HospitalInspections.org

Based on record review and interview the facility failed to assess patient care needs, monitor, provide interventions, and evaluate the care for all patients in 5 of 10 medical records reviewed (Patient (Pt) #1, 2, 3, 4, 6), in a total sample of 10 records reviewed; failed to evaluate and revise the care plan with appropriate interventions and goals to reflect patient's care needs in 3 of 10 medical records reviewed (Patient (Pt) #6, 7, 9), in a total sample of 10 medical records reviewed; failed to ensure that nursing assignments are based on the competency and qualifications of the nursing staff and the patient care needs in 2 of 2 units reviewed (Rehabilitation floor 2 and 3), in a total of 2 units reviewed; and failed to ensure all nursing staff receive the proper training, orientation, and evaluation of competencies/skills to ensure nursing staff are competent to perform their job duties, in 6 of 8 staff interviews (Chief Nursing Officer (CNO), Chief Executive Officer (CEO), Registered Nurse (RN) F, Licensed Practical Nurse (LPN) G, LPN H, House Supervisor J), in a total sample of 8 interviews.

Findings include:

Facility staff failed to assess, provide interventions and re-assess patients after falls including falls with injury; failed to complete safety rounding per policy for patients at risk for falls; failed to assess, provide interventions for and treat patients with skin integrity issues including development of hospital acquired stage 4 pressure ulcer; failed to assess and treat severe pain; and failed to complete and document assessments each shift to monitor for changes of condition. See tag A-0395

Facility staff failed to evaluate and revise the care plan with appropriate interventions and goals to reflect patient's care needs. See tag A-0396

Facility staff failed to ensure that nursing assignments are based on the competency and qualifications of the nursing staff and the patient care needs. See tag A-0397

Facility staff failed to ensure all nursing staff receive the proper training, orientation, and evaluation of competencies/skills to ensure nursing staff are competent to perform their job duties. See Tag A-0398

Based on record review and interview the facility failed to trend, analyze the root cause, and implement an effective action plan to mitigate falls in 5 of 5 adverse events reviewed of patients who fell (Patient (Pt) #1, 6, 7, 8, 9) in a total sample of 5 adverse events reviewed.

Findings include:

Review of policy and procedure titled, "Quality Assurance and Performance Improvement Plan (QAPI)" no date, revealed the following:
- "The Quality Council will meet quarterly."
- "...Staff should complete an incident form by the end of their shift. The incident report will be reviewed by department leadership within about 1 day and by Quality leadership within about 1 business day...the designated leader will ensure appropriate investigation is conducted, action is taken, and documentation on paper or in the electronic incident reporting system..."
- "Data on performance measures will be analyzed to: a. Monitor the effectiveness and safety of services and quality of care. b. Identify opportunities for improvement and changes that will lead to improvement."
- "Performance improvement activities shall -at a minimum- track medical errors and adverse patient events, analyze their causes, and implement preventative actions and mechanisms that include feedback and learning throughout the organization."

Review of policy and procedure titled, "Incident Reports" no date, revealed the following:
-"All incident must be acted upon within 24 hours of its occurrence."
-"Incident reports will be routed to the Director of Quality."
-"The Director of Quality will track and trend incident reports on the Incident Report Log. Trending of incidents will be reported to Quality Council."

Review of Pt #1's Incident Report revealed the following fall:
-Fall on 01/31/2023 at 11:45 PM: "Patient transferred on his own and fell on the floor at end of bed. Fall was unwitnessed and patient was confused sent to ER (emergency room) for evaluation." "Potential Injury" is documented next to "Severity" on the incident report form. "Follow Up/Resolution (CNO) (Chief Nursing Officer)" documented on the incident report form is blank, "Follow Up/Resolution (DQM) (Director of Quality Management)" documented on the incident report form revealed "follow up pending RCA (root cause analysis) process". Under the category "Reviewed", revealed the documentation, "CNO reviewed: N (no)". No additional follow up/resolution was documented by the DQM.

Review of Pt #6's Incident Reports revealed the following falls:
-Fall on 06/25/2023 at 10:15 PM: Pt #6 "...fell going into the the bathroom and sustained a laceration to the back of his head..." "Transferred to higher level of care" box is checked. "Follow Up/Resolution (CNO) (Chief Nursing Officer)" documented on the incident report form is blank, "Follow Up/Resolution (DQM) (Director of Quality Management)" documented on the incident report form is blank. Under the category "Reviewed", revealed documentation "CNO reviewed: N (no)" and "DQM reviewed: N (no)".
-Fall on 06/26/2023 at 4:45 PM: Pt #6 fell in the bathroom "...hit head against bathroom wall and toilet paper holder." "Required Medical Intervention" is documented next to "Severity". "Follow Up/Resolution (CNO) (Chief Nursing Officer)" documented on the incident report form is blank, "Follow Up/Resolution (DQM) (Director of Quality Management)" documented on the incident report form is blank. Under the category "Reviewed", revealed documentation "CNO reviewed: N (no)" and "DQM reviewed: N (no)".
-Fall on 07/07/2023 at 10:45 AM: Pt #6 "fell when he got up on his own patient hit head. Patient sent to ED (Emergency Department) for head CT (computed tomography)." "Follow Up/Resolution (CNO) (Chief Nursing Officer)" documented on the incident report form is blank, "Follow Up/Resolution (DQM) (Director of Quality Management)" documented on the incident report form is blank. Under the category "Reviewed", revealed documentation "CNO reviewed: N (no)" and "DQM reviewed: N (no)".

Review of Pt #7's Incident Reports revealed the following falls:
-Fall on 07/02/2023 at 5:10 PM: Pt #7 fell in the bathroom "...attempted to stand and pull up pants after toileting. Patient had been placed on toilet by CNA (certified nursing assistant) but did not initiate call light until she fell on floor." "Follow Up/Resolution (CNO) (Chief Nursing Officer)" documented on the incident report form is blank, "Follow Up/Resolution (DQM) (Director of Quality Management)" documented on the incident report form is blank. Under the category "Reviewed", revealed documentation "CNO reviewed: N (no)" and "DQM reviewed: N (no)".
-Fall on 07/05/2023 at 4:15 AM: "CNA was in room assisting patient out of bed to the bathroom, clinician turned to get walker and patient fell forward hitting her head against the wall..." "Follow Up/Resolution (CNO) (Chief Nursing Officer)" documented on the incident report form is blank, "Follow Up/Resolution (DQM) (Director of Quality Management)" documented on the incident report form is blank. Under the category "Reviewed", revealed documentation "CNO reviewed: N (no)" and "DQM reviewed: N (no)".

Review of Pt #8's Incident Report revealed the following fall:
-Fall on 07/12/2023 at 9:15 PM: "Patient attempted to self transfer from bed to wheelchair without calling for help and fell on his buttocks at bedside..." "Prior to fall, patient was yelling and swearing at staff. Patient complained staff didn't address his needs quickly." "Follow Up/Resolution (CNO) (Chief Nursing Officer)" documented on the incident report form is blank, "Follow Up/Resolution (DQM) (Director of Quality Management)" documented on the incident report form is blank. Under the category "Reviewed", revealed documentation "CNO reviewed: N (no)" and "DQM reviewed: N (no)".

