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

1. The facility failed to provide care as evidence by failing to reposition every two (2) hours for two (2) of 36 sampled patients (Patient 1 and Patient 4) according to facility's policy and procedure for wound care .

This deficient practice resulted in Patient 1 and Patient 4 had acquired pressure injuries (injuries to skin and underlying tissue resulting from prolonged pressure on the skin such as lying in bed for extended periods of time) while in the hospital. (Refer to A - 0395).

2. The facility failed to assess (initial assessment) and/or reevaluate (after medication administration) for patient's pain for five (5) of 36 sampled patients (Patient 10,16, 20, 22, and 23).

This deficient practice had the potential for Patients 10,16, 20, 22, and 23's pain not being proper identified for proper treatment and relief for the pain. (Refer to A - 395).

3. The facility failed to provide an individualized care plan for two (2) of 36 sampled patients (Patient 4 and Patient 10) as evidence by:

a. Patient 4 had no care plan for pressure injury (pressure injury, injuries to skin and underlying tissue resulting from prolonged pressure on the skin such as lying in bed for extended periods of time).

This deficient practice had the potential for delayed provision of necessary care and services for prevention on the development of a pressure injury (pressure injury, injuries to skin and underlying tissue resulting from prolonged pressure on the skin such as lying in bed for extended periods of time) on Patient 4. (Refer to A - 396).

b. Patient 10 has no care plan for pain management.

This deficient practice had the potential for delayed provision of necessary care and services for pain management for Patient 10. (Refer to A - 396).

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

Based on interview and record review the facility failed to provide care as evidence by failing to:

1. Reposition every two (2) hours for two (2) of 36 sampled patients (Patient 1 and Patient 4). This deficient practice resulted in Patient 1 and Patient 4 had acquired pressure injuries (injuries to skin and underlying tissue resulting from prolonged pressure on the skin such as lying in bed for extended periods of time) while in the hospital.

2. Assess (initial assessment) and/or reevaluate (after medication administration) a patient pain five (5) of 36 sampled patients (Patient 10,16, 20, 22, and 23).

This deficient practice had the potential for Patient 10,16, 20, 22, and 23)'s pain not properly identified for proper treatment and relief for the pain.

Findings:

1a. A record review of Patient 1's Daily Focus Assessment Report (record of assessment and intervention provided to patient) from 4/26/23 at 00:00 (12 a.m.) through 5/2/23 at 23:59 (11:59 p.m.) , indicated Patient 1 was admitted to the facility on 4/26/23 at 21:31 (9:21 p.m.) with acute respiratory distress (a life-threatening lung injury that allows fluid to leak into the lungs). The record indicated an assessment at 8 a.m. indicating Patient 1's mobility was, "Bedrest." The record indicated at 4/27/23 at 9:25 a.m., Patient 1's Braden score was 13 (assessment for risk factors for pressure injury and score scale: very high risk for 9 or less, high risk for score 10 - 12, and moderate risk for score 13 - 14).

A record review of Patient 1's Photographic Documentation - Nursing, dated 4/27/23 indicated Patient 1 had a Stage 1 pressure wound (skin that presents redness with no indication of underlying skin damage) to the sacrum (tailbone, triangular and lowest part of the spine situated between the hips).

During an interview, on 1/25/24 at 10:10 AM, the Wound Care Nurse stated the initial evaluation of this Patient 1's skin indicated Patient 1 had no pressure injury on admission. The Wound Care nurse stated Patient 1 was assessed a low Braden Score (assessment for risk factors for pressure injury, score scale: very high risk for 9 or less, high risk for score 10 - 12, and moderate risk for score 13 - 14) on admission. The Wound Care Nurse asserted that wound evaluations were generally performed based upon the severity of the wound, physical condition, as well as the Braden Score.

A record review of Patient 1's MD orders indicated Patient 1 has a wound care evaluation ordered by Medical Doctor 1 (MD 1), on 4/29/23. The record indicated the wound care evaluation was not implemented until 5/3/23 (four days after the doctor's order was made).

