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Based on interview and record review, the hospital failed to ensure:

1. The physician's order to transfer a patient out of ICU was documented in the medical record for one of 13 patients (Patient 8).

2. The dietary consult for one of 13 patients (Patient 8) with an abnormal lab value was performed and documented in the medical record by the RD.

These failures created an increased risk of substandard health outcomes to this patient.

Findings:

1. Review of the hospitals's Medical Staff Rules and Regulations revised 2021 showed in part, all inpatient and outpatient orders for medication, treatment procedures, diagnostic services or therapy shall be recorded in the medical record. Orders must be reviewed and rewritten, as appropriate, by the responsible practitioner when patients are transferred to or from the ICU and following surgery.

On at 2/3/22 at 1054 hours, an interview and concurrent medical record review was conducted with the DON.

Medical record review showed Patient 8 was admitted to the hospital, ICU A on 11/18/21 at 1958 hour, and transferred to Telemetry Room B on 11/19/21 at 0100 hours (five hours after the ICU admission).

Review of the RN's Additional Note on 11/19/21 at 0437 hours, showed the RN had spoken to Patient 8's family member and the patient was moved from ICU A to Room B (telemetry unit). The DON was asked to show the physician's order for Patient 8 to transfer from the ICU to Telemetry Unit, the DON could not show documented evidence the physician ordered Patient 8 to transfer from the ICU to Telemetry unit. The DON stated there should be a physician's order to transfer for the patient in or out of the ICU.


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2. Review of the hospital's Policy & Procedure, Core: Nutrition Care Process- Identifying Nutrition Problems & Responding to Significant Change dated 6/2020 showed in part, the RD identified patients needing further monitoring and evaluation ...including patients receiving enteral nutrition, receiving dialysis ...RD's were to notify and consult with providers regarding patient's current nutritional status or significant change in nutritional status ....and Re-assess patients upon significant change in condition in nutritional status includes abnormal lab values ....The RD documents assessments, care plan updates, nutritional interventions and updates ...in the patients' medical record.

Review of Patient 8's H&P examination showed the patient was admitted to the hospital on 11/18/21.

Review of the physician's order dated 11/21/21 at 1751 hours, showed to hold the feeding until the potassium level was available.

Review of the physician's order dated 11/22/21 at 0649 hours, showed the Dietitian Consult-enteral nutrition for recommendations on elevated potassium levels ...dialysis patient.

On 2/2/22 at 1316 hours, an interview and concurrent medical record review was conducted with the Director of Nutrition and Culinary Services. After showing the above physician's orders, the Director of Nutrition and Culinary Services stated an elevated potassium was a change in the patient status. The Director of Nutrition and Culinary Services were asked about the expectation for the physician's order for the dietary consult related to an abnormal lab value such as the elevated potassium level. The Director of Nutrition and Culinary Services stated when a physician placed an order, the expectation was for an RD to review the order, assess the patient, and provide a recommendation for the patient as ordered. The Director of Nutrition and Culinary Services stated the assessment note and recommendations given would be documented in the patient's medical record.

The Director of Nutrition and Culinary Services reviewed Patient 8's medical record. The Director of Nutrition and Culinary Services was unable to provide documented evidence Patient 8 had been evaluated by an RD as ordered by the physician. The Director of Nutrition and Culinary Services was unable to provide documented evidence the nutritional recommendations for enteral nutrition had been completed for Patient 8. The Director of Nutrition and Culinary Services stated the evaluation and note completed by the RD should have been in Patient 8's medical record. The Director of Nutrition and Culinary Services verified these findings.

Based on interview and record review, the hospital failed to ensure the nursing services had adequate licensed nurses to provide care for all the patients. This failure posed an increased risk for substandard health outcomes to the patients in the hospital.

Findings:

Review of the hospital's P&P titled Core: Plan for the Provision of Care dated 6/2020 showed the staffing ratio for the Telemetry Unit is one licensed nurse to care for four patients and the M/S Unit staffing ratio is one licensed nurse to care for five patients.

On 2/2/22 at 1530 hours, an interview and concurrent medical record review was conducted with the DON. The DON was asked about the staffing ratio for the licensed nurse and patients on 1/27/22.

Review of the 1/27/22 night shift (7 PM-7 AM) staffing record showed the HS had relieved two staff for break time as follows: the LVN who had five M/S patients from 1232 hours to 0102 hours and the telemetry technician/LVN who had 16 patients from 1237 hours to 0107 hours. The DON stated the HS relieved the two LVNs for their meal breaks overlapping their hours.