Review of Pt #9's Incident Reports revealed the following falls:
-05/16/2023 at 1:22 PM: "Writer responded to staff assist light, entered room to find patient sitting on her bottom...she states she wanted to get into bed but slid out of her w/c (wheel chair) when she tried to stand." "Follow Up/Resolution (CNO) (Chief Nursing Officer)" documented on the incident report form is blank, "Follow Up/Resolution (DQM) (Director of Quality Management)" documented on the incident report form is blank. Under the category "Reviewed", revealed documentation "CNO reviewed: N (no)" and "DQM reviewed: N (no)".
-05/18/2023 at 6:00 PM: "RN (registered nurse) went to room, found patient sitting on floor next to bed" "Patient was getting out of bed trying to reach for call light..." "Follow Up/Resolution (CNO) (Chief Nursing Officer)" documented on the incident report form is blank, "Follow Up/Resolution (DQM) (Director of Quality Management)" documented on the incident report form is blank. Under the category "Reviewed", revealed documentation "CNO reviewed: N (no)" and "DQM reviewed: N (no)".

Review of the "Incidents" log revealed from 02/01/2023 to 08/01/2023 there were 56 patient falls reported; 5 falls in February, 15 falls in March, 11 falls in April, 5 falls in May, 8 falls in June, and 12 falls in July.

Per review of the most recent QAPI meeting minutes dated 02/08/2023, there was no documentation of an action plan to mitigate fall risk.

Per interview with DQM B and CNO C on 08/04/2023 beginning at 4:30 PM, CNO C stated that the CNO and DQM should be following up on incident reports and evidence of this should be documented on the Incident Report under the follow up/resolution documentation on the incident report form. Per DQM B, she/he was unable to find evidence of a QAPI meetings occurring since the last meeting on 02/08/2023 (6 months ago). DQM B confirmed there was no evidence of the facility analyzing and trending the root causes and developing an action plan to address falls.

Based on record review and interview the nursing staff failed to: assess, provide interventions and re-assess patients after falls for 4 of 10 patients at high risk for falls and/or who fell in the facility (Patients #1, 2, 4 and 6) including multiple falls with injury for 1 of 10 patients reviewed (Patient #6); complete safety rounding per policy for 1 of 10 patients (Patient #6) at risk for falls; assess, provide interventions for and treat 3 of 10 patients with skin integrity issues (Patients #3, 4 and 6) with development of stage 4 pressure ulcer for 1 of 10 patients reviewed (Patient #6); assess and treat severe pain for 2 of 10 patients (Patient #1 and 4); and document assessments each shift to monitor for changes of condition for 3 of 10 patients (patients #1 and 3 and 4), in a total sample of 10 records reviewed.

Findings Include:

Review of policy and procedure titled, "Patient Falls" no date, revealed the following:

Standard fall Precautions Interventions:
Morse Fall Risk Score 0-25: Any patient assessed/reassessed or pre-determined to be at risk of fall shall have a basic set of interventions, including but not limited to:
-Beds will be maintained in the lowest position, with the top side rails maintained in the raised position
-Call light within reach
-Purposeful rounding per protocol
-Education to patient and family on standard fall prevention.

Medium Fall Risk Interventions:
Morse Fall Score 25-44: Any patient assessed/reassessed or determined to be a medium risk by interdisciplinary team shall have all Standard Precautions plus:
-Fall risk placed as precaution in the EMR (electronic medical record).
-Staff to stay with patient when assisted to the bathroom.

High Fall Risk:
Morse Fall Risk 45 or more: All standard and medium level interventions plus additional interventions may be deployed to further prevent a fall including, but not limited to the following:
-Bed alarm and/or chair alarm
-Consider the need for safety surveillance
-Consider increasing the frequency of observation
-Moving Pt closer to the nurse's station when possible
-Any additional measures identified by the interdisciplinary team that may benefit the patient

Per Patient Falls policy:
-"Patients assessed/reassessed as a risk for fall should have assessment documented in the medical record, and the medical record should reflect the interventions deployed to prevent a fall."
If a fall occurs:
-"Assess the patient for injury prior to moving."
-"Notify physician and family member."
-"Document the physical assessment and events in the chart and complete the post fall assessment in the EMR."
-"Conduct post fall assessment or consider debrief with team members to determine immediate/root cause of the fall within 15 minutes of the fall and plan further intervention."
-"An incident report should be completed and turned into the quality department."

Review of policy and procedure titled, "Patient Assessment & Care Planning" no date, revealed the following:
-"Patients shall be reassessed at minimum each shift per day within the general areas of: Review of physical and psychosocial status; pain reassessments and response to interventions; the patient's response to any previous care, treatment or interventions that may have been provided; need for further care or need for additional consult or referrals; a significant change in the patient's condition or diagnosis."

Review of the policy and procedure titled, "Wound and Pressure Injury Assessment and Care Guidelines" no date, revealed the following, including but not limited to:
Documentation for any clinical staff:
-Assessment of the area of the wound.
-Assessment and description of the wound to include measurements.
-Document any dressing changes and ordered medications used.
-Braden scale score on admission and daily to monitor for potential risk for skin breakdown with appropriate mitigation strategies such as specialty mattress, off loading techniques, turning schedule, and moisture control.

Review of policy and procedure titled, "Pain Management" no date, revealed the following:
-"Assess the patient's response to care, treatment, and service implemented to address pain."
-"Inpatients will be reassessed for the presence of pain no less frequently than the minimum requirements for taking of vital signs (5th vital sign) in the care setting."
-"Patients will receive education on pain management, treatment options, and safe use of opioid and non opioid medications when prescribed. The education will be documented in the medical record."
-"If a PRN (as needed) treatment intervention for pain is provided, the response to that intervention should be assessed to include progress toward pain goal and side effects...The effect of the pain intervention is to be documented in the medical record."

Patient #6:

Review of Pt #6's medical record revealed Pt #6 was a 85 year old admitted to the Rehab facility on 06/17/2023 at 5:00 PM and discharged home on 07/13/2023 at 11:34 AM.

Review of Pt #6's General H&P dated 06/17/2023 at 9:49 PM revealed a "Rehab Diagnosis" of Acute left frontal stroke. Per H&P, "MRI (magnetic resonance imaging) did show advanced chronic ischemic changes likely hinting toward probable vascular dementia diagnosis...He has slowly improved in the hospital but still very weak and requires acute rehab in the setting of stroke."

Review of Pt #6's Plan Of Care (POC) dated 06/18/2023 revealed Pt #6's "Problem" was "Alteration in Skin Integrity related to redness to coccyx as evidenced by bruising, redness." The "Goal" was "Skin to remain intact without evidence of breakdown, rash, infection, or pruritis (itching)...Target Dt (date): 08/05/2023." The "Interventions" documented revealed, "Change (Pt #6's) position in bed every 2 hours and PRN (as needed)".