During an interview, on 1/25/24 at 11:25 AM, the Wound Care Nurse stated Patient 1 was assessed as having a Braden Score of 13 (moderate risk for score 13 - 14 for pressure injury), upon admission on 4/27/23, and the minimum practice for preventing pressure injury was to reposition the patient off bony parts of the body every 2 hours and apply foam dressing (dressing with silicone [rubber-like substances] provide barrier and a moist wound environment) to affected body parts. The Wound Care Nurse stated wound evaluation order was received on 4/29/23 (Monday) and had multiple visits on Monday and prioritize visits (wound care evaluation) by ED note acuity, wound staging, and patient's status.

A record review of Patient 1's Daily Assessment Inquiry, from 4/28/23 to 4/29/23, indicated under "Activity" Patient 1 should be repositioned every 2 hours. The record indicated Patient 1 had been repositioned from/to his left, right, or face up position every 4 hours for more. The record indicated Patient 1 was turned on the following date and time:

i. On 4/28/23 at 12 PM, Patient 1 was on right side, at 4 PM, Patient 1 on supine (back), and at 8 PM, Patient 1 was on right side. (turned every four hours).

ii. On 4/29/23 at 4 AM, Patient 1 was on right side, and at 8 AM, Patient 1 was on the left side. (8 hours after being last turned/repositioned on 4/28/24 at 8 PM).

iii. On 4/29/23 at 8 PM, Patient 1 was on the right side. (12 hours after being turned/repositioned at 4/28/2024 at 8 AM).

A record review of Patient 1's Chemistry (laboratory, blood test) report indicated Patient 1's albumin level was 3.7 g/dL(gram/deciliter, unit of measurement) on 4/27/23, on 5/1/23 the albumin level was 2.7 g/dL, and on 5/5/23, the albumin level dropped to 1.6 g/dL (normal level range 3.4 to 5.4 g/dL, low level may indicate malnutrition [the body doesn't get enough nutrients and cause wasting, stunting, underweight, and deficiencies in vitamins and minerals]).

A record review of Patient 1's Photographic Documentation - Nursing, dated 5/3/23, indicated Patient 1's sacrum wound had advanced to a Deep Tissue Pressure Injury (DTPI, a form of pressure wound that remains invisible for up to 48 hours and then progresses rapidly to upper and lower levels of skin loss. DTPI is usually purple colored) (Pressure wound was Stage 1 on 4/27/23, initial wound assessment).

A record review of Patient 1's Progress Note Inquiry, dated 5/5/23, indicated Patient 1 had a DTPI to the sacrum. The record indicated the pressure injury as being deep red, maroon, or purple in coloration. The DPTI had a dark wound bed or blood-filled blister. The record indicated the interventions to promote healing included: turning and repositioning, support surfaces, padding, pillows, elevation (of body part), skin care barrier ointments, incontinence (loss of bladder or bowel control) management. The record indicated some of the contributing factors delaying healing: poor nutrition status, abnormal laboratory, worsening of medical condition.

During an interview, on 1/25/24 at 12:07 PM, the Medical Surgical Telemetry (MST, unit for patient requiring medical, surgical, and [Telemetry, care in a hospital where patients undergo continuous heart monitoring]) ) Director stated it (turning/repositioning) was a common practice to reposition patient at risk of pressure injury every 2 hours. MST Director stated she didn't know why nurses would reposition such Patient 1 every 4 hours instead of every 2 hours.

A record review of facility's policy and procedure, titled, Wound Care Policy and Procedure," revised 10/2021, indicated all patients will have a skin integrity assessment during admission and during each shift during the patient's stay at the hospital. The Braden Risk Assessment Scale Tool will be used to assess. The policy and procedure specified a Braden Score of 13 indicates a moderate risk for pressure ulcer. The policy and procedure objectives were to determine risk of developing pressure ulcer and develop plan of care for prevention of pressure ulcers (pressure injury) to patients determined to be at risk and provide guidelines for individualized treatment. The policy and procedure indicated repositioning included for patient unable to turn or reposition related to current health status were to, "Turn every 2 hours ...This will apply to all bedbound patient that require maximum assist every 2 hours turning and all other patients while in bed.

