated a glucose reference range (the set of numbers that 95% of normal results are expected to lie within) between 74 and 106 mg/dL. RN 2 stated she (RN 2) could not locate documentation that addresses the blood glucose of 59 mg/dL. RN 2 also stated, "At 12:18 p.m., Patient 28 was found in asystole (when heart stops beating), and a Code Blue (indicates a patient requiring immediate medical attention such as heart attack) was called."

During a concurrent interview and record review on 10/20/2023 at 3:45 p.m. with the Manager of Medical Surgical Unit (NM) 1 and RN 2, Patient 28's Nursing Progress Note, dated 4/14/2023 at 13:29 p.m., was reviewed. RN 2 stated the nursing progress note indicated a timeline starting at 12:15 p.m. when Patient 28 ' s cardiac (heart) rhythm was discovered by the telemetry cardiac monitor (device that records the electrical activity of the heart) technician to be in asystole (when the heart stops beating) and a code blue was called. NM 1 stated at 12:40 p.m. Patient 28's blood sugar was 11 mg/dL after regaining a heart rhythm. NM 2 stated, "The blood sugar of 11 mg/dL should be addressed in the patient's medical record and staff has to indicate what intervention was done to address the low blood sugar result." NM 1 confirmed that there was no record of what intervention was done when Patient 28 had a blood sugar of 11 g/dl during the code blue. Likewise, NM 1 also stated that when Patient 28 had a blood sugar of 59 mg/dl on 4/14/2023 at 5:55 a.m. (before the code blue was called at 12:15 p.m. later in the day), it (the blood sugar result of 59 mg/dl) should have been reported to the physician.

In addition, NM1 said, "The system will not alert the RN unless the lab value is a critical lab value." NM 1 stated she (NM 1) is unsure if a blood sugar of 59 mg/dl is a critical lab value. During an interview on 10/20/2023 at 10:00 a.m. with the House Supervisor (HS) 2, HS 2 stated, "During a code, if the BS (Blood sugar) is 11, it should be addressed and documented in the patient's medical record." HS 2 further stated that even if the paramedics administered glucose, the primary RN is required to document what was done to treat a blood sugar of 11, a critical lab (Laboratory) value that must be addressed."

During a review of the facility's policy and procedure (P&P) titled, "Blood Glucose (sugar) Testing," dated November 2022, the P&P indicated under General Operating Policy the following:

A physician's order is required for all blood glucose finger-stick monitoring.

Finger-stick blood glucose monitoring will be performed at the bedside by a qualified RN or LVN (Licensed Vocational Nurse) using the Glucometer (a device used for measuring the concentration of glucose [sugar] in the blood).

The licensed staff member performing the test will be responsible for following all operating guidelines and for reviewing the current value and previous values for comparison.

If the values do not correlate the test will be repeated immediately.

If the test result is still out of range, a laboratory serum glucose test will be ordered as STAT (immediately).

If the finger-stick (to make a small prick in the finger tip to obtain blood sample) blood glucose value is less than 60 or greater than 400, the attending physician will be notified.

During a review of the facility's policy and procedure (P&P) titled, "Hypoglycemia (low blood sugar) and Hyperglycemia (high blood sugar) Prevention and Management, and Reporting," dated May 2023, the P&P indicated, "Hypoglycemic Treatment: If hypoglycemia is suspected, discontinue hypoglycemic agents (if receiving) and perform a STAT (immediately) finger stick BG (blood glucose) level. Treatment should be initiated prior to obtaining finger stick BG if the patient's symptoms warrant treatment. If the patient is:

Conscious and can eat or drink with a verified BG < 70 mg/dl, give 15 to 20 gm (gram) of fast acting carbohydrate (4 oz fruit juice, 8 oz nonfat milk, or 3 to 4 glucose tablets), recheck BG in 15 minutes and notify the physician.

Conscious/Unconscious and/or NPO (nothing by mouth) with a verified BG < 70 mg/dl, with an IV (intravenous-through the vein) access, give 50 ml dextrose 50% IVP (intravenous push), recheck BG in 15 minutes and notify the physician.

Unconscious and/or NPO with a verified BG< 70 mg/dl, without an IV access, give glucagon (medication to increase blood glucose level) 1 mg via intramuscular (through the muscles) injection and notify the physician.

Episodes of hypoglycemia should be documented in the medical record and tracked.

The treatment regimen should be reviewed and changed as necessary to prevent further hypoglycemia when a BG of < 70 mg/dl is documented."

Based on interview and record review, the facility failed to develop and implement a care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) for post-operative (after surgery/procedure) care for one out of thirty (30) sampled patients (Patient 6) in accordance with the facility's policy and procedures regarding care plan development.

This deficient practice had the potential to result in Patient 6's treatment and care goals not being met by not identifying the patient's needs and risks post-operatively.

Findings:

During a review of Patient 6's operative report (OR), dated 08/02/2023, the OR indicated Patient 6 underwent left leg percutaneous (done through skin) angioplasty (PTA, an invasive procedure used to open a blocked artery). The OR further indicated, Patient 6 had past medical history (PMH) of multiple medical problems, including peripheral vascular disease (PVD, a systemic disorder that involves the narrowing of peripheral blood vessels), hypertension (elevated blood pressure), and history of multiple bilateral (both) lower legs angioplasties.

During a review of Patient 6's post-surgical recovery record, titled "PACU/Recovery," dated 08/02/2023, at 11:33 a.m., the record indicated, at 12:30 p.m., Patient 6 was not able to move or feel both legs. The record further indicated, Patient 6 was administered Heparin (blood thinning medication to prevent clot formation) 1000 units intravenously (IV, into a vein) push and was taken back to surgery at 1:00 p.m.

