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Based on interview and record review, the facility failed to ensure the facility's Medication Administration, Patient Rights and Responsibilities, and Reassessment policies and procedures (P&P) were implemented, for nine of 30 sampled patients (Patient 3, 4, 5, 6, 8, 19, 24, 25, and 30) when:

1. For Patients 19 and 25, the staff did not assure that the safety clip was in place and the call light was within reach, and both patients sustained a fall. (Refer to A0398)

2. For Patient 19, the Registered Nurse (RN) did not complete a post fall assessment. (Refer to A0398)

3. For Patients 3, 4, 5, 6, 8, 24, and 30, the nurse did not administer pain medication when the patients reported pain, did not reassess the pain level within two hours after intervention, and administered the wrong pain medication, which did not align with the pain scale (1-10, with 10 being the worst pain) order. (Refer to A0398)

The cumulative effect of these systemic failures resulted in the patients to not be provided safe and quality care to meet the patient needs and had the potential to delay provision of care/treatment.

Based on interview and record review, the facility failed to ensure patient's Do Not Resuscitate (DNR-do not resuscitate, medical order that tells doctors and nurses not to perform life-saving procedures) wishes were honored for one (Patient 25) of 30 sampled patients.

This failure had the potential to result in unwanted life saving measures, a violation of Patient 25's end of life choices, and could have caused unnecessary distress for the patient and family.

Finding:

A review of the facility document titled, "Pre-Admission Screening," dated February 23, 2024, indicated, Patient 25's code status ( a patient's instructions to their medical team about what to do if they experience cardiac or respiratory arrest) was a DNR (do not resuscitate, medical order that tells doctors and nurses not to perform life-saving procedures).

A review of the facility document titled, "Case Management Initial Assessment," dated February 27, 2024, indicated, "...Does patient have an Advanced Directive...Yes...Was a copy of the advanced directive requested...Yes...Comment...Requested by son..."

A review of the facility document titled, "History and Physical (H&P)," dated February 26, 2024, authored by Physician 1, indicated, "...Code Status...Full Resuscitation Daily...Request Type...Stat [immediate]...Comment...Full Code..."

On August 16, 2024, at 2:17 p.m., an interview was conducted with the Clinical Liaison (CL). The CL stated the clinical liaison is responsible for conducting pre-admission screenings. The CL further stated upon receiving a referral, the liaisons visit the referring facilities to gather information from the patient which includes the Code Status. She stated every morning, the facility holds an OPS (Operational) meeting with leadership, marketing, admissions, and other departments to discuss upcoming admissions including their advance directives status.

On August 16, 2024, at 2:30 p.m., an interview was conducted with the Registered Nurse (RN) 2. RN 2 stated the process of identifying a patient's DNR status begins with the PAS (pre-admission screening), which includes the code status, medical history, and a report from the referring facility. She stated the nurse then confirms the code status with the patient or family and informs the doctor.

On August 16, 2024, at 3:30 p.m., an interview with the Director of Patients Outcomes (DPO), was conducted. The DPO stated the case managers should have followed up with Patient 25's son regarding Patient 25's code status, but this was not done.

There was no documented evidence in Patient 25's medical record, the nurse communicated Patient 25's code status with the physician.

There was no documented evidence in Patient 25's medical record, the facility updated the Electronic Health Record (EHR) regarding Patient 25's DNR status.

A review of the facility's policy and procedure (P&P) titled, "Patient Rights," dated December 2022, was reviewed. The documented indicated, "...The right to formulate advance directives and appoint a surrogate to make health care decisions on his or her behalf and to have those advance directives respected and honored to the extent allowed by law..."

Based on interview and record review, the facility failed to ensure their Medication Administration, Patient Rights and Responsibilities, and Reassessment policies and procedures (P&P), were implemented for nine of 30 patients (Patient 3, 4, 5, 6, 8, 19, 24, 25, 30) when:

1. For Patients 19 and 25, the staff did not assure the safety clip was in place and the call light was within reach, and both patients sustained a fall.