Based on observation, interview, and record review, the nursing staff failed to evaluate the care for three of 39 patients (Patients 8, 9, and 10) on an ongoing basis in accordance with accepted standards of nursing care as evidenced by:

1. Failed to ensure Patients 9 and 10's IV sites were evaluated and properly maintained.

2. Failed to ensure the licensed nurse documented the insertion of the rectal tube for Patient 8 and performed the assessment, reassessment, and evaluation of the patient's response.

These failures had the potential to adversely affect the patients outcomes.

Findings:

1.a. Review of the medical record for Patient 9 showed Patient 9 was admitted on 1/11/22, with diagnosis of Acute Respiratory Failure (ARF), sepsis, and severe hypertension (HTN).

On 2/1/22, during a tour of the M/S unit with the DON, Patient 9 was observed lying in bed with eyes closed. Patient 9 had a saline lock on the right hand that was covered with a 2 x 2 gauze, not labeled.

On 2/1/22 at 1420 hours, an interview was conducted with RN 4. When asked, RN 4 stated it was the responsibility of the night shift RN to change the saline lock dressing and ensure it was labeled.

On 2/2/22 at 0810 hours, an interview was conducted with the Education Coordinator. The Education Coordinator stated she was responsible for the staff training upon hire. The Education Coordinator stated due to the facility's patients population, poor vein access, and to prevent insertion of a central line, all patients would have a saline-lock placed upon admission. The Education Coordinator also stated there was no time frame as to how long the saline-lock would stay in place as long as it was patent and not infected per the intravenous society's protocol.

The Education Coordinator further stated the RN documented the date and their initial when inserting the saline-lock or change of the dressing. The saline-lock dressing was changed every three days and flushed with normal saline every shift. When asked, the Nurse Educator stated the facility did not have a protocol, and the insertion of an intravenous line was based on the nursing standards of practice.

Review of Patient 9's medical record was initiated on 2/2/22. Patient 9's medical record showed the patient was admitted to the facility with a left internal jugular central venous line. The patient's left jugular central venous line was discontinued on 1/31/22 at 1015 hours, and the tip was sent for culture. A saline-lock was inserted on the patient's right hand on 1/31/22 at 1620 hours.

On 2/1/22 at 1420 hours, the DON verified and acknowledged the findings.


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b. Review of the hospital's P&P titled Core: Short Peripheral IV site placement, Maintenance and dressing change, released date 9/2020 showed the transparent semi permeable membrane dressings will be changed every five to seven days and/or as soon as possible after discovery when the integrity of the dressing is compromised .... label the dressing with the current date or the date the dressing is due to be changed as directed by your facility.

Review of Patient 10's H&P examination showed the patient was admitted to the hospital on 12/24/21.

On 2/2/22, during a tour of the M/S unit with the DON, Patient 10 was observed lying in bed with eyes closed. Patient 10 was observed to have a peripheral IV line on the left forearm, with a transparent membrane dressing and a date of 1/19/22.

On 2/2/22, during the tour, the DON was asked if the date on the dressing was when the peripheral IV was placed or was to be changed. The DON stated it was when the peripheral IV was placed. The DON stated he was the Director of Nursing and provided the nursing staff with training and answered the staff's nursing questions. The DON was asked how long a peripheral IV could remain in a patient's arm before it needed to be changed. The DON stated 72 hours was the maximum timeframe and the peripheral IV needed to be rotated to a new site to avoid infiltration and skin damage. The DON stated he taught his staff to remove it after 72 hours. The DON stated it was the protocol he used as a standard of care. The DON stated the peripheral IV should have been removed. The DON also stated the dressing was to be changed every 72 hours when the peripheral IV was removed or sooner if needed.

On 2/22/22, during the tour, an interview was conducted with RN 5. RN 5 was asked how long a peripheral IV could remain in a patient's arm before it needed to be removed. RN 5 stated her practice was to remove the peripheral IV every 96 hours and a dressing change performed when the peripheral IV was removed and changed to another location. RN 5 also stated she assessed the peripheral IV daily for problems and flushed it for patency daily. RN 5 stated the expectation for the staff was to assess and flush the peripheral IV every shift and document it in the patient's medical record.

On 2/3/22 at 0833 hours, an interview was conducted with the Education Coordinator. The Education Coordinator stated she was responsible for training the newly hired staff. The Education Coordinator stated training for peripheral IVs was done by the assigned preceptor on the floor and by training with her on a mannequin. The Education Coordinator stated a dressing change was to be completed every three days. The Education Coordinator stated there was no time frame as to how long the peripheral IV could remain in place as long as it was assessed and flushed every shift to ensure it was working. The Education Coordinator stated the expectation of staff was for the peripheral IV to be assessed and flushed every shift and charted in the medical record.