Per review of Pt #6's Nursing Shift Assessments, the Skin Assessment documentation revealed Pt #6 had a "spot on R (right) toe" measuring 3 centimeters (cm) x 1 cm, and "redness on coccyx"; on the shift assessments completed on 06/24/2023 at 10:21 AM; 06/24/2023 at 10:00 PM; 06/25/2023 at 9:17 AM; 06/25/2023 at 7:45 PM, 06/26/2023 at 11:41 AM; and 06/27/2023 at 5:46 AM. There was no documentation of a detailed assessment of these skin concerns and specific interventions implemented, including but not limited to, position changes every 2 hours as per Plan of Care.

Review of Pt #6's Nursing Shift Assessment revealed that there was no documentation addressing "redness on coccyx" between 06/27/2023 at 5:46 AM and 07/04/2023 at 8:13 PM (7 days later) at which time documentation on 07/04/2023 revealed, "3 open areas to buttocks-applying barrier cream."

Review of Pt #6's Wound Treatment order dated 07/04/2023 at 8:10 PM, revealed, "Barrier Cream every shift...apply barrier cream to patient's buttocks every shift and as need during toileting." Review of the "Administration History" revealed this was not documented as completed for nursing shifts on 07/4/2023, 07/05/2023, 07/06/2023, 07/07/2023, and 07/08/2023.

Review of Pt #6's Nursing Shift Assessments from 6/27/2023 through 7/8/2023 revealed there was no documentation of a detailed wound assessments for Pt #1's "spot on right toe."

Review of Pt #6's Nursing Shift Assessment dated 06/29/2023 at 8:35 PM revealed, "New wound (open pressure ulcer) to R lateral ankle..."

Review of Pt #6's Wound Care Treatment order for the right ankle, dated 07/01/2023 at 10:39 AM, revealed to "...Apply triple antibiotic ointment TID (three times daily); avoid pressure to area..."

Per review of Pt #6's nursing documentation on the "Administration Record" revealed on 07/01/2023 to 07/05/2023 (4 days), the ankle Wound Care interventions were documented as completed twice a day (BID) and not 3 times per day (TID) as per wound care order.

Review of Pt #6's Nursing Shift Assessments from 06/29/2023 through 07/05/2023 revealed nursing staff were not documenting a detailed wound assessment of Pt #6's right ankle pressure ulcer.

Review of Pt #6's Wound Care Consult notes dated 07/12/2023 at 8:07 PM revealed, that Pt #6 had a Stage 4 (full thickness ulcer with the involvement of the muscle or bone) wound of the right ankle, a diabetic wound of the left toe, and an unstageable (due to necrosis) sacrum (coccyx) full thickness wound. Per review of Pt #6's medical record, Pt #6 did not have these wounds on admission.

Review of Pt #6's Nursing Shift Assessment and progress notes from 06/25/2023 through 07/8/2023 revealed that there was no documented evidence of nursing staff changing or updating interventions to address Pt #6's actual skin impairment.

Review of Pt #6's Incident Report revealed on 06/25/2023 at 10:15 PM revealed, "Patient got out of bed to go to bathroom without calling for help or using walker; he fell going into the bathroom and sustained a laceration to the back of his head..."

Review of Pt #6's Post Fall Assessment signed by the nurse on 06/25/2023 at 11:19 PM revealed, "Bed alarm not in use...", per the post fall assessment, "No" was documented for "Was the patient wearing appropriate footwear."

Review of Pt #6's Nursing Shift Assessment dated 06/25/2023 at 7:45 PM (before the fall), the nurse documented safety measures and fall precautions including "Non-skid foot wear" and "Bed alarm"; this documentation was inconsistent with the post falls assessment.

Review of Pt #6's Nurse progress notes dated 06/25/2023 at 11:20 PM revealed, "Pt transported to (acute care hospital) per EMS (Emergency Medical Service) transport at 10:49 PM.

Review of Pt #6's medical record revealed there was no documentation of nursing staff performing a physical assessment including a neurological assessment and vital signs check post fall, before Pt #6 was transported via EMS to the acute care hospital.

Review of Pt #6's medical record revealed that Pt #6 returned back to the Rehab hospital on 06/26/2023 at 6:50 AM, nursing staff did not document performing a physical assessment when Pt #6 returned to the Rehab hospital from the ER. Per review, the nursing assessment was documented as completed at 11:41 AM (4 hours and 51 minutes later).

Review of Pt #6's Nursing Shift Assessments dated 06/26/2023 at 11:41 AM and 06/27/2023 at 5:46 AM, revealed nursing staff did not document addressing Pt #6's laceration to the back of the head until 06/27/2023 at 11:36 AM (more than 16 hours later), at which time the nursing documentation revealed, "Patient has 3 stitches to the back of head." No interventions were documented, until wound care treatment orders were entered on 07/02/2023 at 4:13 PM (6 days after injury occurred).

Review of Pt #6's Post Fall Assessment revealed Pt #1 had a fall on 06/26/2023 at 4:40 PM (fall #2). Per Post Fall Assessment, "Patient hit head against bathroom wall and toilet paper holder." Per documentation, "Pt is forgetful, pt does not follow his limitations plan, pt is impulsive."

Review of Pt #6's Incident Report dated 07/07/2023 at 10:45 AM, revealed, "Patient Fell when he got up on his own patient hit head. Patient sent to ED for head CT (computed tomography)." (Fall #3)

Per review of Pt #6's Post Fall Assessment signed by the nurse on 07/07/2023 at 12:05 PM revealed, "Patient reported he hit his head-bleeding observed from part of previous head laceration & increased swelling in region of laceration."

Per review of Pt #6's nursing progress note dated 07/07/2023 at 4:36 PM, patient returned back to Rehab hospital from the ER at 4:05 PM. Per review of Pt #6's medical record, there was no documentation of staff reevaluating the effectiveness of Pt #6's falls interventions, and updating/revising the interventions to mitigate Pt #6's fall risk due to impulsivity and forgetfulness..

Review of Pt #6's nursing progress note dated 07/07/2023 5:30 PM (after return from ER) revealed, "Patient's chair alarm went off & per (CNA)...when she got to patient's room she reported the patient was walking towards the window using the bedside table as a walker in order to shut the blinds...Writer also contacted supervisor to recommend an order for a sitter is requested because of patient's forgetfulness & impulsivity."

Review of Pt #6's medical record showed no documentation of a sitter being ordered and implemented during Pt #6's hospital stay.

Per interview with DQM B on 08/04/2023 at 3:10 PM, DQM B stated that staff should be performing hourly rounding on all patients to ensure patient safety and fall prevention; Per DQM B patient rounding should be documented in the medical record. When asked if staff document hourly rounding in real time, DQM B responded, "I'm not sure." DQM B stated that nursing staff typically document there assessments and interventions at the end of the shift, and not necessarily when it was done.

Review of Pt #6's History of Patient Rounding on 06/25/2023 revealed the following:
-The 8:30 PM "Safety Check" was documented as "Yes" at 7:19 PM, (1 hour and 11 minutes before the check).
-The 9:30 PM "Safety Check" was documented as "Yes" at 7:19 PM, (2 hours and 11 minutes before the check).

Review of Pt #6's History of Patient Rounding on 06/26/2023 revealed the following:
-The 5:00 AM "Safety Check" was documented as "Yes" at 4:13 AM, (47 minutes before the check).
-The 6:00 AM "Safety Check" was documented as "Yes" at 4:13 AM, (1 hours and 47 minutes before the check).
-The 7:00 AM "Safety Check" was documented as "Yes" at 4:13 AM, (2 hours and 47 minutes before the check).