2. For Patient 19, the Registered Nurse (RN) did not complete a post fall assessment.

3. For Patients 3, 4, 5, 6, 8, 24, and 30, the nurse did not administer pain medication when the patients reported pain, did not reassess the pain level within two hours after intervention, and administered the wrong pain medication, which did not align with the pain scale (1-10, with 10 being the worst pain) order.

These failures had the potential to not provide safe and quality care to meet the patient needs and had the potential to delay provision of care/treatment.

Findings:

1a. On August 14, 2024, at 2:45 p.m., an interview was conducted with Patient 19. Patient 19 stated she fell from her wheelchair while trying to reach for her call light for assistance to the bathroom. Since the call light was not within reach, she leaned forward, which caused her to fall. Patient 19 reported back and arm pain after the fall and stated her inability to walk was due to her left sided weakness, requiring assistance to get up.

A review of Patient 19's medical record was conducted on August 15, 2024, at 3 p.m., with RN 3.

The facility document titled, "History and Physical (H&P)," dated July 2, 2024, indicated, Patient 19 was admitted on June 30, 2024, with left sided weakness and slurred speech.

A review of the facility document titled, "Hendrich II Fall Risk Model, [tool used to assess a patient's risk of falling]," dated July 6, 2024, indicated, Patient 19's Hendrich II fall risk score was three (three indicates moderate risk for falling and a score of five or greater equals high risk).

A review of the facility untitled document, dated July 6, 2024, authored by Licensed Vocational Nurse (LVN) 1, indicated, "...unwitnessed fall at 1:20 p.m...Patient states she tried reaching over to reach her call light when she lost control and slid down on the floor, she states her back aches. MD [Medical Doctor] made aware and order for the patient to be transported to ED [emergency department]..."

On August 15, 2024, at 10:30 a.m., an interview was conducted with the RN 3. RN 3 stated Patient 19 attempted to reach for her call light and fell out of the wheelchair. He further stated the safety clip, which should have been attached to trigger the alarm, was not secured, preventing the alarm from activating and this oversight resulted in the patient's fall without immediate notification.

A review of the facility's document titled, "Plan of Care," dated July 2, 2024, indicated, "...Risk for falls...[Patient name] will be free from falls during this hospitalization...Intervention...Maintain fall precautions...utilize chair/bed alarms as needed..."

RN 3 verified there was no documented evidence fall prevention measures were in place, as no assistive devices were securely attached to her, and her call light was not within her reach.

1b. On August 16, 2024, at 2 p.m., a review of Patient 25's medical record was conducted with RN 2.

The facility document titled, "H&P," dated February 26, 2024, indicated, Patient 25 was admitted on February 26, 2024, for a CVA (cerebral vascular accident, when blood flow to a part of the brain is suddenly blocked).

The facility document titled, "Hendrich II Fall Risk Model," dated March 12, 2024, indicated, Patient 25's Hendrich II fall risk score was one (one indicates low risk of falling and a score of five or greater equals high risk).

The facility document untitled, dated March 5, 2024, authored by RN 1, indicated, "...was found on the floor in the room. Patient states she was getting something from her recliner...did not use her walker and chair alarm was not on...Notified [Name of Physician- Physician 1] at 1915 [7:15 p.m.] and patients' son [sons name] at 1920 [7:20 p.m.]...Received orders from [Physician 1] for neuro checks q6h [every six hours] x1 day [for one day]..."

A review of the facility's document titled, "Plan of Care," dated February 26, 2024, indicated, "...risk for falls related to age 70 as evidence by recent history of falls, seizures, syncope [loss of consciousness]...Goal...[Patient 25] will be free of falls during hospitalization...Intervention...maintain fall precautions...utilize chair/bed alarms as needed..."

RN 2 verified there was no documented evidence fall prevention measures were in place, as no assistive devices were securely attached to her.

A review of the facility's P&P titled, "Interdisciplinary Fall Precautions," dated November 2023, indicated, "...to provide guidelines and processes that identify patient who are at risk for falls...Consider implementing standard fall precautions...Initiating assistive devices for activities...assure call light is within reach...place personal items such as call light...within patient's reach..."