1b. A record review of Patient 4's Progress Note Inquiry, indicated Patient 4 was admitted on 1/19/24. The record indicated the following pressure injuries during admission:

i. A stage 4 pressure ulcer (injury displaying severe skin tissue damage, possibly exposing muscle, bone, or tendon) on the right hip. The record indicated the wound size/measurement was 5 centimeters (cm) by 6 cm (width and length), and depth of 3.5 cm, "Full thickness tissue loss with exposure of bone. Tendon, and/or muscle." The record indicated treatment orders that included: cleansing right hip wound with normal saline (mixture of sodium chloride and water), patting wound dry, applying Medihoney (dressing used to provide a moist healing environment), applying moist normal saline (NS, saltwater solution) gauze dressing and foam dressing daily and as needed.

ii. A unstageable wound (a type of bed sore that occurs due to prolonged pressure on a specific area of the skin), on the right ankle/foot. The record indicated the wound size/measurement was 1 cm by 1 cm. The record indicated treatment order to cleanse the right foot/ankle with NS, pat dry, apply betadine (a topical solution with used as disinfectant), and leave open to air daily and prn (as needed).

iii. A stage 3 wound (pressure injuries extend through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) on the left heel. The record indicated the wound size/measurement was 3.5 cm by 5.5 cm, and depth 0.5 cm. The wound had, "Full thickness tissue (damage extends all layers of the skin) loss involving damage or necrosis of subcutaneous (fatty) tissue, may extend down but not through underlying fascia (sheath of connective tissue)." The record indicated treatment order to cleanse heel wound with NS, pat dry, apply Medihoney, cover with dry dressing, wrap with Kerlix (a gauze roll) daily and prn when soiled.

iv. A stage 3 wound on the left ankle. The record indicated wound size/measurement was 3.5 cm by 3.5 cm and depth 0.7 cm. The record indicated the wound had, "Full thickness tissue loss involving damage or necrosis of subcutaneous, may extend down to but not through underlying fascia ...obscured by granulation tissue (new connective tissue). The record indicated treatment order to cleanse left ankle wound with NS, pat dry, apply Medihoney, cover with dry dressing, wrap with Kerlix.

v. A diabetic ulcer (open wound due to diabetes [condition of having high blood sugar[) on the left lateral (side) foot. The record indicated the wound size/measurement was 9 cm by 6 cm, and depth 0.9 cm. The wound had "Full thickness tissue loss involving damage or necrosis of subcutaneous tissue, may extend down to but not though underlying fascia ...obscured by granulation.

A record review of Patient 4's Daily Assessment Inquiry, indicated Patient 4 was bedbound (someone who has become very weak and is no longer able to move easily) and should be repositioned every 2 hours. The record indicated Patient 4 was not repositioned every 2 hours. The record indicated Patient 4's position between 1/20/24 and 01/21/24:

i. On 1/20/24 at 8 a.m. and 8 p.m., Patient 4 was supine (not repositioned for 12 hours).

ii. On 1/21/24 at 00:00 (12 a.m.), Patient 4 was on the right side, at 4 a.m., Patient 4 was supine, at 8 a.m. Patient 4 was supine, at 19:47 (7:47 p.m., Patient 4 was on supine.
Patient 4 was not repositioned every 4 hours and was on the same position for more than 4 hours.

During an interview on 1/25/24 at 12:07 PM, the ICU (Intensive Care Unit, unit for the critical and acutely ill and injured patients)/Telemetry Director acknowledged repositioning was common practice to reposition patient at risk of pressure injury to be turned every 2 hours. ICU/Telemetry Director stated she didn't know why nurses would reposition such patients every 4 hours instead of every 2 hours.

A record review of facility's policy and procedure, titled, Wound Care Policy and Procedure," revised 10/2021, indicated all patients will have a skin integrity assessment during admission and during each shift during the patient's stay at the hospital. The Braden Risk Assessment Scale Tool will be used to assess. The policy and procedure specified a Braden Score of 13 indicates a moderate risk for pressure ulcer. The policy and procedure objectives were to determine risk of developing pressure ulcer and develop plan of care for prevention of pressure ulcers (pressure injury) to patients determined to be at risk and provide guidelines for individualized treatment. The policy and procedure indicated repositioning included for patient unable to turn or reposition related to current health status were to, "Turn every 2 hours ...This will apply to all bedbound patient that require maximum assist every 2 hours turning and all other patients while in bed.