During a review of Patient 6's post-surgical (after surgery) recovery record, titled "PACU/Recovery," dated 08/02/2023, at 4:35 p.m., the record indicated, Patient 6 had bilateral (both) legs angiogram (a type of test to examine and visualize blood vessels) with stents placed (a small sheath placed in the artery to keep it open) and was started on Heparin infusion IV at 1000 units per hour. The record further indicated, Patient 6 complained of numbness in the left thigh.

During a review of Patient 6's primary nurse documentation, titled "Interdisciplinary Team Progress Note," dated 08/02/2023, at 7:39 p.m., the primary nurse documented, Patient 6 complained of pain to the left thigh and was unable to feel touch all over left leg. The primary nurse documentation further indicated, Patient 6 had no palpable (inability to feel) pulse, and the primary nurse documentation indicated no pulse was detected in the left leg using doppler machine (a test to estimate the blood flow through the blood vessels).

During a concurrent interview and record review on 10/19/2023, at 2:33 p.m., with case manager (CM), Patient 6's nursing care plan (CP, provides a framework for evaluating and providing patient care needs related to the nursing process), titled "Interdisciplinary Care Plan," dated 08/02/2023, was reviewed. The CP indicated, on 08/02/2023, nursing initiated a CP for "Hypertension" and "Pain" for patient 6 on admission. The CM stated, nursing did not initiate post-operative (after surgery) CP for Patient 6 specific to Patient 6's ongoing problems/needs.

During an interview on 10/19/2023, at 2:40 p.m., with Nurse Manager (NM 1), the NM 1 stated, nursing should initiate care plans for patients as required by the facility's policy. The NM 1 further stated, CP is required to be initiated for all patients based on problems/needs identified because nursing care plans serve to facilitate coordination and communication of care specific to problems identified.

During a review of the facility's policy and procedures titled "Multidisciplinary (comprise of clinicians from difeerent specialties such as physicians, dietitian, Registered Nurse, etc.) Plan of Care," dated 11/2022, the P&P indicated, "It is the policy of the facility to develop a Care Plan for each patient admitted at the facility. The Care Plan is updated every 24 hours or whenever a new problem occurs. This plan should include problems/needs goals and interventions. The plan will serve to facilitate continuity, coordination, and communication among team members. When a problem/need is identified, it is to be documented on the plan "Problem List" and then addressed with goals and interventions."

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

1. Ensure two of the thirty sampled patients (Patient 25 and Patient 28) had complete documentation for medications that were administered in accordance with the facility's policies and procedures regarding medication documentation. Patient 28 was administered with Levophed (norepinephrine, an intravenous medication used in critical care settings to treat severe low blood pressure), and patient 25 was administered with Epinephrine (a hormone used as a medication for life-threatening conditions).

This deficient practice had the potential to compromise Patient 25 and Patient 28's health and safety when medications administered were not completely and accurately documented, which increased the risk of medication administration errors and may create a challenge for healthcare providers to make informed decisions based on incomplete documentation.

2. Perform rounds (monitoring and reassessment to ensure patient safety) every fifteen (15) minutes for one of thirty sampled patients (Patient 15), who was located in a combined medical surgical (services the general population of patients with a variety of illness that are not life threatening and the behavior health unit (an area of the hospital to stabilize a patient with a mental health emergency) in accordance with the facility's policies and procedures regarding patient monitoring for patient's behavior, respiratory (breathing status) and location.

This deficient practice had the potential to result in lack of assessment of Patient 15's behavior, respiratory status, and location, which may result in delayed treatment/interventions for Patient 15.

Findings:

1a. During a review of Patient 25's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 7/23/23, the "H&P" indicated that Patient 25's medical history included metabolic encephalopathy (an alteration in consciousness caused by brain dysfunction), diabetes type 2 (a disease in which blood sugar levels are too high) with hyperglycemia (high blood sugar). The H&P also indicated Patient 25 presented with poor oral intake, refusal of care, and aggressive behavior. The H&P further indicated that Patient 25 was "in the observation area (an area where patients are held in the facility to wait for medical clearance, such as lab results and diagnostic testing), and his glucose level was 569..." The H&P indicated Patient 25 was placed on 5150 hold (a law which allows an adult who is experiencing a mental health crisis to be involuntarily detained in the hospital for 72 hours when evaluated to be a danger to others or self) for DTO (danger to self)/GD (gravely disabled, a condition in which a person, as a result of mental disorder, is unable to provide for his/her basic personal needs such as food and hygiene) and was admitted to the medical floor for further management.

During a concurrent interview and record review on 10/18/2023 at 2:10 p.m. with Registered Nurse (RN) 2, Patient 25's "Code Blue (indicates a patient requiring immediate medical attention such as heart attack)" sheet, dated April 7/30/2023, was reviewed. The "Code Blue" sheet indicated the following:

On 7/30/2023 at 3:54 p.m., the first dose of 1 mg (a milligram, a unit of mass or weight measurement) of epinephrine (a hormone used as a medication for life-threatening conditions) was administered. RN 2 confirmed there was no route of administration documented.

On 7/30/2023 at 3:56 p.m., a second dose of 1 mg of epinephrine was administered. RN 2 confirmed there was no route of administration documented.

On 7/30/2023 at 3:59 p.m., a third dose of 1 mg of epinephrine was administered. RN 2 confirmed there was no route of administration documented.