2. On August 15, 2024, at 3:30 p.m., a review of Patient 19's medical record was conducted with Registered Nurse (RN) 3.

The facility document titled, "History and Physical (H&P)," dated July 2, 2024, indicated, Patient 19 was admitted on June 30, 2024, with left sided weakness and slurred speech.

The facility document titled, "Hendrich II Fall Risk Model (tool used to assess a patient's risk of falling)," dated July 6, 2024, indicated, Patient 19's Hendrich II fall risk score was three (three indicates moderate risk for falling and a score of five or greater equals high risk).

The facility untitled document, dated July 6, 2024, authored by Licensed Vocation Nurse (LVN) 1, indicated, "...unwitnessed fall at 1:20 p.m...Patient states she tried reaching over to reach her call light when she lost control and slid down on the floor, she states her back aches. MD [Medical Doctor] made aware and order for the patient to be transported to ED [emergency department].

On August 14, 2024, at 2:45 p.m., an interview and record review was conducted with the Chief Nursing Officer (CNO). The review of Patient 19's medical record indicated there was no documented evidence of an RN assessment after the patient's fall. The CNO stated RN 3 did not document an assessment and stated it should have been done per facility policy.

On August 14, 2024, at 3 p.m., an interview was conducted with the RN 3. RN 3 stated after Patient 19's fall he assessed the patient, obtained vital signs, and notified the doctor, but did not document any of the findings in the Electronic Health Record (EHR). RN 3 further stated he failed to document an assessment and stated he should have documented the assessment and vital signs.

A review of the facility's P&P titled, "Reassessment," dated, November 2023, indicated, "...A patient's need for care related to his/her admission is assessed by a Registered Nurse...Patient need...response to treatments/interventions, and change in condition...All assessments and reassessments are performed by an RN..."

3a. On August 15, 2024, at 3:06 p.m., a review of Patient 3's medical record was conducted with the Registered Nurse Manager (RNM).

The facility document titled, "History and Physical (H&P)," dated July 19, 2024, indicated Patient 3 was admitted to the facility post (after) anterior cervical corpectomy C7 with fusion from C6-T1 (fusion of spinal bones). The document further indicated patient had a Ground Level Fall (GLF) prior to admission.

The facility document titled, "[Name of facility] MEDICATION ADMINISTRATION RECORD," dated July 19, 2024, to August 15, 2024, was reviewed. The document indicated, for entry on July 21, 2024, at 9:51 a.m., indicated, "...oxyCODONE IR (OXYIR) [a pain medication] Give 10 mg [milligram, unit of measurement] (1 tablet(s) by mouth Every Four Hour PRN [As needed] Pain VAS [Visual Analogue Scale, measures pain intensity] 4-10...Pain Scale...6..."

The facility document titled, "Plan of Care, Alteration in Comfort," dated August 8, 2024, was reviewed. The document indicated, "...Assess/reassess effectiveness of interventions daily and after use of medications or alternates..."

There was no documented evidence that Patient 3's pain was reassessed after pain medication administration in the Electronic Health Record (EHR).

On August 15, 2024, at 3:17 p.m., an interview was conducted with the RNM. The RNM stated on July 21, 2024, at 9:51 a.m., the patient was given OXYIR 10 mg, and the pain was not reassessed within two hours after administration. The RNM further stated the expectation would be the nurse administered the ordered medication and reassess pain level in two hours. She stated there is no documentation in the chart of a pain reassessment.

3b. On August 16, 2024, at 9:09 a.m., a review of Patient 4's medical record was conducted with RN 1.

The facility document titled, "H&P," dated August 8, 2024, indicated Patient 4 was admitted to the facility due to debility (state of being weak, feeble, or infirm).


The facility document titled, "Vital Sign Flow Sheet," dated August 8, 2024, at 4:08 p.m., indicated, "...Pain Scale...6..."

