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Based on interview and record review, the Governing Body (GB) failed to provide adequate oversight to ensure safe and effective patient care for a universe of 34 patients admitted on January 22, 2024, as evidenced by:

1. The GB did not ensure an ongoing quality improvement program. (Refer to A-0049).

2. The GB did not ensure the medication administration observation was evaluated. (Refer to A-0049).

The cumulative effects of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on observation, interview, and record review, the hospital failed to implement patient rights for 30 sampled patients, as evidenced by:

1. For Patient 9, the nursing staff delayed in starting the blood transfusion. (Refer to A-0129)

2. For Patient 14, the facility failed to ensure patient's representative was informed and involved in the plan of care in a timely manner after an unwitnessed fall. (Refer to A-0131)

3. For a universe of three (3) patients admitted to the Intensive Care Unit (ICU) on January 22, 2024, the needle supply cart was left unlocked. (Refer to A-0144)

4. Licensed Nursing staff removed, two patient (Patient 15 and 16) medications from the medication room at the same time, taken into a contact precaution (actions to prevent spread of germs by direct or indirect contact) room, and left unattended at Patient 16's room. (Refer to A-0144)

The cumulative effects of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on observation, interview, and record review, the hospital failed to maintain an effective and on-going hospital wide, data driven Quality Assessment and Performance Improvement (QAPI) program for a universe of 34 patients admitted on January 22, 2024, as evidenced by:

1. The hospital did not ensure an ongoing program to monitor, collecting data and analyze the process of the medication administration, implementation of transmission-based precaution (used to help stop the spread of germs from person to another), and the utilization of Personal Protective Equipment (PPE- disposable equipment worn to decrease exposure to germs). (Refer to A-0273)

2. The hospital failed to maintain an effective and ongoing hospital wide, data driven QAPI program to identify the collected data of the issues regarding nursing assessment, documentation, medication administration, and infection control practices to improve patient outcomes. (Refer to A-0283)

The cumulative effects of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care and nursing services in a safe environment.

Based on observation, interview, and record review, the facility failed to maintain an organized Nursing Services to patients for 30 sampled patients, as evidenced by:

1. For Patient 2, the nursing staff did not follow up or clarify on the STAT (as soon as possible) order for the Electroencephalogram (EEG-a test that record the brain activities) to ensure it was completed as ordered and did not closely monitor Patient 2 in response with seizure (SZ-a condition that causes abnormalities in muscle tone or movements) activity. (Refer to A-0395)

2. For Patient 3, Enoxaparin (Lovenox-medication to treat or prevent blood clot) syringe was left on the patient's side table. (Refer to A-0398)

3. For Patient 4, patient's own medications (POM) were left on the patient's side table. (Refer to A-0398)

4. For Patient 1, the nursing staff did not administer Colace (stool softener) appropriately. (Refer to A-0405)

5. For Patient 1, the nursing staff did not administer Fluoxetine (Prozac-medication to treat depression) appropriately. (Refer to A-0405)

6. For Patient 10, the nursing staff did not check blood pressure (BP) before Hydralazine (medication to treat high blood pressure) administration. (Refer to A-0405)

7. For Patient 12, the nursing staff did not check blood sugar (BS) as ordered. (Refer to A-0405)

8. For Patient 5, the nursing staff did not assess BP and titrate (the process of adjusting the dose of a medication for the maximum benefit without adverse effects) Norepinephrine (Levophed-a medication to treat life-threatening low BP) appropriately. (Refer to A-0410)

The cumulative effects of these systemic problems resulted in the hospital's inability to ensure the provision of safe and quality nursing care in a safe environment.