On 7/30/2023 at 4:04 p.m., a fourth dose of 1 mg of epinephrine was administered. RN 2 confirmed there was no route of administration documented.

On 7/30/2023 at 4:08 p.m., a fifth dose of 1 mg of epinephrine was administered. RN 2 confirmed there was no route of administration documented.

During a concurrent interview and record review on 10/18/2023 at 2:10 p.m. with Registered Nurse (RN) 2, Patient 25's "Medication Administration Record (MAR)," dated 7/30/2023, was reviewed. The MAR indicated that on 7/30/2023, there was no documentation of the five doses of epinephrine administered. The RN 2 confirmed that the five doses of epinephrine administer was not entered into the Patient 25's medication administration record.

During an interview on 10/19/2023 at 4:07 p.m. with Pharmacist (Pharm) 1, Pharm 1 stated, "After the emergency medications are given, they should be put into the patient ' s medical record." Pharm 1 further stated that the pharmacist will check the emergency medication to see what has been given and account for the medications administered in the facility's electronic system. However, the pharmacist will not be able to account for the precise time that the medication was administered since there was no documentation in the patient's medical record.

During a review of the facility's policy and procedure (P&P) titled, "IV (intravenous, through the vein) Fluid Therapy," dated November 2022, the P&P indicated the following:

Documentation:

1. All IV fluids, IV push medications, and IVPB (Intravenous Piggyback, a small bag of solution attached to a primary infusion) will be documented in the MAR (Medication Administration Record) and will include:

Solution Name

Amount of Solution

Rate of Solution

Time Started or Added

Signature of Nurse

1b. During a review of Patient 28's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 6/6/2023, the "H&P" indicated, Patient 28's medical history included diabetes (a condition that causes the blood sugar to become too abnormally high), epilepsy (is a brain condition that causes sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements, feelings), Osteoarthritis (OA, disease that causes swelling and tenderness of one or more joints), and major depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest). The H&P indicated Patient 28 was admitted to the facility for further evaluation of poor oral intake and generalized weakness (weak in most areas of your body).

During a concurrent interview and record review on 10/18/2023 at 2:00 p.m. with Registered Nurse (RN) 2, Patient 28 ' s electronic medical record titled, "eMAR (electronic medical administration record)," was reviewed. The eMAR indicated, on 4/11/2023 at 4:13 p.m. an order for "Levophed Bitartrate (otherwise known as Norepinephrine, medication used to increase blood pressure) 4 Mg (milligram, a unit of measurement of mass) per 4 mL (milliliter, a unit of mass or weight equal to one thousandth of a gram) injection ampule in Normal saline (NS) 250 mL intravenous (IV, through the vein) bag was ordered for Patient 28 and was administered by Registered Nurse (RN) 4 on 4/11/2023 at 6:13 p.m. The MAR indicated, "Special Instruction: Titrate (adjusting rate of medication to administer the least amount of medication to maintain a desire affects), START at 0.5 Mcg (microgram a weight - base measurement unit) per minutes. Titrate 2-10 Mcg per minutes every 10 minutes."

During a concurrent interview and record review on 10/19/2023 at 2:30 p.m. with RN 2, Patient 28's "Flow Sheet" (documents that provide around-the-clock information regarding the medication and treatment the patient received)" in regard to the input (intravenous medication injected into the patient) and output (fluid the patient excretes, such as urine) was reviewed. RN 2 stated that according to the flow sheet, there was no hourly documentation of the Levophed medication as to how much was infused. RN 2 showed the flowsheet; the flow sheet spaces following norepinephrine (Levophed) were left blank. RN 2 stated, "Every patient receiving intravenous medication must have the input and output documented hourly."

During a concurrent interview and record review with RN 2 on 10/19/2023 at 2:45 p.m., Patient 28's "Nursing Progress Note," dated 4/11/2023 at 7:31 a.m., was reviewed. The "Nursing Progress Note" indicated, "Levophed was started at 4:00 p.m. at 10 mcg/min (microgram per minute), blood pressure 100/56; MAP (mean arterial pressure, the average pressure in a patient's arteries during one cardiac cycle) was 65." RN 2 confirmed that the nursing progress note does not have a complete documentation of Levophed administration. RN 2 confirmed that the route in which the medication was administered was not documented, the titrated change in rate (date, time, dose, route, and correlating blood pressure) was not documented, and the hourly documentation of the medication administered was not documented.

During an interview on 10/19/2023 at 4:07 p.m. with the Pharmacist (Pharm) 2, Pharm 2 stated, "Levophed administration should be documented every hour because it is a drip (the continuous, slow introduction of a fluid's medication into a vein of the body) and is an intravenous medication that requires accurate documentation."

During an interview on 10/20/2023 at 10:00 a.m. with House Supervisor (HS) 2, HS 2 stated, "The input and output should be accounted for with any patient receiving titrated medication, especially Levophed or vasopressors (medication used to increase blood pressure)." HS 2 stated it is important that the intake and output of the Levophed medications are documented because they need to account for how much the patient has received due to the risk of liver toxicity (injury to the liver or impairment of liver function caused by exposure to foreign substances in the body such as drugs and alcohol) and be correlated to the parameter in which the medication should be titrated.

During a review of the facility's policy and procedure (P&P) titled, "Continuous Intravenous - Levophed (norepinephrine)," dated May 2022, the P&P indicated, the purpose of the policy is "To provide guidelines for the safe and proper use of levophed (Norepinephrine) ...

1. The nurse shall document:

Date and time of norepinephrine administration in EMAR (Electronic Medication Administration Record).

Date and time of tubing and bottle changes.