The facility document titled, "Orders," dated August 8, 2024 and August 9, 2024, indicated, "Acetaminophen (Tylenol) [pain medication] 650 mg (2 tablets) by mouth every 6 hours PRN for pain level 1-3...Hydrocodone-APAP [pain medication] 5/325 mg (Norco) give 1 tablet by mouth every 8 hours PRN Monitor vitals and alertness 30 minutes before and after administration...Indication...pain (7-10).

There was no documented evidence the nurse called the physician to obtain pain coverage for pain level of 6 in the EHR.

There was no documented evidence Patient 4 received any pain medication after a pain level of 6 was reported to the nurse in the EHR.

On August 16, 2024, at 9:19 a.m., an interview was conducted with RN 1. RN 1 stated the nurse should have called the physician to get orders because there was no pain coverage for a level of 6 ordered. RN 1 further stated there was no documented evidence that the nurse called the physician to get orders or that pain medication was given in the chart. She stated the expectation would have been to call the doctor, get an order for pain level of 6, administer medication, and reassess pain within two hours.

3c. On August 16, 2024, at 9:22 a.m., a review of Patient 5's medical record was conducted with RN 1.

The facility document titled, "H&P," dated August 4, 2024, indicated Patient 5 was admitted to the facility post left frontal lobe neoplasm (abnormal growth of cells in the body) s/p (status post) left frontal craniotomy (removing a part of the bone from the skull to expose the brain) and resection.

The facility document titled, "Vital Signs Flow Sheet," dated August 10, 2024, at 5:25 a.m., indicated, "...Pain Scale...3..."

The facility document titled, "[Name of facility] MEDICATION ADMINISTRATION RECORD," dated August 10, 2024, indicated ordered medication for pain level of 3, "...Acetaminophen (Tylenol) Give 650 mg (2 tablet(s) by mouth Every Six Hours PRN for pain level 1-3..."

There was no documented evidence Patient 5 was given pain medication after a pain level of 3 was reported to the nurse in the EHR.

On August 16, 2024, at 9:25 a.m., an interview was conducted with RN 1. RN 1 stated the nurse should have given Tylenol which was ordered for pain level 1-3. RN 1 further stated the expectation would be to assess pain, administer ordered pain medication, reassess in two hours. She stated there was no documentation in the chart reflecting that pain medication was given at this time.

3d. On August 16, 2024, at 10:10 a.m., a review of Patient 6's medical record was conducted
with RN 1.

The facility document titled, "H&P," dated August 11, 2024, indicated Patient 6 was admitted to the facility s/p right tib-fib (leg bone) ORIF (Open reduction and internal fixation).

The facility document titled, "Vital Signs Flow Sheet," dated August 11, 2024, at 9: 35 p.m., indicated, "...Pain Scale...4..."

The facility document titled, "[Name of facility] MEDICATION ADMINISTRATION RECORD," dated August 11, 2024, indicated ordered medication for pain level of 4, "...oxyCODONE IR (OxyIR) Give 5 mg (1 tablet(s) by mouth Every Four Hours PRN Monitor vitals and alertness 30 min before and after administration. Moderate to severe pain (4-10)..."

There was no documented evidence Patient 6 was given pain medication after a pain level of 4 was reported to the nurse in the EHR.

On August 16, 2024, at 10:34 a.m., an interview was conducted with RN 1. RN 1 stated the nurse should have given the ordered medication, OxyIR for a pain level of 4. RN 1 further stated I do not see any documentation in the chart this medication was administered to Patient 6.

3e. On August 16, 2024, at 10:28 a.m, a review of Patient 8's medical record was conducted
with RN 1.

The facility document titled, "H&P," dated August 5, 2024, indicated Patient 8 was admitted to the facility s/p subarachnoid hemorrhage (bleeding in the brain), s/p decompressive craniotomy (remove a portion of the skull to relieve pressure on the brain) after a fall from roof.

The facility document titled, "Vital Signs Flow Sheet," dated August 6, 2024, at 12:07 p.m., indicated, "...Pain Scale...7..."