Review of Pt #6's History of Patient Rounding on 06/27/2023 revealed the following:
-The 1:00 PM "Safety Check" was documented as "Yes" at 11:38 AM, (1 hour and 22 minutes before the check).
-The 2:00 PM "Safety Check" was documented as "Yes" at 11:38 AM, (2 hour and 22 minutes before the check).
-The 3:00 PM "Safety Check" was documented as "Yes" at 11:38 AM, (3 hour and 22 minutes before the check).
-The 4:00 PM "Safety Check" was documented as "Yes" at 11:38 AM, (4 hour and 22 minutes before the check).
-The 5:00 PM "Safety Check" was documented as "Yes" at 11:38 AM, (5 hour and 22 minutes before the check).
-The 6:00 PM "Safety Check" was documented as "Yes" at 11:38 AM, (6 hour and 22 minutes before the check).

Per review of Pt #6's patient rounding, there was no evidence that staff were completing hourly rounding at the scheduled time. Per review, nursing staff were documenting that they completed Safety Checks before the patient rounding occurred.

Patient #1:

Review of Pt #1's medical record revealed Pt #1 was admitted to the Rehab (Rehabilitation) facility on 01/30/2023 at 6:45 PM and was discharged on 02/02/2023 at 4:43 AM, due to death.

Review of Pt #1's Rehab History and Physical (H&P) dated 01/31/2023 at 4:53 PM revealed Pt #1 is a "....69 year old who presented to the hospital (acute care) on 01/23/2023 after he fell and complained of left hip pain....CTA (computed tomography angiography) chest showed moderate to severe emphysema...(Pt #1's) hip xray showed angulated impacted left femur fracture. Patient subsequently underwent left hip arthroplasty, and was treated for acute hypoxic respiratory failure...Patient now demonstrates limited ability to function on {sic} presents for acute inpatient rehabilitation."

Review of Pt #1's General H&P physical exam dated 01/31/2023 at 3:24 PM (before fall) revealed that Pt #1 was "Alert and oriented x 3 (person, place, and time)."

Review of Pt #1's Nursing Shift Assessment completed on 01/31/2023 at 10:56 PM (before fall), revealed a Neurological nursing assessment with boxes checked indicating that Pt #1 was "Alert", "Oriented to Person", "Oriented to Place", and "Oriented to Time."

Review of Pt #1's Incident Report dated 01/31/2023 at 11:45 PM revealed, "Patient transferred on his own and fell on the floor at end of bed, Fall was unwitnessed and patient was confused sent to ER (emergency room) for evaluation."

Per Review of Pt #1's medical records, there was no documented evidence of nursing staff performing a physical/neurological assessment of Pt #1 post fall and before Pt #1 was transferred to the ER as per policy. Pt #1 arrived back to the Rehab hospital from the ER on 02/01/2023 at 4:45 AM (5 hours later), and the nurse did not document a physical assessment until 11:28 AM (6 hours and 43 minutes later).

Review of Pt #1's Nursing Shift Assessment completed on 02/01/2023 at 11:28 AM (after fall), revealed a Neurological nursing assessment with boxes checked indicating that Pt #1 was "Alert", but only "Oriented to Person" and "Oriented to Place." The nursing assessment revealed that Pt #1's, "Confused at times. Patient can follow directions with assistance" (this was a change from previous nursing assessment).

Review of Occupational Therapy (OT) progress note dated 02/01/2023 at 11:30 AM revealed that "Patient had fall overnight and appears/reports more confusion and pain." Per OT progress note, "...Limited by tremors, pain, and demonstrated decline in cognition/awareness since fall."

Review of Nurse Practitioner Progress Notes dated 02/01/2023 at 12:59 PM (after fall) revealed, "Patient is very confused this morning. Reported he wants to go to his own room in his own bed. Did have a fall last night was sent out to the ER for evaluation...If patient remains confused will get UA (urinalysis) and lab."

Review of Pt #1's Nursing Shift Assessment completed on 02/01/2023 at 11:07 PM (after fall) revealed a Neurological nursing assessment with boxes checked indicating that Pt #1 was "Alert", but only "Oriented to Person". The nursing documentation is repeated from the previous assessment that Pt #1's, "Confused at times. Patient can follow directions with assistance."

Review of Nursing progress note dated 02/02/2023 at 4:43 AM revealed, "Went into patient room to perform a straight cath for a urinalysis, patient was unresponsive and not breathing..."

Review of Pt #1's nursing assessments and progress notes revealed no evidence of nursing staff performing more frequent neuro assessments to monitor Pt #1's mental status changes post fall.

Review of Pt #1's medical record revealed there was no documentation of nursing staff informing the provider of Pt #1's continued change in condition.

Per interview with Interim Director of Quality Management (DQM) B on 08/03/2023 beginning at 4:06 PM, the facility does not have a standard nursing protocol to monitor and assess patients post falls. Per DQM, the provider should order neuro checks if there is a concern for hitting head or an unwitnessed fall. DQM B confirmed there are no specific guidelines or a policy that guides staff on the requirements for monitoring patients post fall.

Per interview with Medical Director (MD) K on 08/04/2023 at 1:20 PM, MD K stated that an order is not required for the nursing staff to complete neuro checks when there is an unwitnessed fall or a head injury. MD K stated that he/she expects nursing staff to use "critical thinking" skills when it comes to completing additional assessments post fall. MD K stated that nursing staff should be performing a physical assessment after a patient falls and when patients return from the ER.

Review of Pt #1 Medication Administration Record revealed the following pain medication administrations:
-On 01/31/2023 at 12:17 AM Pt #1 was given Oxycodone 5 milligrams (pain medication) for left hip pain; Pt #1's pain assessment revealed a pain score of 10 out of 10 (severe pain). Nursing staff did not reassess Pt #1's pain until 2:57 AM (2 hours and 40 minutes later). The nurse documented that the intervention was "effective" but a pain scale of "10" was documented.
-On 01/31/2023 at 6:59 AM Pt #1 was given Oxycodone 5 milligrams (pain medication) for left hip pain; Pt #1's pain assessment revealed a pain score of 9 out of 10 (severe pain). Nursing staff did not reassess Pt #1's pain until 9:54 AM (2 hours and 53 minutes later). The nurse documented that the intervention was "effective" but a pain scale of "9" was documented.
-On 01/31/2023 at 3:51 PM Pt #1 was given Oxycodone 5 milligrams (pain medication) for left hip pain; Pt #1's pain assessment revealed a pain score of 8 out of 10 (severe pain). Nursing staff did not reassess Pt #1's pain until 6:24 PM (2 hours and 33 minutes later). The nurse documented that the intervention was "effective" but a pain scale of "8" was documented.

Per interview with DQM B on 08/03/2023 at 4:06 PM, DQM B stated that pain reassessments should be performed 30 minutes to a hour after oral pain medication is administered.

Review of the Pain Management policy does not have a specific timeline for pain reassessments after providing a medication intervention.

Patient #2:

Review of Pt #2's medical record revealed Pt #2 was admitted to the Rehab hospital on 04/21/2023 at 5:45 PM and discharged AMA (against medical advice) on 04/23/2023 at 12:08 PM.