Review of Patient 10's medical record was initiated on 2/3/22, with the DQM. Patient 10's medical record showed the patient had a left forearm peripheral IV placed on 1/19/22. A review of the medical record from 1/19/22 to 2/3/22, showed no documented evidence Patient 10's peripheral IV had been removed or changed, and the dressing had not been changed.

Review of Patient 10's peripheral IV assessment from 1/19/22-2/3/22 showed no documentation the peripheral IV semi-permeable dressing had been changed. The documents also showed the following:

- On 1/21, 1/22, and 1/24/22, no peripheral IV assessment or saline flush was documented as performed for the day shift.

- On 1/26 and 1/30/22, no peripheral IV assessment or saline flush was documented as performed for the night shift.

- There was no documented evidence of saline flush for the patient's peripheral IV on 1/21/22 at 2120 hours, 1/22/22 at 2059 hours, 1/23/22 at 1713 hours, 1/31/22 at 1352 hours, 1/31/22 at 1950 hours, 2/01/22 at 1235 hours.

An interview was conducted with the DQM. The DQM provided a copy of the hospital's policy for peripheral IV. The DQM stated he was unfamiliar with the hospital's policy for peripheral IV's. The DQM was asked to define a transparent semi-permeable membrane dressing. The DQM stated it was the type of dressing used on a peripheral IV. The DQM was asked, based on the hospital's policy, when a dressing change was to be completed for a peripheral IV with a transparent semi permeable membrane dressing. The DQM stated, after reading the hospital's policy, he was unsure based on the policy wording and could not provide time frame.

The DQM verified Patient 10's medical record did not show a dressing change for the peripheral IV had occurred anytime during the period from 1/19/22-2/3/22.

The DQM reviewed and verified the above days and shifts during which the peripheral IV was not assessed or saline flushed.


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2.a. Review of the hospital's P&P titled Core Interdisciplinary Assessment and Reassessment released date 6/21 showed the following:

* Purpose was to establish guidelines to assure the care provided to each patient is based on an assessment of the patient's relevant physical, psychological, and social needs.

* The policy was to ensure all patients will have initial assessment and appropriated follow up assessments based upon identified specific needs, including physical and psychological needs. The goal of the assessment or reassessment process is to provide interdisciplinary approach for the assessment and ongoing reassessment of individual patient care needs and for planning and implementing specific interventions.

* Procedure: Patients are re-evaluated by licensed nurse (RN, LVN) at a minimum every 12 hours shift based on level of care and patient care needs. A LVN may gather clinical data and clinical observations in between the RN assessments. The clinical data are reported to the RN for evaluation and determination of needed change in the patient care plan. Patient reassessment is based on but not limited to evaluate response to care, treatment, and services. All nursing assessment(s) or reassessments are recorded in the patient medical record by a licensed nurse.

Review of the hospital's P&P titled Core for Incontinence Diarrhea Management released date 6/19 showed for intra-anal management system, assess the patient to assure the intra-anal management is not contraindicated per policy. For the management of the device, observe the device frequently for obstruction from kinks, solid fecal particles, external pressure, check the balloon for over inflation, and document the output every shift.

On 2/2/22 at 0832 hours, interview and concurrent medical record review for Patient 8 was conducted with the Director of Quality.

Review of the physician's telephone order dated 11/25/21 at 1258 hours, showed to insert a rectal tube. On 11/25/21 at 1536 hours, showed the RN acknowledged the physician's telephone order.

Review of the RN Notes for the GI Assessment on 11/25/21 at 1536 hours, did not show documented evidence the rectal tube was in place or inserted. However, review of the CNA's note observation dated 11/25/21 at 1243 hours, showed the bowel elimination was through the rectal tube. The Director of Quality was asked about the hospital's policy for documentation when inserting a rectal tube. The Director of Quality stated the hospital used the Lippincott for reference.

Review of the Lippincott Procedures for Rectal Tube Insertion and Removal revised 11/19/21, showed to record the date and time the rectal tube was inserted; record the amount, color, and consistency of any evacuated matter; describe the patient's abdomen - hard, distended, soft, or drumlike on percussion; note the patient's bowel sounds before and after rectal tube insertion and patient's tolerance of the procedure; and document teaching provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow up teaching.

On 2/2/22 at 1110 hours, an interview and concurrent medical record review was conducted with RN 3 and LVN 1. LVN 1 stated Patient 8 had a large Stage 4 PI at the sacral area and was having loose stools. LVN 1 stated she obtained the rectal tube order from the wound doctor to keep the liquid stools away from the Stage 4 sacral PI. When asked if she inserted the rectal tube, LVN 1 stated no, the primary RN inserted the rectal tube.