Rate of norepinephrine in the Flowsheet and/or in the EHR (Electronic Health Record).

All vital signs (temperature, blood pressure, heart rate, respiratory rate, and pain) including oxygen saturation (measures the amount of oxygen in the blood), ECG (Electrocardiogram, EKG- a test that records the electrical signal from the heart to check for different heart conditions, it can detect irregular heart rhythms and heart attacks), blood pressure, respiratory and hemodynamic status (evaluates how well the heart is working) will be assessed every 15 min x 4 at initiation of drip and with every change in rate of infusion as needed, then hourly if stable with no titration changes.

The nurse must notify the ordering provider and pharmacist immediately of any adverse sequelae ..."

During a review of the facility ' s policy and procedure (P&P) titled, "IV Fluid Therapy," dated November 2022, the P&P indicated, " ...The purpose of this policy is to provide guidelines for the administration and maintenance of Intravenous (IV) fluids, and to outline the responsibilities of the Licensed staff. Intravenous (IV) Therapy is used for:

Maintenance and restoration of fluid and electrolyte balance.

Administration of drugs, transfusing blood and delivering parenteral nutrition.

Rapid drug administration.

Documentation:

All IV fluids, IV push medications, and IVPB (Intravenous Piggyback, a small bag of solution attached to a primary infusion) will be documented in the MAR and will include:

Solution Name

Amount of Solution

Rate of Solution

Time Started or Added

Signature of Nurse

All total amounts of I.V. fluids infused will be included on the l &O (input and output) record ..."

2. During an observation on 10/17/2023 at 10:55 a.m., on the 6th floor (medical and behavioral unit- area of the hospital designated to stabilize a patient with a mental health emergency), the door to Patient 15's room was observed closed. Upon opening the door, Patient 15 was observed awake and sitting on a chair. There were dried scabs and dried blood on the right side of the face (Patient 15). Patient 15 also had two dry scabs on the left side of the head.

During a concurrent interview on 10/17/2023 at 11 a.m., with registered nurse (RN) 1, RN 1 stated the following: Patient 15 was admitted with dried scabs on his face and had a tendency to pick at the scabs. Patient 15 was on a 5250 hold (14-day involuntary hold, a law which allows an adult who is experiencing a mental health crisis to be involuntarily detained in the hospital when evaluated to be a danger to others or self) for being a danger to others (likely to perform acts of violence) and gravely disabled (a condition in which a person, as a result of mental disorder, is unable to provide for his/her basic personal needs such as food and hygiene). RN 1 stated that rounding (monitoring and reassessment to ensure patient safety) was conducted every 15 minutes for all patients on the unit. RN 1 verified that there was no documentation of rounding every 15 minutes on 10/16/2023 between 5 p.m. and 7:45 p.m., for Patient 15. RN 1 stated she (RN 1) was the primary nurse for Patient 15 on 10/16/2023 and was required to check Patient 15 every 15 minutes for Patient 15 ' s behavior, breathing status, and location. However, RN 1 went on her break, and the nurse who covered her (RN 1) during her break should have documented in the "Patient Rounding Sheet."

During an interview on 10/17/2023 at 11:10 a.m., with the Compliance Officer (CO), the CO verified there was no documentation of rounding for Patient 15 on 10/16/2023 between 5 p.m. and 7:45 p.m. The CO stated that nursing staff was required to perform rounding on patients every 15 minutes to ensure patient safety because "psych (psychiatric, a person with a mental disorder)" patients were unstable. The CO was asked to provide a policy with regards to rounding, the CO provided a policy titled "Restraint and Seclusion Policy," dated 3/9/2022 and stated that the facility used this policy to address rounding.

During a review of Patient 15's "History and Physical" (H&P, a formal and complete assessment of the patient and the problem) dated 10/10/2023 at 1:34 p.m., the H&P indicated the following: Patient 15 was admitted due to chronic psychiatric decompensation (worsening of mental health symptoms). Patient 15 had a past medical history of " ...psychosis (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality), and anxiety (feelings of worry, nervousness, or unease) ... Plan: Admit to behavior psych floor for further evaluation and treatment."

During a review of Patient 15's progress note titled, "Interdisciplinary Team Progress Note Nursing," dated 10/10/2023 at 10 p.m., the progress note indicated the following: Patient 15 was on a "5150 hold (72-hour hold) for danger to others (DTO) and Gravely Disabled (GD) ... will continue to monitor every 15 minutes."

During a review of Patient 15's "Patient Rounds Sheet," dated 10/16/2023, the rounding sheet indicated that rounding (every 15 minutes) was not conducted between 5 p.m. and 7:45 p.m. The rounding sheet indicated that patients would be monitored and assessed "every 15 minutes for behavior (walking, eating, crying, or agitated ...), status (respirations present or absent), and location."

During a review of the facility's policy and procedure titled, "Restraint and Seclusion Policy," dated 3/9/2023, the P&P indicated the following: "This policy applied to the Hospital as a hospital-wide policy that would apply to any department providing patient care ..." The purpose was " ...to maintain a safe environment for both patients and staff ...Monitoring and Reassessment: Restrained or secluded patients shall be continuously monitored every 15 minutes for the psychological and psychological effect of the restraint/seclusion on the patient ..."

Based on interview and record review, the facility failed to ensure one of thirty sampled patient's (Patient 28) blood pressure medications were administered following a physician's order and that Patient 28's blood pressure was reassessed after administration of a blood pressure medication.

This deficient practice had the potential to compromise Patient 28's health and safety, placing Patient 28 at risk for experiencing hypotensive (low blood pressure) or hypertensive (high blood pressure) conditions. .