Review of Pt #2's General H&P dated 04/22/2023 at 9:45 AM revealed Pt #2 was a 73 years old admitted for weakness and Parkinson disease exacerbation.

Review of Pt #2's Nursing Shift Assessment completed on 04/21/2023 at 6:40 PM revealed the following:
-Musculoskeletal assessment was documented as "WNL (within normal limits) Except" and a box was checked indicating "Weakness"; there was no evidence of a nursing assessment identifying what areas of Pt #2's body showed weakness, to ensure patient safety when transferring and ambulating.
-Review of Pt #2's Morse Falls Screening revealed a score of 65 (high fall risk). There are no boxes checked under the "Nursing Education Record" indicating that Pt #2 and family received education on "Safety" including Fall precautions.

Review of Pt #2's Nursing Shift Assessment completed on 04/22/2023 at 5:55 AM revealed the following:
-Review of Pt #2's Morse Falls Screening revealed a score of 65 (high fall risk); No interventions were documented for Medium Fall Risk interventions (25-44) and High Fall Risk Interventions (>45).
-There is no documentation that the nurse completed a pain assessment.
-There is no documentation that the nurse completed an EENT (ear, eyes, nose, throat) assessment.
-There is no documentation that the nurse completed a Musculoskeletal assessment.
-There is no documentation that the nurse completed a Genitourinary assessment.
-There is no documentation that the nurse completed a Gastrointestinal assessment
-There is no documentation that the nurse completed, "Safety" education in the "Nursing Education Record."

Review of Pt #2's Incident Report dated 04/22/2023 at 6:30 PM revealed, "Bed alarm sounding. Patient found lying next to bed. Wife stated that he 'slid out of bed' attempting to self transfer with no assistance and no equipment..."

Per interview with DQM B while reviewing medical records on 08/04/2023 at 9:30 AM, DQM B stated that the nursing staff should perform a physical assessment every shift to include all the body systems and documenting findings on the nursing shift assessment form. DQM B stated that at a minimum nursing staff should be educating patients and family on safety and falls precautions and checking the "Safety" box in the "Nursing Education Record."

Patient #3:

Review of Pt #3's medical record revealed Pt #3 was admitted to the Rehab hospital on 05/07/2023 at 12:38 PM and discharged (acute care transfer) on 05/09/2023 at 12:33 PM.

Review of Pt #3 General H&P dated 05/07/2023 at 5:24 PM revealed that Pt #3 is a 45 year old with a past medical history of Lupus, diabetes, asthma, and chronic bilateral lower leg and foot pain from peripheral vascular disease.

Per Wound Care Treatment order dated 05/08/2023 at 12:28, "Continue Acticoat Flex cut to the size of the wound followed by dry secondary dressing. Changed 3x/week and PRN (as needed) (MWF) (Monday, Wednesday, Friday)..Elevate lower extremities whenever able to aid in chronic edema control...Avoid pressure to the wounds."

Review of Pt #3's orders revealed to notify MD (medical doctor) of pulse >120.

Review of Pt #3's Physical Therapy Note completed 05/08/2023 3:54 PM revealed, "Patient limited due to left LE (lower extremity) pain, weakness, impaired activity tolerance and standing balance..."

Review of Pt #3's admission Nursing Shift Assessment completed on 05/07/2023 at 1:38 PM revealed the following:
-The Skin assessment was documented as "WNL" and there was no assessment and interventions documented to address the surgical wound to the left leg as per the H&P.

Review of Pt #3's Nursing Shift Assessment completed on 05/08/2023 at 12:28 AM revealed the following:
-There was no documentation that the nurse completed a pain assessment; "Pain Severity (Pain scale)" and "Pain location" are blank.
-There was no documentation that the nurse completed an EENT (ear, eyes, nose, throat) assessment.
-There was no documentation that the nurse completed a Musculoskeletal assessment; to include assessment of leg edema (swelling) and strength, and intervention performed.
-Pt #3's Blood Pressure on the Nursing Shift Assessment was 141/93 (normal 120/80); and the Cardiovascular Assessment was documented as "WNL".
-The Skin assessment revealed, "Incision scars present to LLE (left lower extremity) covered with steristrips." There was no documentation of a surgical wound assessment and interventions performed.

Review of Pt #3's Nursing Shift Assessment completed on 05/08/2023 at 1:58 PM revealed the following:
-There was no documentation that the nurse completed an EENT (ear, eyes, nose, throat) assessment.
-The Musculoskeletal assessment was documented as "WNL", this was not consistent with H & P and Physical Therapy's assessments. There was no documentation assessing Pt #3's chronic leg edema and weakness, and performing interventions including leg elevation as per wound care orders (leg edema/swelling assessment is within the Musculoskeletal assessment).
-The Cardiovascular assessment was documented as "WNL", but the Vitals signs documented on the shift assessment revealed a pulse of 133 (normal 60 to 100) and a Blood Pressure of 156/94 (normal 120/80). There was no documentation of notifying the physician of Pt #3's elevated pulse, as per vital sign orders to notify MD with a pulse >120.
-The Skin assessment revealed, "Incision scars present to LLE (left lower extremity) covered with steristrips" (same as previous nursing shift). There was no documentation of a surgical wound assessment and interventions performed; including applying the wound dressing (Acticoat Flex) and leg elevation and pressure reduction, as per Wound Care Treatment orders on 05/08/2023 at 12:28 PM.
-Respiratory assessment documented as "WNL", but Vital signs on the shift assessment revealed a respiratory rate of 22 (normal 12-20). (Pt #1 has a history of asthma)
-There is no documentation that the nurse completed, "Safety" education in the "Nursing Education Record."

Review of Pt #3's Nursing Shift Assessment completed on 05/08/2023 at 6:05 PM revealed the following:
-The Musculoskeletal assessment was documented as "WNL", this was not consistent with H & P and Physical Therapy's assessments. There was no documentation assessing Pt #3's chronic leg edema and weakness, and performing interventions including leg elevation as per wound care orders (leg edema/swelling assessment is within the Musculoskeletal assessment).
-The Skin assessment revealed, "Incision scars present to LLE (left lower extremity) covered with steristrips" (same as previous nursing shift). There was no documentation of a surgical wound assessment and interventions performed; including applying the wound dressing (Acticoat Flex) and leg elevation and pressure reduction, as per Wound Care Treatment orders on 05/08/2023 at 12:28 PM.
-There is no documentation that the nurse completed, "Safety" education in the "Nursing Education Record."

Review of Pt #3's Vital signs revealed the following :
-05/08/2023 12:18 AM: Pulse 108; respiratory rate (RR) 16
-05/08/2023 7:00 AM: Pulse 120; RR 22
-05/08/2023 9:58 AM: Pulse 120; RR 22
-05/08/2023 12:57 PM: Pulse 133; RR 22
-05/08/2023 2:10 PM: Pulse 120; RR not assessed.

Review of nursing progress note dated 05/08/2023 at 4:50 AM revealed, "At approximately 0400 CNA (certified nursing assistant) notified writer that patient was wheezing and c/o (complained of) SOB (shortness of breath). Writer auscultated lung sounds and heard wheezing throughout bilateral lungs...writer administered PRN (as needed) dose of albuterol inhaler..."