2a. A record review of Patient 10's History and Physical Note, dated 1/24/224, indicated Patient 10 was admitted with complaints of fever, vomiting, and elevated heart rate (heart beating fast). Patient 10 had a history of multiple abdominal surgeries and left hip dislocation (event where thighbone is forced out of its socket in the hip bone) related to a gunshot wound.

During an interview on 1/22/24 at 4:15 PM, Patient 10 stated he had an open wound to the abdomen and his right leg was broken. Patient 10 stated he received pain medication every 4 hours as needed. Patient 10 stated he was unable to not recall if the nurse ever came back to ask if the pain had been relieved.

A record review of Patient 10's Medication Administration History Report, ] indicated Patient 10 was prescribed 1 milligram (mg, unit of measurement) of Diluadid (medication for severe pain relief) to be given every 3 hours as needed. This record indicated Patient 10 was given Diluadid on the following dates and times:

i. On 1/23/24 at 2:56 AM, for pain level 9 (Pain scale using numbers from 0 to 10. A score of 0 means no pain, and 10 means the worst pain).

ii. On 1/23/24 at 6:02 AM, for pain level 10.

iii. On 1/23/24 at 9:11 AM, for pain level 10.

iv. On 1/23/24 at 12:52 PM for pain level 10.

A review of Patient 10's Vitals Inquiry, for indicated no reassessment of pain level after the medication (Diluadid) was given for pain on 1/23/24 at 2:56 AM; on 1/23/24 at 6:02 AM; on 1/23/2024 at 9:11 AM; and on 1/23/24 at 12:52 PM.

b. A review of Patient 16's emergency department (ED) physician note, dated 1/20/24, indicated Patient 16 came from home with complaint of chest pain for 30 minutes and received medications in the ambulance for chest pain, on the way to the facility.

A review of Patient 16's History and Physical (H&P - a physician's examination of a patient which includes a thorough medical history, a physical examination and complete assessment of the patient's problems) note, dated 1/21/24, indicated Patient 16's chief complaint was chest pain.
Patient 16 had history of stroke (a brain attack, occurs when something blocks blood supply to part of the brain) with right-sided weakness, high blood pressure, and diabetes (a serious condition where your blood glucose level is too high).

On 1/23/24, at 1:27 PM, during concurrent interview with IT Nurse 1 (Informatic Nurse, nurse that facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers) and record review of Patient 16's Triage Notes (a note by an RN in the emergency department who is responsible for assessing patients and determining their level of need for medical assistance), dated 1/20/24, at 10:20 PM, IT Nurse 1 stated Patient 16, who came to the facility with chest pain. IT Nurse 1 stated Patient 16 was assessed on 1/20/24, at 11:06 PM, with a pain score of 7 out of 10 (severe pain). IT Nurse stated Patient 16 record had no documentation of nursing interventions done to relieve Patient 16's pain including pain medication.

On 1/23/24, at 2:20 PM, during concurrent interview with ICU/Tele Director, ICU/Tele director stated pain assessment should be done every four hours with vital signs. ICU/Telemetry Director stated a pain of 7 out of 10, or greater, was severe pain. ICU/Telemetry Director stated, if pain medicine was given through a vein, the patient's pain should be re-assessed after 30 minutes of giving pain medicine.

A record review of the facility's policy and procedure, titled, Assessment/Reassessment of Patient,' revised 10/2023, indicated the "Patient's condition will be reassessed and documented whenever treatment requires or a change in condition or diagnosis occurs, such as: medication affecting hemodynamics, medication administration, patient verbalizes change, receipt of abnormal diagnostic test results." The policy and procedure indicated, "A patient condition will be reassessed and documented whenever treatment requires or a change in condition or diagnosis occurs, such as ...medication administration."

c. A record review of Patient 20's ED Triage note, admit date 1/28/24, indicated Patient 20 was brought to the ED for abdominal (stomach) pain for 3 months with history of diabetes (condition of having high blood sugar) and hypertension (high blood pressure).