Findings:

During a review of Patient 28's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 6/6/2023, the "H&P" indicated that Patient 28's medical history included diabetes (a condition that causes the blood sugar to become too high), epilepsy (a brain condition that causes a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements, and feelings), osteoarthritis (OA, a disease that causes swelling and tenderness of one or more joints), and major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The H&P indicated Patient 28 was admitted to the facility for further evaluation of poor oral intake and generalized weakness (weakness in most areas of your body).

During a concurrent interview and record review on 10/18/2023 at 2:00 p.m. with Registered Nurse (RN) 2, Patient 28's medication administration record (MAR) dated 4/9/2023 at 8:17 p.m. was reviewed. Patient 28's MAR indicated that on 4/9/2023 at 9:35 p.m., 25 mg of metoprolol tartrate (Lopressor), a medication used to lower blood pressure and treat other heart complications, was administered orally. The MAR indicated under Special Instruction, "Hold (do not administer) if SBP (systolic blood pressure, the top number that measures the pressure in the arteries) is below 120 or HR (heart rate) is below 50. Notify MD (physician)." Patient 28's MAR also indicated that on 4/9/2023 at 10:30 p.m. 5 mg of intravenous (administered in the vein) metoprolol tartrate was administered. The order also indicated under Special Instruction, "Hold if SBP is below 120 or HR below 50. Notify MD." RN 2 verified that Patient 28's vital signs (temperature, blood pressure, heart rate, respiratory rate, and pain) were taken at 9:33 with a SBP reading of 101/64. RN 2 stated there were no other blood pressure measures on 4/9/2023 after 9:33 p.m. to reassess Patient 28's SBP after administration of metoprolol administered oral and intravenously. RN 2 also verified that there was no communication from the RN to the physician regarding Patient 28's blood pressure of 101/64 and that it (the blood pressure of 101/64) did not meet the parameter (special instruction) on the order.

During a review of Patient 28's "Nursing Vital Signs (blood pressure, pulse, respiration, and temperature)" and "CNA Vital Signs" flow sheets, dated 4/9/2023, the flow sheet indicated that Patient 28's vital signs taken on 4/9/2023, the day that Metoprolol tartrate was administered, were as follows:

At 5:30 a.m., SBP was 124/69, respiration rate (RR, the number of breaths per minute) was 20, and oxygen saturation (O2 Sat, measures the percentage of oxygen in the blood) was 92 percent.

At 8:00 a.m., SBP was 114/72, HR was 138, RR was 20, and oxygen saturation was 95 percent.

At 12:00 p.m., SBP was 96/72, HR was 134, RR was 16, and oxygen saturation was 99 percent.

At 9:33 p.m., SBP was 101/64, HR was 150, RR was 17, and oxygen saturation was 98 percent.

During an interview on 10/20/2023 at 10:00 a.m. with House Supervisor (HS) 2, HS 2 stated, "All blood pressure medication administered must follow the order's specific guideline to prevents medication error."

During a review of the facility's policy and procedure (P&P) titled "IV Fluid Therapy," dated November 2022, the P&P indicated, "To give an intravenous piggyback (a small bag of solution attached to a primary infusion line) and/or IV push medication as ordered by a physician ... Method: Important Steps: 1. Assemble equipment. 2. Recheck order ..."

During a review of the facility's policy and procedure (P&P) titled "Vital Signs," dated March 2022, the P&P indicated, "Purpose: To ensure continuity of care and proper monitoring of each patient... The assessment of vital signs (blood pressure, pulse, respiration, and temperature) is required of all patients upon admission. Based on the condition of the patient, the RN or physician may increase the frequency of vital sign measurements. Patients undergoing diagnostic and/or therapeutic procedures shall have their vital signs taken in conformance with the standards for each individual procedure. Vital signs, i.e., temperature, pulse rate, respiratory rate, blood pressure, pain, and oxygen saturation, shall be performed routinely on all [facility's name] patients. Vital signs may be taken more often if it is deemed necessary ..."

Based on interview and record review, the facility failed to ensure two (2) of thirty (30) sampled patients (Patient 6 and Patient 25) had a physician order or a standing order (an order that continues to be followed until it is changed or canceled) for medications (epinephrine [a hormone used as a medication for life-threatening conditions]) that were administered during a code blue (any patient with an unexpected cardiac or respiratory arrest requiring resuscitation and activation of a hospital-wide alert).

This deficient practice resulted in the unauthorized administration of emergency medication and had the potential to compromise Patient 6 and Patient 25's health and safety.

Findings:

1. During a review of Patient 6's operative report (OR), dated 08/02/2023, the OR indicated Patient 6 underwent left leg percutaneous (done through skin) angioplasty (PTA, an invasive procedure used to open a blocked artery). The OR further indicated, Patient 6 had past medical history (PMH) of multiple medical problems, including peripheral vascular disease (PVD, a systemic disorder that involves the narrowing of peripheral blood vessels), hypertension (elevated blood pressure), and history of multiple bilateral (both) lower legs angioplasties.

During a review of Patient 6's primary nurse documentation, titled "Med-Surg (Medical Surgical, serves the general population of patients with a variety of illnesses that are not life threatening)/Telemetry (hospital unit where cardiac rhythm is constantly monitored) Admission Assessment," dated 08/03/2023, at 2:43 a.m., the primary nurse documentation indicated, Patient 6 was admitted to telemetry unit on 08/02/2023 at 7:00 p.m.