On 2/3/22 at 1054 hours, an interview and concurrent medical record review was conducted with CNA 1, the House Supervisor, and DON. CNA 1 was asked about the observation documented dated 11/25/21 at 1243 hours, for bowel elimination through the rectal tube. CNA 1 stated she saw the rectal tube at the time and had to clean the patient with the nurse. When asked if she helped the nurse to insert the rectal tube, CNA 1 stated she could not remember if she helped the nurse inserting the rectal tube. The CNA was asked about the intake and output recorded on 11/25/21 at 1921 hours, if there was blood for the color brown liquid stools. The CNA stated if there was anything found in the stool, they would document the color red, not blood. When the DON was asked to show documented evidence who inserted the rectal tube and when it was done, the DON could not find such documentation.

b. On 2/2/22 at 1110 hours, an interview was conducted with LVN 1 and RN 3. LVN 1 and RN 3 were asked how often the nurses should assess or reassess the patient with the rectal tube. LVN 1 stated the nurses should assess the patient with the rectal tube every shift.

On 2/3/22 at 1054 hours, interview and concurrent medical record review was conducted with the DON. The DON was asked to show where in the medical record that the nurses would document assessment, reassessment, and response of Patient 8 with the rectal tube.

Review of the Nurses Notes for GI Assessments from 11/25/21, the 7 AM-7 PM shift, to 11/29/21, the 7 PM to 7 AM shift, did not show documented evidence of the assessment, reassessment, and response of Patient 8 with the rectal tube.

Review of the licensed nurses Assessment of Lines, Tubes, and Drains from 11/25/21, the 7 AM to 7 PM shift, to 11/30/21, the 7 AM-7 PM shift did not show documented evidence of the assessment and reassessment of Patient 8 with the rectal tube.

The DON verified the above findings.

Based on interview and medical record review, the hospital failed to ensure a care plan was developed for one of 13 patients (Patient 8) to address the use of the rectal tube. This failure posed an increased risk of substandard health outcomes to the patient.

Findings:

Review of the hospital's P&P titled Core - Plan for the Provision of Patient Care dated 6/2020 showed the following:

* Standard of Patient Care: Patient-focused standards outline the elements for safe, effective, and efficient delivery of patient care. The standards provide a guide for patient care. Each patient has a plan of care. An interdisciplinary approach is utilized, as appropriate to promote continuity of care.

Review of the Core Interdisciplinary Assessment and Re-Assessment released date 6/21 showed the licensed staff nurse(s) RN or LVN may update the patient's needs or problems and plan of care based on results of clinical findings gathered by the licensed nurse.

On 2/2/22 at 0832 hours, an interview and concurrent medical record review was conducted with the Director of Quality. The Director of Quality was asked about the Care Plan for Patient 8 in regards to the use of the rectal tube ordered for the patient.

Review of the Care Plan for Patient 8 did not show document evidence a care plan was developed to address the use of the rectal tube.

The Director of Quality verified the findings.

Based on interview and record review, the hospital failed to ensure the licensed nurses' competency was validated as evidenced by:

- The licensed nurses' competency did not show validation for the rectal tube insertion and maintenance.

- The Education Coordinator's Annual Skills Competency was not validated for 2021.

These failures had the potential for increased risk of substandard health outcomes to the patients in the hospital
.

Findings:

Review of the hospital's P&P titled Core-Incontinence Diarrhea Management released date 6/19 showed for the intra-anal management system, the clinicians should have competencies on file for the maintenance and insertion of the system.

Review of the hospital's P&P titled Core-Plan for the Provision of Patient Care dated 6/2020 showed in part, for the Staff Education, the hospital provides ongoing education, inservice education, and quality improvement education. Education programs are provided to maintain staff competency and enrich staff knowledge for enhancing quality patient care. Educational programs are based on the organization's mission, the case mix of patient served, the technology utilized, the identified learning needs of the staff (on an individual, departmental, and organizational bases), the required and personal competency needs of the staff, learning needs related to expertise development, and the identified issues that influence staff recruitment and retention, and issue identified in the Corporate Compliance agreement.

On 2/3/22 at 1315 hours, interview and concurrent record review was conducted with the Education Coordinator. The Education Coordinator was asked if the licensed nurses were required to have validation of competency for the insertion and maintenance of the rectal tube. The Education Coordinator stated the hospital had a new rectal tube product and the information was given to the licensed nurses. However, the Education Coordinator could not show documented evidence the licensed nurses were validated for the competency of rectal tube insertion and maintenance. The Education Coordinator was asked for her annual skills competency validation. The Education Coordinator could not show documented evidence for the annual skills competency validation. When asked if she currently performed patient care, the Education Coordinator stated she performed patient care when needed and she just recently worked to provide patient care.