On 1/25/24, at 10:27 AM, during concurrent interview with IT Nurse 2 and record review of Patient 20's ED Triage note, dated 1/18/24, from 10:06 PM, IT Nurse 2 stated Patient arrived by ambulance from home, complained of abdominal pain. IT Nurse stated Patient 2 was not assessed for pain during triage assessment with vital signs.

A record review of Patient 20's CPOE (computer provider order entry) Order, dated 1/18/24, indicated a physician order for Morphine 4 milligram (mg, unit of measurement) IV (medication given into the vein) one time dose (x 1 only).

On 1/25/24, at 10:27 AM, during concurrent interview with IT Nurse 2 and record review of Patient 20's ED medication administration records (MAR), dated 1/18/24, IT Nurse 2 stated on 1/18/24, at 11:03 PM, Patient 20 had a pain score of 10 out of 10. IT Nurse 2 stated on 1/18/2024 at 11:05 PM, Patient 20 was given Morphine 4 mg IV.

On 1/25/24, at 10:27 AM, during concurrent interview with IT Nurse 2 and record review of Patient 20's vital signs report, dated 1/18/24 to 1/19/24, IT Nurse 2 stated, on 1/18/24, at 11:17 PM, patient was re-evaluated for pain and had a pain score of 10 out of 10, after having received pain medicine, at 11:05 PM.

A record review of Patient 20's CPOE Order, dated 1/18/24, indicated a physician order Tylenol (pain medication) 1000 mg by mouth (oral) x1 only.

On 1/25/24, at 10:27 AM, during concurrent interview with IT Nurse 2 and record review of Patient 20's ED MAR, IT Nurse 2 stated, on 1/18/24, at 11:18 PM, Patient 20 received Tylenol (pain medication) 1000 milligrams by mouth. IT Nurse 2 stated, on 1/18/24, at 11:31 PM, patient's vital signs were done without pain re-assessment. Patient 20 was not re-assessed for effectiveness of pain medicine given.

A record review of the facility's policy and procedure, titled, Assessment/Reassessment of Patient,' revised 10/2023, indicated the "Patient's condition will be reassessed and documented whenever treatment requires or a change in condition or diagnosis occurs, such as: medication affecting hemodynamics, medication administration, patient verbalizes change, receipt of abnormal diagnostic test results." The policy and procedure indicated, "A patient condition will be reassessed and documented whenever treatment requires or a change in condition or diagnosis occurs, such as ...medication administration."

d. A review of Patient 22's Face Sheet, dated 12/1/2023, indicated patient was admitted with abdominal pain.

On 1/26/24, at 10:13 AM, during concurrent interview with IT Nurse 2 and record review of Patient 22's ED records and Triage Notes, dated 12/1/23, IT Nurse 2 stated Patient 22's paramedics records indicated Patient 22 was picked up from home and complained of having abdominal pain for three days. IT Nurse 2 stated Patient 22's triage notes, patient complained of abdominal pain and vomiting blood.

On 1/26/24, at 10:13 AM, during concurrent interview with IT Nurse 2 and record review of Patient 22's Patient 22's pain assessment in ED, dated 12/1/2023 to 12/2/2023, IT Nurse 2 stated, on 12/1/2023, at 10:11 AM, patient had pain score of 0/10 pain, during triage. IT Nurse 2 stated, on 12/1/2023At 4:26 PM, patient had a pain score of 10 of 10. There was no pain assessment for six hours since triage (for 10:11 a.m. to 4:26 p.m., 6 hours and 15 minutes). IT Nurse 2 stated, on 12/2/2023, at 2:00 AM, pain had no pain with a pain score of 0/10 pain (No pain assessment for 9 hours and 34 minutes, since 12/1/23, at 4:26 PM).

