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Based on observation, interview, and record review, the hospital failed to ensure the nursing staff supervised and evaluated the nursing care for seven of 12 sampled patients (Patients 1, 2, 7, 8, 10, 11, and 12) as evidenced by:

1. The nursing staff failed to ensure the physician's order for the use of non-violent restraint was completed for Patient 1 as per the hospital's P&P.

2. The nursing staff failed to ensure the GT dressing was changed daily for Patient 2 as per the hospital's Lippincott nursing standards of practice.

3. The nursing staff failed to ensure the call lights for Patients 8, 10, 11, and 12 and ventilator alarms for Patient 7 were addressed on a timely manner.

These failures had the potential for unsafe care to the patients.

Findings:

1. Review of the hospital's P&P titled Physical Restraints (Violent and Non-Violent Behavior) and Seclusion dated June 2023 showed for non-violent behavior restraints, initial restraint order from the attending physician or other licensed practitioner (LP) is required immediately or within a few minutes from initiating restraints. The initial face-to-face assessment by MD/LP must be performed within one calendar day after the restraints are applied. The ordering practitioner must complete their part of the assessment attending to any nursing findings and new findings related to the restraint use, type of restraint to be used, and criteria for release.

On 4/10/25 at 1438 hours, a medical record review for Patient 1 was conducted with the Director or Quality Management. Patient 1's medical record showed the patient was admitted to the hospital on 2/3/25.

Review of the Restraint Initiation/Order (Non-Violent Non-Self Destructive Behavior) showed the following:

* On 2/7/25 at 1200 hours, the right hand and left wrist limb/soft restraints were applied for Patient 1.

* The section for Nursing Assessment/Reason for Restraint was left blank.

* The section for Telephone Order was checked. However, the sections for Nurse Name/Signature, Physician/LIP/AHP Name, Time, and Date were left bank.

* The section for Physician/LIP/AHP Assessment/Restraint Order Confirmation showed a signature. However, the sections for Time and Date were left blank.

The Director of Quality Management verified the above findings.

2. Review of the hospital's Lippincott nursing standards of practice titled Enteral Feeding Tube Exit Site Care, Gastrostomy and Jejunostomy dated 11/18/24, showed to wash the surrounding skin with soap and water daily, rinse the area with water and pat it dry when the tube exit site has healed.

On 4/10/25 at 0920 hours, during an observation of the medication administration for Patient 2 via the GT was conducted with LVN 1. The dressing of the patient's GT was observed dated 4/6/25, the LVN confirmed the date written on the GT dressing showed the last date that the patient's GT dressing was changed. The LVN stated the night shift nurse usually changed the GT dressing for Patient 2.

On 4/10/25 at 1120 hours, an interview and concurrent review of Patient 2's medical record was conducted with LVN 1. Patient 2's medical record showed the patient was admitted to the hospital on 3/12/25, with a GT.

When asked how often the GT dressing was changed, LVN 1 stated the GT dressing was supposed to be changed every day and when it was soiled.

On 4/14/25 at 1128 hours, an interview was conducted with the DON. When asked about the GT dressing change, the DON stated the hospital followed Lippincott nursing standard of practice for GT care, and the hospital did not have the P&P for GT care. The DON acknowledged the GT dressing should be changed every day as per hospital's nursing standard of practice.


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3.a. On 4/10/25 at 1516 hours, an observation at the telemetry room was conducted with the DON and Director of Quality Management. MT 1 was observed watching the cardiac monitors. MT 1 was asked about the ventilator alarms. MT 1 stated the ventilator alarms were connected to the call light system. The unit secretary was assigned to answer the call light and she would take over when the unit secretary was on break. She would call the room and ask if the staff was inside the room, if the staff was not in the room, and she would overhead page the RT. The DON stated at night the call light system was assigned to the MT, there was no unit secretary assigned for the night shift.

On 4/11/25 at 1150 hours, interview and concurrent record review was conducted with the Director of Quality Management.

Review of the call light log showed the following patient calls:

- On 4/10/25, Patient 10 called at 1748 hours and the call was cancelled at 1830 hours. The patient's call was completed after 42.23 minutes.

- On 4/11/25, Patient 11 called at 1902 hours and the call was canceled at 1948 hours. The patient's call was completed after 45.59 minutes.

- On 4/12/25, Patient 12 called at 1740 hours and the call was canceled at 1830 hours. The patient's call was completed after 49.54 minutes.

The Director of Quality Management was asked about answering the patient's calls. The Director of Quality Management stated the call light could only be canceled inside the patient's room when the staff went to the room to answer the patient's call. The Director of Quality Management stated he could not say anything about the above calls, sometimes the staff would not cancel the call light until they were done with the patient care.

On 4/15/25 at 1010 hours, an interview was conducted with Patient 8 and the patient's family member with the presence of the Director of Quality Management. Patient 8 was asked if the staff answered the call light when he called for the staff. Patient 8 stated he called last night, and no one came. Patient 8 stated could hear them laughing, but no one came. Patient 8 stated a male staff answered the call light and clicked to cancel the call light, but no one came. The patient called again. The staff answered the call light and clicked to cancel the call light, but no one came. When Patient 8 was asked for the reason he called the staff, Patient 8 stated he had a headache. Patient 8 was asked if he had gotten what he needed, Patient 8 stated eventually someone gave what he needed. Patient stated he was not happy at all with the hospital.