During further review of Patient 6's nursing progress notes (NPN), titled "Interdisciplinary Team Progress Note Nursing," dated 08/03/2023, at 4:45 a.m., the NPN indicated, Patient 6's heart rate changed on telemetry monitor and Patient 6 was found to be unresponsive, and pulseless and a Code Blue (indicates a patient requiring immediate medical attention such as heart attack) was activated. The NPN also indicated, on 08/03/2023 at 4:46 a.m., 1 milligram (mg, a unit of measurement) of epinephrine (a hormone used as a medication for life-threatening conditions) was administered to Patient 6 intravenously (IV, through a vein). The NPN further indicated, on 8/3/2023 at 4:49 a.m., Patient 6 received a second dose of 1 mg of epinephrine IV.

During an interview on 10/17/2023 at 10:15 a.m., with Nurse Manger (NM) 1, the NM 1 stated, the facility's ACLS (Adult Cardiovascular Life Support) certified nurses (ACLS is a certification granted to healthcare professionals who pass evidence-based course designed to equip them with the skills and knowledge needed to respond effectively to cardiac and other life-threatening emergencies) are allowed to follow ACLS algorithm (a guide used by medical professional to provide immediate care to individuals experiencing cardiac [heart] events ) and administer medications as specified in the ACLS algorithm. The NM further stated, the facility does not have a standing order signed by a physician to be used for emergency medication administration during a Code Blue.

During a concurrent interview and record review on 10/17/2023, at 10:15 a.m., with Nurse Manager (NM 1), the facility ' s policy and procedure (P&P), titled "Cardiopulmonary Emergencies Code Blue," dated 3/2022 was reviewed. The P&P indicated, "Verbal orders issued during a Code Blue are acceptable and need to be transcribed by a licensed staff member and then must be countersigned by the provider within 24 hours. All participants in a Code Blue will perform duties as outlined in their scope of practice or training. ACLS protocols will be adhered to during the Code Blue and an RN will administer intravenous (IV) medications, following ACLS guidelines." The NM1 then, demonstrated a print-out from the "American Heart Association," titled "Advanced Cardiovascular Life Support," dated 10/2020 and stated, the facility allows licensed registered nurses (RN) to give emergency medications as listed in the ACLS algorithm guidelines print-out by the "American Heart Association" (AHA) when a Code Blue is activated.

During a concurrent interview and record review on 10/18/2023 at 4:00 p.m., with Case Manager (CM), Patient 6's "Code Blue" record, dated 08/03/2023 was reviewed. The record indicated: on 08/03/2023, at 4:46 a.m., Patient 6 received first dose of 1 milligram (mg, a unit of measurement) of epinephrine and on 8/03/2023 at 4:49 a.m., Patient 6 received a second dose of 1 mg of epinephrine. The record further indicated, Patient 6's medical doctor notification was done on 8/3/2023 at 5:25 a.m. The CM confirmed, no documentation of medical doctor physically present during the Code Blue on 8/3/2023.

During a concurrent interview and record review on 10/18/2023, at 4:00 p.m., with Case Manager (CM), Patient 6's "medication Administration Record (MAR)," dated 8/3/2023 was reviewed. The MAR indicated no physician's order was entered for 2 doses of 1 mg epinephrine on 8/3/2023. The CM confirmed that the 2 doses of 1 mg epinephrine were not found to be recorded in Patient 6's MAR.

During an interview on 10/19/23 at 4:07 p.m., with Pharmacist (Pharm) 1, Pharm 1 stated the facility does not have an established standing order for emergency medication such as Epinephrine. Pharm 1 further stated, "All medications, including ACLS medication, should be ordered by a physician."

During an interview on 10/20/2023, at 10:23 a.m., with House Supervisor (HS2), the HS 2 confirmed to have participated in Patient 6's Code Blue on 8/3/2023 at 4:45 a.m. The HS 2 stated, when the Code Blue for Patient 6 was activated on 8/3/2023, at 4:45 a.m., there was no on-call physician present during the time of the Code Blue. The HS 2 further stated, the Code Blue Team followed ACLS guidelines by the "AHA (American Heart Association)" to administer medications to Patient 6 during Patient 6 ' s Code Blue on 8/3/2023 as per facility's policy and procedures.

During a review of the facility's rules and regulations (R&R) for medical staff, dated 10/19/2022, the R&R indicated, "6.5-4, "When specific orders are not written by the attending physician, hospital protocols will constitute the orders for treatment." 6.5-1, "All orders for treatment shall be in writing or via computerized provider order entry (CPOE) and shall be timed and signed by the provider."

During a review of the facility's policy and procedure (P&P), titled, "Medication Ordering," dated 1/2022, the P&P indicated, "A. 1. Only the personnel who have been authorized by the medical staff to practice and are acting within the scope of their professional practice are allowed to write (prescribe) an order for a medication. E. 3. Pre-printed physician's orders as approved by Medical Staff may be used when authenticated by prescriber."

A review of the Nursing Practice Act, Business and Professions Code Section 2725, indicated, that the practice of nursing means those functions, including basic health care, which help people cope with difficulties in daily living which are associated with their actual or potential health or illness problems, or the treatment thereof, which require a substantial amount of scientific knowledge or technical skill. No registered nurse in the U.S. (United States) can prescribe medications according to federal laws. Registered nurses should not confuse nursing policies and procedures with standardized procedures.