A record review of the facility's policy and procedure, titled, Assessment/Reassessment of Patient,' revised 10/2023, indicated the "Patient's condition will be reassessed and documented whenever treatment requires or a change in condition or diagnosis occurs, such as: medication affecting hemodynamics, medication administration, patient verbalizes change, receipt of abnormal diagnostic test results." The policy and procedure indicated, "A patient condition will be reassessed and documented whenever treatment requires or a change in condition or diagnosis occurs, such as ...medication administration."

e. A review of Patient 23's Face Sheet, dated 1/5/2024, indicated patient was admitted for generalized weakness after multiple falls.

On 1/26/24, at 1:26 PM, during interview with IT Nurse 2 and record review of Patient 23's Triage and ED notes, dated 1/5/24, IT Nurse 2 stated Patient was brought to facility by paramedics from home for evaluation regarding generalize weakness and after having missed two days of hemodialysis treatments. IT Nurse 2 stated Patient lived at home alone and has been having multiple falls at home. IT Nurse 2 stated on 1/5/2024 at 7:03 AM, Patient 23 was triaged and was not assessed for pain. IT Nurse stated on 1/5/2024 at 12:44 PM, Patient 23 was assessed for pain level at 8/10 (pain scale using numbers from 0 to 10. A score of 0 means no pain, and 10 means the worst pain). No pain assessment for more five [5] hours and 41 minutes after arrival to the ED at 7:03 AM.

On 1/26/24, at 1:26 PM, during interview with IT Nurse 2 and record review of Patient 23's Triage and ED notes, dated 1/5/24, On 1/5/2024 at 12:44 PM, Patient 23 was given Morphine 2 milligrams by vein. IT Nurse 2 stated, there was no re-assessment for the effectiveness of pain medicine given on 1/5/2024 at 12:44 PM.

A record review of the facility's policy and procedure, titled, Assessment/Reassessment of Patient,' revised 10/2023, indicated the "Patient's condition will be reassessed and documented whenever treatment requires or a change in condition or diagnosis occurs, such as: medication affecting hemodynamics, medication administration, patient verbalizes change, receipt of abnormal diagnostic test results." The policy and procedure indicated, "A patient condition will be reassessed and documented whenever treatment requires or a change in condition or diagnosis occurs, such as ...medication administration."

Based on record interview and record review the facility failed to complete an individualized care plan for two (2) of 36 sampled patients (Patient 4 and Patient 10) as evidence by:

1. Patient 4 had no care plan for pressure injury (pressure injury, injuries to skin and underlying tissue resulting from prolonged pressure on the skin such as lying in bed for extended periods of time)

This deficient practice had the potential for delayed provision of necessary care and services for prevention of the development of a pressure injury (pressure injury, injuries to skin and underlying tissue resulting from prolonged pressure on the skin such as lying in bed for extended periods of time) on Patient 4.

2. Patient 10 has no care plan for pain management.

This deficient practice had the potential for delayed provision of necessary care and services for pain management for Patient 10.

This deficient practice had the potential for delayed provision of necessary care and services for chest pain.

Findings:

1. A record review of Patient 4's History and Physical (H&P, physician examination record), dated 1/19/2024, indicated Patient 4 was admitted with a history of cirrhosis of the liver (condition in which the liver is scarred and permanently damaged), history of seizure (uncontrolled electrical activity in the brain which can affect a person's movement and level of consciousness). The record indicated Patient 4 was admitted with chronic feet ulceration (formation of a break on the skin or on the surface of an organ) and Patient has multiple bruises on the patient's body.

A record review of Patient 4's Daily Assessment Inquiry, indicated Patient 4 was bedbound (someone who has become very weak and is no longer able to move easily) and should be repositioned every 2 hours. The record indicated Patient 4 was not repositioned every 2 hours. The record indicated the following between 1/20/24 and 01/21/2024:

a. On 1/20/2024 at 8 a.m. and 8 p.m. Patient 4 was supine (not repositioned for 12 hours).

b. On 1/21/2024 at 00:00 (12 a.m.) Patient 4 was on the right side, at 4 a.m., Patient 4 was supine, at 8 a.m. Patient 4 was supine, at 19:47 (7:47 p.m., Patient 4 was on supine (not repositioned for 4 hours and on the same position on the same position).