There was no documented evidence the nurse called the physician to obtain pain coverage for pain level of 7 in the EHR.

There was no documented evidence Patient 8 was given pain medication appropriate for pain level of 7, or ordered medication indicated for pain level of 7 in the EHR.

On August 16, 2024, at 10:34 a.m., an interview was conducted with RN 1. RN 1 stated the expectation would be for the nurse to call the physician for medication appropriate for a pain level of 7 if there was none ordered. RN 1 stated the nurse gave Tylenol, which is indicated for pain level of 1-3, she most likely gave this because there was no ordered medication for a pain level of 7, she should have called the physician, received orders for pain coverage of 7, administered the ordered drug and reassessed pain within two hours. She further stated the policy was not followed.

3f. On August 16, 2024, at 2 p.m., a review of Patient 24's medical record was conducted with
RN 2.

The facility document titled, "H&P," dated January 26, 2024, indicated Patient 24 was admitted to the facility for acute/subacute left pontine stroke (decrease blood flow to left side of brain)

The facility document titled, "Vital Signs Flow Sheet," dated February 9, 2024, at 5:45 a.m., indicated, "pain scale...0..."

The facility documented title, "Medication administration record," date February 9, 2024, indicated, ordered medication for pain level of (1-3), "...Tylenol 325 mg...Give 650 mg (2 tablets) by mouth Every Six Hours PRN mild pain (1-2)...Indication...pain..."

There was no documented evidence for pain medication administration with a pain level of 0 in the EHR.

There was no documented evidence Patient 24's pain was reassessed after pain medication administration in the EHR.

On August 16, 2024, at 2 p.m., an interview was conducted with RN 2. RN 2 stated there was no documented evidence why Tylenol was given for pain level of 0/10. She stated additionally, the pain reassessment should have been done two hours after the administration. She stated there was no documentation in the chart of the reassessment.

3g. On August 16, 2024, at 3 p.m., a review of Patient 30's medical record was conducted
with RN 2.

The facility document titled, "H&P," dated February 11, 2024, indicated, Patient 30 was admitted to the facility for metastatic (cancer) to the brain with craniotomy (skull surgery).

The facility document titled, "Vital Signs Flow Sheet," dated February 25, 2024, at 5:50 p.m., indicated, "...Pain Scale...3..."

The facility documented title, "Medication administration record," dated February 25, 2024, indicated, ordered medication for pain level of (1-3), "...Tylenol 325 mg...Give 650 mg (2 tablets) by mouth Every Six Hours PRN mild pain (1-2)...Indication...pain..."

There was no documented evidence Patient 24's pain was reassessed after pain medication administration in the EHR.

On August 16, 2024, at 3:10 p.m., an interview was conducted with RN 2. RN 2 stated the pain reassessment should have been done two hours after the administration. She stated there is no documentation in the chart of the reassessment.

On August 16, 2024, at 3:29 p.m., an interview was conducted with the Director of Compliance (DOC). The DOC stated the facility does not have a policy that speaks to the time pain reassessment needs to be done but we audit to two hours. She stated the expectation would be two hours after pain intervention, pain should be assessed for effectiveness.

A review of the facility's policy and procedure (P&P) titled, "Medication Administration," dated June 2024, was reviewed. The document indicated, "...Patient's response to medications should be documented in the medical record, including but not limited to as needed (PRN) medications and scheduled pain medications..."

A review of the facility's P&P titled, "Patient Rights & Responsibilities," dated November 2023, was reviewed. The document indicated, "...Patients at the hospital have the following rights, to the extent allowed by law...The right to have pain assessed and managed appropriately..."

A review of the facility's P&P titled, "Reassessment," dated November 2023, was reviewed. The document indicated, "...A patient's need for care related to his/her admission is assessed by a RN. Patient needs, response to treatments/interventions, a change in condition...Patients will also have reassessments occur when...Changes in condition...Changes occur in the response to care received/provided...Reassessments by the interdisciplinary team will occur weekly or more frequently as determined by the patient need..."