Review of Respiratory Therapy progress notes dated 05/08/2023 at 11:30 AM revealed, "...Wheezing heard throughout on auscultation and labored breathing noted..."

Review of Pt #3's Nursing Shift Assessments from 05/08/2023 revealed that the Respiratory and Cardiovascular assessments were documented as "WNL" despite concerns with increased respiratory rate, SOB, and Wheezing, and elevated pulse.

Patient #4:

Review of Pt #4's medical record revealed Pt #4 was admitted to the Rehab hospital on 07/15/2023 at 2:24 PM and discharged (acute care transfer) on 07/17/2023 at 6:23 PM.

Review of Pt #4's General H&P dated 07/16/2023 at 11:30 AM revealed that Pt #4 was a 73 year old "with a history of kidney transplant, atrial fibrillation, and a previous right middle cerebral artery CVA (cerebral vascular accident), presented to the hospital (acute care) with new onset aphasia (loss of ability to understand or express speech).

Review of Pt #4's Rehab H&P dated 07/16/2023 at 5:42 AM revealed the "Rehab Diagnosis" was Ischemic stroke with right sided weakness, and global aphasia.

Review of Pt #4's admission Nursing Shift Assessment completed on 07/15/2023 at 5:31 PM revealed the following:
-The Cardiovascular nursing assessment is documented "WNL Except", there is no additional documentation of an assessment.
-The Musculoskeletal assessment revealed boxes checked indicating "weakness", "Decreased strength" in left lower extremity and "Decreased strength" in Right lower extremity. Per review of shift assessment, the category of "Equipment Owned Prior to Admission," the box is checked indicating Pt #4 uses a "Straight Cane."
-Review of the Morse Falls Scale risk assessment revealed under the category "Ambulatory Aid" the circle is filled in indicating "None" (use of a cane adds 15 points); under the category "Gait Transfer" the circle is filled in indicating "Normal" (Weakness adds 10 points); this documentation was not consistent with the previous assessment and decreased the Morse fall scale score by 25 points making Pt #4 a "moderate fall risk " instead of a "High Fall Risk".
-The Falls precautions/interventions indicating high risk are not checked, including Bed alarm, chair alarm, and low bed.
-The Skin assessment revealed that skin tears were present, there was no documentation of wound assessment completed or interventions performed for the skin tears.

Review of Pt #4's admission Nursing Shift Assessment completed on 07/16/2023 at 5:51 PM revealed the following:
-The Nursing Safety Interventions are blank, including Fall precautions and safety measures implemented.
-The Morse Fall Scale was documented the same as the previous shift assessment.
-The Falls precautions/interventions indicating high risk are not checked, including Bed alarm, chair alarm, and low bed.
-The Musculoskeletal assessment is documented as "WNL", this was inconsistent with the Rehab H&P diagnosis of a stroke causing left sided weakness.
-The Skin assessment revealed that skin tears were present, there was no documentation of wound assessment completed or interventions performed for the skin tears.

Review of Pt #4's admission Nursing Shift Assessment dated 07/17/2023 at 5:13 PM, signed as completed on 07/21/2023 at 1:13 PM (4 days after discharge) revealed the following:
-The Morse Fall Scale assessment for "Gait Transfer" is now documented as "Impaired" compared to the last assessment of "Normal". "Ambulatory Aid was documented as "Normal" despite Pt #4 using ambulatory device. There are no interventions documented for Medium Fall Risk or High Fall risk (score was documented as 40-Medium fall risk).
-The Neurological assessment was documented as "WNL", this was inconsistent with Pt #4's diagnosis of a stroke causing aphasia.
-The Musculoskeletal assessment was documented as "WNL", this was inconsistent with the Rehab H&P diagnosis of a stroke causing Pt #4 to have left sided weakness.
-The Cardiovascular assessment was documented as "WNL", this was inconsistent with the Vital signs documented on the nursing shift assessment revealing an elevated pulse of 104 (normal 60-100) and a elevated blood pressure of 160/90 (normal 120/80).
-The Skin assessment revealed that skin tears were present, but there was no documentation of wound assessment com

Based on record review and interview staff failed to reevaluate and revise the care plan with appropriate interventions and goals to reflect patient's care needs in 3 of 10 medical records reviewed (Patient (Pt) #6, 7, 9), in a total sample of 10 medical records reviewed.

Findings Include:

Review of policy and procedure titled, "Patient Assessment & Care Planning" no date, revealed the following:
-The plan of care should identify...The needs to be addressed; The care goals relative to the need identified; interventions planned by the healthcare team to address the need and meet the care goal; monitoring of the patient's progress towards achieving the care goals; Any revisions necessary based on the patient's needs.

Review of policy and procedure titled, "Patient Falls" no date, revealed the following:

Standard fall Precautions Interventions:
Morse Fall Risk Score 0-25: Any patient assessed/reassessed or pre-determined to be at risk of fall shall have a basic set of interventions, including but not limited to:
-Beds will be maintained in the lowest position, with the top side rails maintained in the raised position
-Call light within reach
-Purposeful rounding per protocol
-Education to patient and family on standard fall prevention.

Medium Fall Risk Interventions:
Morse Fall Score 25-44: Any patient assessed/reassessed or determined to be a medium risk by interdisciplinary team shall have all Standard Precautions plus:
-Fall risk placed as precaution in the EMR (electronic medical record).
-Staff to stay with patient when assisted to the bathroom.

High Fall Risk:
Morse Fall Risk 45 or more: All standard and medium level interventions plus additional interventions may be deployed to further prevent a fall including, but not limited to the following:
-Bed alarm and/or chair alarm
-Consider the need for safety surveillance
-Consider increasing the frequency of observation
-Moving Pt closer to the nurse's station when possible
-Any additional measures identified by the interdisciplinary

Pt #6:

Review of Pt #6's Medical Record revealed Pt #6 was a "high fall risk"; Per Review Pt #6 fell on 06/25/2023 at 10:15 PM; 06/26/2023 at 4:45 PM; and 07/07/2023 at 10:45 AM.

Review of Pt #6's Plan Of Care (POC) dated 06/18/2023 revealed Pt #6's "Problem" was "(Pt #6) is at risk for falls related to Hx (history) of falls within the past 30 days, unsteady gait as evidenced by bruising." The "Goal" was "(Pt #6) will have no falls through next review..Target Dt (date): 08/05/2023." The "Interventions" documented revealed, "Physical therapy as ordered", "Occupation Therapy as ordered", "Administer Medications as ordered", and Monitor lab values as ordered". Per review of Pt #6's plan of care, there were no revisions/updates to Pt #6's plan of care to address Pt #6 falling 3 times during the hospital stay. Pt #6's plan of care Fall interventions were not individualized to meet Pt #6's specific care needs and mitigate Pt #6's risk for falls, as per interventions documented in the Patient Falls policy.

Review of Pt #6's Medical record revealed Pt #6 developed pressure wounds to the coccyx, toe, and ankle during Pt #6's hospital stay from 06/17/2023 to 07/13/2023. Per review of Pt #6's medical record, Pt #6 did not have these wounds on admission to the hospital.