Review of the call light log for Patient 8 was conducted with the Director of Quality Management. The call light log showed on 4/14/25 the patient's call was placed at 1807 hours and was cancelled at 1822 hours; the call was completed after 14 minutes and 24 seconds.

b. Review of the ventilator log for Patient 7 showed the following:

* The short, repeated ventilator alarm generated calls and call cancellation were recorded on 4/11/25 from 1633 hours to 1651 hours (for 18 minutes).

* The patient's short, repeated ventilator alarm was on and off for 9 minutes on 4/12/ 25 at 0039 hours to 0053 hours.

The RT Manager and Director of Quality Management was asked about these short, repeated ventilator alarms. The RT Manager stated there was no indication of the source of alarm, the alarm could be coming from the loose pulse oximeter, the patient might be coughing or moving. The alarms would reset itself. The Director of Quality Management stated the MT did not have to call unless the ventilator alarm was sustained. The MT might notify the nurse if the ventilator was alarming continuously. The Director of Quality Management was asked for the P&P for alarms. The Director of Quality Management stated there was no policy when the MT would initiate to call the RT. The Director of Quality Management was asked for the staff training for the medical device alarms.

Review of the hospital's reference for staff training titled Medical Device - Alarm Safety - Alarm Fatigue showed the following:

- In an effort to improve the safety of clinical alarm system, the hospital leaders are required to set alarm management as a priority, established a formal policy and provide staff training around alarm safety.

- The risk associated with sensory overload from beeping alarms has been cited as the number one technology -associated risk to patients for several years. When the nurses are unable to distinguish critical versus non-critical alarms, a condition known as "alarm fatigue", they risk not responding to a life threatening emergency.

- Device alarms are intended to alert clinicians of a hazardous condition and potential problems. However, when a caregiver is subjected to too many alarms, it disrupts his or her usual workflow and may result in errors due to omission, distraction, or inattention.

- The lack of response due to excessive numbers of alarms resulting in sensory overload and desensitization is known as alarm fatigue.

- Many medical devices have alarm systems; among them are bedside physiologic monitors that include call lights and ventilator.

The findings were shared with the Director of Quality Management.

Based on observation, interview, and record review, the hospital failed to ensure the hospital's P&P was implemented for one of 12 sampled patients (Patient 2) when the nursing staff failed to ensure the medications were administered separately through the enteral feeding tube for Patient 2. This failure increased the risk of substandard healthcare outcomes to the patients.

Findings:

Review of the hospital's P&P titled Administration of Medications via Feeding Tube dated June 2023 showed in part:

* Purpose: This procedure establishes a system by which medications will be administered to patients safely, accurately, and efficiently by qualified personnel.

* Procedure

- Prepare medications: crush tablets using a pill-crushing device and appropriate container to a fine powder, mix the crushed medication in a medication cup with 5 to 10 ml of fresh tap water.

- Draw up medication. If ENFit syringe, use a medication straw.

- Identify patient by two forms of identification on the wristband.

- Observe feeding tube for a change in external tube length or incremental marking at the exit site to assure tube has not migrated.

- After verifying proper tube placement, in the RUNNING mode, hit the Flush Now button, input desired flush volume (15-30 ml), then press ENTER. Place the pump to HOLD.

- Remove the medication straw and attach the ENFIT medication syringe into the port of the feeding tube.

- Slowly deliver the medication: each medication is administered separately through the enteral feeding tube; avoid mixing medications; do not add medication directly to enteral formula; whenever possible, use liquid medications to minimize risk of tube clogging.

- After medication is administer, flush with 15- 30 ml fresh tap water either using syringe or use Flush Now on pump.

On 4/10/25 at 0920 hours, an observation of medication administration for Patient 2 via GT was conducted with LVN 1. LVN 1 verified Patient 2's identification and reconciled the following administered medications:

* Magnesium oxide (a supplement) 400 mg tablet
* Vitamin C (a supplement) 500 mg tablet
* Multivitamin (a supplement) one tablet
* Fenofibrate (an anti-cholesterol medication) 145 mg tablet
* Desmopressin acetate (an antidiuretic medication) 0.1 mg tablet
* Famotidine (an antacid - treat heartburn due to acid indigestion) 20 mg tablet
* Lactobacillus (a probiotic) one tablet
* Vitamin D (a supplement) 1000 IU two tablets

Patient 2 was observed having a GT and was on continuous tube feeding. LVN 1 was observed priming the GT with water and started to prepare the medications. LVN 1 was observed placing all medications into a small bag and crushed all medications together by using the pill-crushing device. LVN 1 then draw 30 ml of tap water to flush the patient's GT and checked for the residue of the GT for Patient 2. LVN 1 mixed the crushed medications with 50 ml of tap water in a cup, withdrew the mixture of medications and water in a syringe, and administered them to Patient 2's GT. LVN 1 was observed rinsing the cup with 30 ml of tap water, withdrew the mixture in the syringe, and administered to Patient 2's GT. LVN 1 was then observed flushing the GT with 30 ml of tap water.

On 4/10/25 at 1120 hours, an interview and concurrent review of Patient 2's medical record was conducted with LVN 1.

Patient 2's medical record showed the patient was admitted to the hospital on 3/12/25, and had a GT. The physician's order to administer the medications to the patient via GT. LVN 1 confirmed LVN 1 she did not administer the medications via GT separately as per the hospital's P&P.

On 4/10/25 at 1140 hours, an interview was conducted with the DON. The DON verified the above findings.