2. During a review of Patient 25's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated7/23/2023, the "H&P" indicated that Patient 25's medical history included metabolic encephalopathy (an alteration in consciousness caused by brain dysfunction), diabetes type 2 (a disease in which blood sugar levels are too high) with hyperglycemia (high blood sugar), dysphagia (difficulty or discomfort in swallowing), muscle wasting (the wasting or thinning of muscle mass), and cognitive impairment (difficulty remembering, learning new things, concentrating, or making decisions). The H&P indicated Patient 25 presented with poor oral intake, refusal of care, and aggressive behavior. The H&P also indicated that Patient 25 was "in the observation area (an area where patients are held in the facility to wait for medical clearance, such as lab results and diagnostic testing), and his glucose level was 569..."

The H&P further indicated Patient 25 was placed on 5150 hold (a law which allows an adult who is experiencing a mental health crisis to be involuntarily detained in the hospital for 72 hours when evaluated to be a danger to others or self) for DTO (danger to self)/GD (gravely disabled, a condition in which a person, as a result of mental disorder, is unable to provide for his/her basic personal needs such as food and hygiene) and was admitted to the medical floor for further management. The H&P further indicated that Patient 25 was a "cachexic (physical wasting with loss of weight and muscle mass) patient trying to catch his breath, although he denies shortness of breath."

During an interview on 10/17/2023 at 10:15 a.m. with Nurse Manager (NM) 1, NM 1 stated, "We follow ACLS's algorithm (Advanced Cardiovascular Life Support, a guide use by medical professional to provide immediate care to individuals experiencing cardiac [heart] events) to administer medications; we do not have a standing order for emergency medications administered during a code blue (indicates a patient requiring immediate medical attention such as heart attack)." NM 1 confirmed that the facility's Rapid Response (group of clinicians who responds to the patient's bedside when a patient demonstrates signs of imminent clinical deterioration) Protocol does not indicate that a registered nurse can administer emergency medication without an order from a physician.

During a concurrent interview and record review on 10/18/2023 at 2:10 p.m. with Registered Nurse (RN) 2, Patient 25's "Code Blue" sheet dated April 7/30/2023 was reviewed. RN 2 confirmed there was no route of administration documented for the five doses of Epinephrine that was administered to Patient 25. The "Code Blue" sheet indicated the following:

On 7/30/2023 at 3:54 p.m., the first dose of 1 mg (a milligram, a unit of mass or weight measurement) of epinephrine (a hormone used as a medication for life-threatening conditions) was administered.

On 7/30/2023 at 3:56 p.m., a second dose of 1 mg of epinephrine was administered.

On 7/30/2023 at 3:59 p.m., a third dose of 1 mg of epinephrine was administered.

On 7/30/2023 at 4:04 p.m., a fourth dose of 1 mg of epinephrine was administered.

On 7/30/2023 at 4:08 p.m., a fifth dose of 1 mg of epinephrine was administered.

During a concurrent interview and record review on 10/18/2023 at 2:10 p.m. with Registered Nurse (RN) 2, Patient 25's "Medication Administration Record (MAR)," dated 7/30/2023, was reviewed. The MAR indicated that on 7/30/2023, there was no physician's order entered for the five doses of 1 mg of epinephrine administered by the registered nurse. RN 2 stated, "There are no standing orders for epinephrine; we follow the ACLS algorithm." The RN 2 further confirmed that the five doses of epinephrine administered were not entered into the patient's medication administration record.

During an interview on 10/19/2023 at 4:07 p.m. with Pharmacist (Pharm) 1, Pharm 1 stated the facility does not have an established standing order for emergency medication such as Epinephrine. Pharm 1 further stated, "All medications, including ACLS's medication, should be ordered by a physician."

During a review of the facility's policy and procedure (P&P) titled, "Medication Ordering," dated January 2022, the P&P indicated the following: To ensure medications within the organization are ordered/prescribed safely and in accordance with state and federal regulation ... Who May Prescribe:

1. The following personnel are allowed to write (prescribe) an order for a medication, provided they are members in good standing with the Medical Staff or practitioners who have been authorized by the Medical Staff to practice and are acting within the scope of their professional practice

Licensed Physician, Surgeon and Doctor of Osteopathic Medicine

Licensed Dentist

Licensed Podiatrist

Licensed Certified Registered Nurse Anesthetist

Licensed Physician's Assistant

Licensed Nurse Practitioners

2. Conditions under which a specific practitioner may write (prescribe) a chart order:

Licensed Certified Registered Nurse Anesthetist (CRNA) ...

Licensed Physician's Assistant (PA) ...

Licensed Nurse Practitioners (NP) ...

During a review of the facility's policy and procedure (P&P) titled, "Hospital Plan for Provision of Care," dated 2023, the P&P indicated, "Medications may only be ordered by practitioners who are lawfully authorized to give such an order. Medication management and patient safety is the responsibility of the entire health care team."

Based on interview and record review, the facility failed to minimize the use of telephone orders for one of 30 sampled patients (Patient 15), in accordance with the facility's policy and procedure regarding telephone orders.

This deficient practice had the potential for medications not to be prescribed in a safe manner, which can adversely affect the patient's health and safety.

Findings:

During a review of Patient 15's "History and Physical" (H&P, a formal and complete assessment of the patient and the problem) dated 10/10/2023 at 1:34 p.m., the H&P indicated the following: Patient 15 was admitted due to chronic psychiatric decompensation (worsening of mental health symptoms). Patient 15 had a past medical history of " ...psychosis (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality), and anxiety (feelings of worry, nervousness, or unease) ... Plan: Admit to behavior psych floor for further evaluation and treatment."