Review of Pt #6's Plan Of Care (POC) dated 06/18/2023 revealed Pt #6's "Problem" was "Alteration in Skin Integrity related to redness to coccyx as evidenced by bruising, redness." The "Goal" was "Skin to remain intact without evidence of breakdown, rash, infection, or pruritis (itching)...Target Dt (date): 08/05/2023." The "Interventions" documented revealed, "Change (Pt #6's) position in bed every 2 hours and PRN (as needed)"; "Manager Nutrition by requesting dietary consult"; "Promote mobility." Per review of Pt #6's plan of care, there were no revisions/updates and interventions documented recognizing and addressing Pt #6's wounds that developed during the hospital stay. Review Pt #6's medical record revealed no documented evidence of nursing staff performing position changes every 2 hours as per plan of care interventions.

Pt #7:

Review of Pt #7's Medical Record revealed Pt #7 was a "high fall risk"; Per Review Pt #7 fell on 07/02/2023 at 5:10 PM; and 07/05/2023 at 4:15 AM.

Review of Pt #7's Plan Of Care (POC) dated 07/01/2023 revealed Pt #7's "Problem" was "(Pt #7) is at risk for falls related to unsteady gait as evidenced by limited muscle strength or control." The "Goal" was "(Pt #7) will have no falls through next review...Target Dt (date): 07/31/2023." The "Interventions" documented revealed, "Falls risk assessment to be completed upon admission, quarterly and with significant change in condition." Per review of Pt #7's plan of care, there were no revisions/updates to Pt #7's plan of care to address Pt #7 falling 2 times during the hospital stay. Pt #7's plan of care Fall interventions were not individualized to meet Pt #7's specific care needs and mitigate Pt #7's risk for falls, as per interventions documented in the Patient Falls policy.

Pt #9:

Review of Pt #9's Medical Record revealed Pt #9 was a "high fall risk"; Per Review Pt #9 fell on 05/16/2023 at 1:22 PM; and 05/18/2023 at 6:00 PM.

Review of Pt #9's Plan Of Care (POC) dated 05/09/2023 revealed Pt #9's "Problem" was Risk for Fall related to >70 as evidenced by recent history of fall, seizures, syncope." The "Goal" was "(Pt #9) will remain free of falls during the hospitalization...Target Dt (date): 06/10/2023; (Pt #9) will request assistance when feeling unsteady...Target Dt (date): 06/10/2023." Per review of Pt #9's plan of care, there were no revisions/updates to Pt #9's plan of care recognizing and addressing Pt #9 falling 2 times during the hospital stay.

Per interview with Interim Director of Quality Management (DQM) B on 08/04/2023 at 3:10 PM, DQM B agreed that staff should be updating/revising the Plan of Care to address patient care needs, and documenting the interventions completed.

Based on interview and record review the staff failed to ensure that nursing assignments are based on the competency and qualifications of the nursing staff and the patient care needs in 2 of 2 units reviewed (Rehabilitation floor 2 and 3), in a total of 2 units reviewed.

Findings Include:

Review of policy and procedure titled, "Nursing Staffing Plan" no date revealed the following:
-"An RN (Registered Nurse) must assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available."
-"The licensed nurse to patient ratios will be in accordance with the acuity of the patient..."
-"Nurse Staffing requirements and assignments will be assessed and evaluated based on the following demonstrated patient needs: a) Ability of patient to care for himself/herself. b) Patients's degree of illness/acuity. c) Requirements for special nursing activities, e.g. frequency of assessment, medications, and nursing treatment. d) Skill level of personnel required to care for patient. e) Skill level and competency of the nursing staff. f) Placement of the patient in the nursing unit. g) Assessment skills."

Per interview with Interim Chief Nursing Officer (CNO) C on 08/02/2023 at 10:00 AM, the facility has a contract with a company that provides Agency/Traveling Registered Nurses (RN) and Licensed Practical Nurses (LPN) to work in the hospital and provide nursing care to patients. On 08/08/2023 at approximately 12:00 PM, CNO C revealed that the hospital currently has 73 RNs/LPNs that are approved to work at the facility through the Agency, and 14 RNs and LPNs that are direct employees of the hospital.

Review of the staffing schedules and assignments for the 2nd floor revealed the following:
-On 08/02/2023 Day shift (7 AM to 7 PM): Agency RN F was assigned to Pt rooms 201-206 (6 Pts); Agency LPN G was assigned to patient rooms 207-212 (6 Pts); and Agency LPN H was assigned to Pt rooms 213-220 (7 Pts). There was no evidence of nursing staff assigning Pts based on skill level and competency of nursing staff, Pts degree of illness/acuity, and ability of Pt to care for self, as per policy.

Review of staffing schedule and assignments for the 3rd floor revealed the following:
-On 08/02/2023 Day shift: LPN L was assigned to Pt rooms 301-308 (7 Pts); Agency RN I was assigned to Pt rooms 309-317 (7 Pts). There was no evidence of nursing staff assigning Pts based on skill level and competency of nursing staff, Pts degree of illness/acuity, and ability of Pt to care for self, as per policy.

Per interview with House Supervisor (Sup) J on 08/02/2023 at 4:41 PM, Sup J stated that as the House Supervisor, she/he makes the nursing assignments. Sup J stated that she/he does not staff by Pt acuity and nursing experience/competency. Sup J stated that they should be using an Acuity form that helps determine nurse to pt ratios and nursing assignments but she/he is not currently using this form due to non-compliance of staff. Per Sup J, staffing assignments are made based on the geographical location of the rooms, so staff are assigned to rooms that are within close proximity. Sup J stated that there are a large number of Agency staff that work shifts at the hospital; Sup J stated that she/he does not know if Agency staff have been oriented to the unit or competency/skills have been completed prior to making nursing assignment for Agency nursing staff.

Per interview with RN F on 08/02/2023 at 11:09 AM, RN F stated that she/he has picked up shifts at this hospital for approximately 1 year. RN F stated that she/he feels that the patient acuity (severity of illness) has increased. RN F stated that she has never received orientation to the unit, training on policy and procedures, and an evaluation of his/her competency and skills.

Per interview with LPN G on 08/02/2023 at 12:16 PM, LPN G stated that she has picked up approximately 4 shifts at the hospital. LPN G stated that she/he did not receive an orientation to the unit, training on policy and procedures, and an evaluation of his/her competency and skills.

Per interview with Interim CNO C on 08/03/2023 at 9:45 AM, CNO C confirmed that nursing staff should be making assignments based on Pt acuity and staff experience and criteria as per policy. CNO C stated that she/he was not aware the nursing staff were not using the Acuity form to determine nursing assignments and nurse to pt ratios.

Based on record review and interview the staff failed to ensure all nursing staff receive the proper training, orientation, and evaluation of competencies/skills to ensure nursing staff are competent to perform their job duties, in 6 of 8 staff interviews (Chief Nursing Officer (CNO), Chief Executive Officer (CEO), Registered Nurse (RN) F, Licensed Practical Nurse (LPN) G, LPN H, House Supervisor J), in a total sample of 8 interviews.