A record review of Patient 4's Patient Care Plan Report," printed 1/23/2024, indicate there were care plans for "Resp - Pulmonary Changes (Potential)," "Safety - Risk for Injury (Potential)," "Infection - Risk for (Potential),""Fall Risk/Potential for Falls (Potential),", "Seizure Disorder (Actual),"and "Functional - Impaired Physical Mobility (Actual)." There was no care plan for pressure injury for Patient 4.

During an interview, on 1/25/2024 at 12:19 PM, the ICU (Intensive Care Unit, area that provide treatment and monitoring for patients, who are very ill)/ Telemetry (area that provide treatment and monitoring for patients with heart conditions) Director stated all patients should have a nurse care plan so that nursing recognizes patient needs and can act upon those needs.

A record review of the facility's policy and procedure (P&P), titled, "Care Plan, Multidisciplinary," effective 10/2019, indicated purpose for the P&P were the following:

a. To establish guidelines to provide personalized and high-quality care.

b. To provide best practice care; to facilitate communication among all care givers.

c. Within 24 hours of patient admission to the hospital, and updated every shift,

d. The care plan will include the provider's plan of care along with orders.

e. The nursing plan of care will include the specific patient problems addressing short term goals and measurable outcomes, interventions to meet the goals, nursing summary of responses to these care interventions, and any nursing care plan changes or recommendations.
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2. A record review of Patient 10's History and Physical Note, dated 1/24/2024, indicated Patient 10 had complaints of fever, vomiting, and elevated heart rate. The record indicated Patient 10 had a history of multiple abdominal surgeries and left hip dislocation (event where thighbone is forced out of its socket in the hip bone) related to a gunshot wound.

A record review of Patient 10's Medication Administration History Report, ] indicated Patient 10 was prescribed 1 milligram (mg, unit of measurement) of Diluadid (medication for severe pain relief) to be given every 3 hours as needed. This record indicated Patient 10 was given Diluadid on the following:

a. On 1/23/2024 at 2:56 AM, for pain level 9 (Pain scale using numbers from 0 to 10. A score of 0 means no pain, and 10 means the worst pain).

b. On 1/23/2024 at 6:02 AM, for pain level 10.

c. On 1/23/2024 at 9:11 AM, for pain level 10.

d. On 1/23/2024 at 12:52 PM for pain level 10.

A review of Patient 4's Vitals Inquiry, for indicated no reassessment of pain level after the medication (Diluadid) was given for pain on 1/23/2024 at 2:56 AM; on 1/23/2024 at 6:02 AM; on 1/23/2024 at 9:11 AM; and on 1/23/2024 at 12:52 PM.

A record review of Patient 10's Patient Care Plan Report, dated 1/23/2024, indicate Patient 10's care plans included, "Resp. (respiratory) - Ineffective Breathing Pattern (Actual),"Knowledge Deficit; Hospitalization (Potential)," 'Impaired Skin Integrity: Moderate Risk (13-14) (Actual)', 'Safety - Risk for Injury (Potential)," "Infection (Actual)," and "Functional - Impaired Physical Mobility (Actual)." Patient 10 had no nursing care plan for pain.

During an interview, on 1/25/2024 at 12:19 PM, the ICU (Intensive Care Unit, area that provide treatment and monitoring for patients, who are very ill)/ Telemetry (area that provide treatment and monitoring for patients with heart conditions) Director stated all patients should have a nurse care plan so that nursing recognizes patient needs and can act upon those needs.

A record review of the facility's policy and procedure (P&P), titled, "Care Plan, Multidisciplinary," effective 10/2019, indicated purpose for the P&P were the following:

a. To establish guidelines to provide personalized and high-quality care.

b. To provide best practice care; to facilitate communication among all care givers.

c. Within 24 hours of patient admission to the hospital, and updated every shift,

d. The care plan will include the provider's plan of care along with orders.

e. The nursing plan of care will include the specific patient problems addressing short term goals and measurable outcomes, interventions to meet the goals, nursing summary of responses to these care interventions, and any nursing care plan changes or recommendations.