During a review of a document for Patient 15 titled, "All Orders," dated 10/12/2023, the record indicated the following. Forty-six (46) of forty-nine (49) orders were Telephone orders, as follows:

On 10/12/2023 at 12:43 p.m., the following Telephone orders were entered in the electronic medical record for Patient 15.

NAS (No Added Salt), Routine.

Dysphagia Advanced (Mechanical Soft Texture [chopped, ground, and pureed foods])

Consistent Carbohydrate CCD (used to control diabetes [a condition that causes the blood sugar to become too abnormally high])/Diabetic Diet

On 10/12/2023 at 12:56 p.m., the following Telephone orders were entered in the electronic medical record for Patient 15.

MOM/Milk of Magnesia (softens stool) 2400 MG/30 ML Suspension, Routine.

Consult, Routine.

NAS (NO Added Salt), Routine.

Fall (unintentional event resulting in a person coming to rest on the ground or another lower level Precautions, Routine (interventions to prevent patient fall).

DC (Discharge) 6th Floor, Routine.

Psychiatrist To Cover For Medications, Routine.

Continue Home Meds, Routine.

Admit Inpatient, Routine.

Restoril (sleeping pill) 15 MG CAP (Temazepam), Routine.

Internist to Follow Patient, Routine.

Mylanta (relieves stomach upset) Suspension REG STR (Alum-Mag Hydroxidie-Simeth), Routine.

Exit Criteria: Demonstrates Ability to Maintain Safety, Routine.

5150 Hold (law which allows an adult who is experiencing a mental health crisis to be involuntarily detained in the hospital for 72 hours when evaluated to be a danger to others or self), Routine.

Psychiatrist to Follow Patient, Routine.

Exit Criteria: Demonstrates Ability to Maintain Safety, Routine.

Tylenol (for pain/fever) 650 MG (325 MG x 2 tabs) (acetaminophen) oral tablet, Routine.

Vital Signs (blood pressure, pulse, respiration, and temperature) Per Unit Protocol, Routine.

Consistent Carbohydrate CCD / Diabetic Diet

Level II - Q15Min (every 15 minutes frequency of monitoring) with Precaution, Routine.

Exit Criteria: Shows Positive Response To Medication/Participates in T (treatment) / Activity, Routine.

Exit Criteria: Shows Positive Response To Medication/Participates in T (treatment) / Activity, Routine

Admit to Behavior Health, Routine.

Ativan (anti-anxiety pill) 1 MG Tablet (lorazepam) oral, Routine.

Psychologist To Follow Patient, Routine.

On 10/12/2023 at 12:59 p.m., the following Telephone orders were entered in the electronic medical record for Patient 15.

Continue Home Meds (Medications), Routine.

Continue Home Diet, Routine.

Continue POLST (Physician Orders for Life Sustaining treatment, a written medical order that specifies the type of medical treatment a patient wants to receive during serious illness)- Full Code (all resuscitation [to revive someone from death] procedures will be provided when the heart stops beating), Routine

On 10/12/2023 at 1:52 p.m., the following Telephone orders were entered in the electronic medical record for Patient 15.

Farxiga (dapagliflozin propanediol, used to treat diabetes [high blood sugar]) oral tablet, Routine.

Actos 15 MG Tablet (TAB) (Pioglitazone, helps control blood sugar levels), Routine.

Baby Aspirin 81 MG TAB Chew (Aspirin Chewable, used to treat minor aches, pains, fever, and a blood thinner), Routine.

Depakote 125 MG TAB (Divalproex Delayed Release, treats seizure and Bipolar(mood) disorder, Routine.

Glucophage 850 MG TAB (metformin, treats diabetes), Routine.

Haldol 5 MG TAB (Haloperidol, treats mental disorders), Routine.

Haldol 5 MG TAB (Haloperidol), Routine.

Haldol Decanoate 50 MG/ML Injection (INJ) (Haloperidol Decanoate), Routine.

Lipitor 10 MG TAB (Atorvastatin, treats high cholesterol), Routine.

Melatonin 5 MG TAB (Melatonin, sleep aid), Routine.

MVI TAB (Therapeutic Multivitamin, dietary supplement), Routine.

Norvasc 5 MG TAB (amlodipine, reduces blood pressure), Routine.

Vitamin C 500 MG TAB (ascorbic acid, a dietary supplement found in citrus fruits), Routine.

Zoloft 25 MG TAB (Sertraline, helps improve mood and reduce symptoms of depression, and other mental conditions), Routine.

Tylenol 650 MG (325 MG x 2 TABS) (acetaminophen, treats minor aches and pain, and reduces fever) oral tablet, Routine.

On 10/13/2023 at 7:30 a.m., the following Telephone order was entered in the electronic medical record for Patient 15.

RDA (For RD Tracking Only [patient medication tracking system]), Routine

During an interview on 10/20/2023 at 4:30 p.m., with the Compliance Officer (CO) and Case Manager (CM), the CO and CM provided the policy regarding Medication Ordering. The CM and CO verified that the policy indicated the telephone orders should be kept to a minimum, and that most physician orders were telephone orders. The CO and CM were asked what the facility's policy meant regarding keeping verbal and telephone orders to a minimum, the CO and CM could not provide an answer as to the acceptable amount of verbal and telephone orders.

During a review of the facility's policy and procedure (P&P) titled, "Medication Ordering," dated 1/2022, the P&P indicated the following. Purpose: "To ensure medications within the organization are ordered/prescribed safely and in accordance with state and federal regulation." ... "The hospital minimizes the use of verbal and telephone orders." ... "The use of verbal and telephone orders should be minimized." ... "Telephone orders should be limited to the immediate clinical needs of the patient."