Findings Include:

Review of policy and procedure titled, "Management of Contract Staff" no date, revealed the following:
-HR (Human Resources) will maintain an employee file for each clinical agency employee working at the hospital. The file must include: Clinical contract Employee/Agency Attestation; Primary source Verification; Agency Staff Evaluation after 1st shift; General Orientation; Department/Unit Specific Orientation & Initial Competencies Assessment Form.
-If the contract states the agency will not provide orientation before reporting for their first shift, the hospital will develop an agency orientation binder that the agency employee must review, attest to completion and successfully pass the post test.
-The hospital must assure that each individual is oriented to at least the following prior to or at the time of their first working shift: pertinent hospital and/or department specific policies and procedures that govern their job function; Emergency response procedures such as fire and disaster; Infection Control Policies.
-The hospital must validate the competency of each individual in performing critical aspects of their job function on the Department/Unit Specific Orientation and Initial Competencies Assessment Form. At a minimum this includes: The ability to perform tasks, skills or procedures that carry a high risk of safety or injury to patients; the ability to safely operate equipment that is used on a patient.
-At the completion of the first shift, Agency Staff Evaluation form must be completed and turned in to HR.

Review of the "Department/Unit Specific Orientation & Initial Competency Assessment Form" last reviewed 01/2020 revealed the following:
1. "Orientation items must be covered as soon as possible--Preferably during the individual's first day in the Department/Unit."
2. "The individual is not to independently perform a critical aspect of their job function until competency has been established.
Review of the "Activities" for the Orientation and Competency Assessment Form revealed the following, including but not limited to:
General:
-Welcome & Orientation to Department/Unit Physical Layout and Scope of Services
-Orientation of how to access Healthicity for all policies and procedures
Environment of Care:
-Department/Unit Specific Safety Hazards and Response Procedures.
-Department/Unit Specific Fire Response Plan
-Location of Fire Extinguishers, Fire Alarm Pull Stations, Fire Doors, and Smoke Compartments
-Evacuation Routes
-Department/Unit Specific Emergency Preparedness Response Plan
-Department/Unit Specific Response to Loss of Utilities
-Department/Unit Specific Security Systems and Emergency Procedures
-Use of Personal Protective Equipment
-Department/Unit Specific Medical Equipment Safety Issues
Infection Control:
-Location & Use of Isolation Supplies, Equipment, and Personal Protective Gear
-Low level Disinfection of Equipment & Surfaces/ Use of Cleaning/ Disinfection Agent
Other:
-Patient Visitation Policy
Assessment of Competency, including but are not limited to:
-Restraints/Restraints First Aid; Transfers; Alarm Safety; Pain Management; Oral care; Wound Care; Phlebotomy (lab draws) Centrifuge; Lab process; Narcotic Safety; Organ and Tissue Donation; Code Blue; EKG (electrocardiogram); Patient and family education; Paging System; Nurse Call system; Pyxis (medication dispenser); Glucometer; Urinalysis; Bladder Scanner; Lifts; AED (Automatic External Defibrillator) IV (intravenous) pumps; feeding pumps.

Per interview with Interim Chief Nursing Officer (CNO) C on 08/02/2023 at 10:00 AM, the facility has a contract with a company that provides Agency/Traveling Registered Nurses (RN) and Licensed Practical Nurses (LPN) to work in the hospital and provide nursing care to patients. On 08/08/2023 at approximately 12:00 PM, CNO C revealed that the hospital currently has 73 RNs/LPNs that are approved to work at the facility.

Per interview with Chief Executive Officer (CEO) A on 08/03/2023 at 9:15 AM, CEO A stated that she/he was unable to find General Orientation, Department/Unit Specific Orientation & Initial Competencies Assessment Form, and Agency Staff Evaluation forms after 1st shift completed for any of the 73 Agency nursing staff, as per policy. CEO A stated that she/he was also unable to find Department/Unit Specific Orientation & Initial Competencies Assessment Form and Competency Based Performance Evaluations completed for the hospital employed nursing staff (14 RNs/LPNs including House Supervisors). CEO A confirmed that this should have been completed by the hospital. CEO A confirmed during the interview that there are no agency orientation binders or post test completed by Agency staff as per policy.

Per interview with Agency RN F on 08/02/2023 at 11:09 AM, RN F stated that she/he has picked up shifts at this hospital for approximately 1 year. RN F confirmed that she did not receive General Orientation with the hospital, Department/Unit Specific Orientation & Initial Competencies, and Agency Staff Evaluation after his/her 1st shift, as per policy. RN F, stated that if she/he had to call for staff assistance for an aggressive patient, RN F stated that she/he would "yell for help." to obtain assistance; when asked about the process for calling a Code 4 (Patient's heart stops), RN F stated that she would "pull on the cord"; RN F was not aware of the 2 call buttons in the room for Code 4 and Staff Assist. When asked about who responds to a Code 4, RN F stated that she/he was not aware of a Code 4 team/assignments. When asked what the Restraint process was for the hospital, RN F stated "I don't know how it is here."

Per interview with Agency LPN G on 08/02/2023 at 11:45 AM, LPN G stated that this was her/his 4th day at the hospital. LPN G confirmed that she/he did not receive a General Orientation, Department/Unit Specific Orientation & Initial Competencies, and Agency Staff Evaluation after his/her 1st shift, as per policy. LPN G stated that she/he arrived for the first shift with the hospital and was given her/his patient assignment and EMR (electronic medical record) log in information and told to just do assessments on every patient and patient rounding. LPN G stated she was not sure if there was a Code 4 button in the rooms and stated, "I'm assuming" there is. LPN G confirmed she/he has not been trained on Restraints, Deescalation, and Emergency response/Rapid response. Per LPN G, she/he has not been trained on lab draws, but admitted to having attempted lab draws and never being successful. LPN G stated stated that she has administered Intravenous (IV) antibiotics using an IV pump but was not trained on how to use the pump; LPN G stated that she did have previous experience with the IV pump at other hospitals, but the nursing staff never checked her/him for competency.

Per interview with Agency LPN H on 08/02/2023 at 12:16 PM, LPN H stated that she/he has worked 4 shifts at this hospital. LPN H confirmed that she/he did not receive a General Orientation, Department/Unit Specific Orientation & Initial Competencies, and Agency Staff Evaluation after his/her 1st shift, as per policy. LPN H stated that her/his first shift the House Supervisor showed her how to log into the EMR and Pyxis and that was it. LPN H stated that she/he was not told to complete hourly checks on patients. LPN H confirmed she/he has not received training on Emergency response/Rapid response and was not aware of the Code 4 and Staff Assist buttons in the patient rooms. LPN H stated that she/he was not aware of the process for Adverse Event reporting.

Per interview with House Supervisor (Sup) J on 08/02/2023 at 4:41 PM, Sup J stated that nursing staff are not trained on IV pumps, IV insertion, and blood draws; Sup J stated that typically the Agency RNs and LPNs will ask the House Supervisor to perform these tasks. Sup J stated there was no formal training or orientation for the Agency RNs and LPNs before they work their first shift. Sup J confirmed she/he does not perform an Agency Staff Evaluation after their first shift. When asked what training Sup J received to be House Supervisor, Sup J stated that she/he did not receive any additional training. Sup J stated that she/he was responsible for the oversight of the Agency RNs and LPNs.