Based on observation, interview, and record review, the facility failed to ensure the infection prevention control program demonstrate adherence and control the transmission of infectious diseases including Hospital Acquired Infections (HAIs) for 30 sampled patients, as evidenced by:

1. For Patient 2, the nursing staff cleaned the intravenous (IV-into the vein) port with a used alcohol wipe after the medication administration. (Refer to A-0749)

2. For Patient 1, 27, and 29, intravenous infusion tubing (tubing that administers fluids and medication onto a patients vien) was not labeled and dated. (Refer to A-0749)

3. For Patient 16, the nursing staff did not clean/disinfect the IV port during two medication administration opportunities. (Refer to A-0749)

4. For Patient 15, the nursing staff did not clean/disinfect the glucometer (a portable device used to measure blood sugar) properly after used. (Refer to A-0750)

5. For Patient 15 and 16, the nursing staff did not wear Personal Protective Equipment (PPE- disposable equipment worn to decrease exposure to germs) appropriately. (Refer to A-0750)

6. For a universe of 34 patients admitted on January 22, 2024, the facility failed to have a system in place to audit implementation and interventions for transmission-based precautions (used to help stop the spread of germs from person to another). (Refer to A-0770)

7. For Patient 16, the nursing staff implemented an incorrect transmission-based precaution. (Refer to A-0772)

8. For Patient 1, the nursing staff did not wash her hands after the medication administration. (Refer to A-0776)

The cumulative effects of these systemic problems resulted in the hospital's inability to ensure safe and quality infection control program.

Based on observation, interview and record review, the Governing Body (GB) failed to ensure the quality of care was provided to patients for a universe of 34 patients admitted on January 22, 2024, when,
1. The GB did not ensure an ongoing quality improvement program.
2. The GB did not ensure medication administration process was evaluated appropriately to improve the quality of care.

This failure had resulted in the facility's failure to deliver quality patient care with the GB oversight and failure to provide safe medication administrations for patients.

Findings:

1.During an observation on January 23, 2023, at 9:50 AM, in the Medical Surgical Telemetry [monitoring of heart activity] (MST) Unit, Patient 1 was lying in bed with a trach attached to a ventilator, Registered Nurse 3 (RN 3) was observed using a needle to puncture a capsule of Colace (stool softner) 100 milligrams (mg-unit dosing medication), squeezed out the clear gel substance inside the capsule onto Patient 1's apple sauce, and administered to Patient 1.

During an observation on January 23, 2023, at 9:50 AM, in the MST Unit, Patient 1 was lying in bed with a trach attached to a ventilator, RN 3 was observed opening a capsule of Prozac (anti depressant) 10 mg, poured the white powder inside the capsule onto Patient 1's apple sauce, and administered to Patient 1.

During an interview on January 26, 2024, at 8:55 AM, in the conference room, with the Director of Pharmacy Department (DPD) and Pharmacist 1 (Pharm 1), the DPD stated, the department had not observed, tracked, or collected data regarding the "medication pass [med pass-a process of giving medication to patient]."

A follow-up interview and record review on January 26, 2024, at 9:00 AM, with the DPD and Pharm 1, the facility's document titled, "Performance Improvement Quality Council/Committee," dated November 30, 2023, was reviewed. The "Performance Improvement Quality Council/Committee" indicated, the "medication administration" received 100 percent (%) with no issues identified. There was no documentation of data collection and analysis, description for mitigation plans or person responsible. The DPD verified and stated, the data did not come from the pharmacy department. The DPD further stated, there were no opportunities of med pass to observe in the year of 2023 from the pharmacy department.

2. During a concurrent interview and record review on January 26, 2024, at 9:45 AM, in the conference, with the Director of Quality Department (DQD), the facility's document titled, "Performance Improvement Quality Council/Committee," dated November 30, 2023, was reviewed. The "Performance Improvement Quality Council/Committee" indicated, the nursing assessment, documentation, and medication administration received 100% with no issues identified. The DQD verified and confirmed the results. The survey team brought up some issues identified during survey related to inappropriate medication administration observation during med pass in the Medical Surgical Telemetry [monitoring of heart activity] (MST) Unit. The DQD stated, each service area would be responsible to conduct its own audit and his department would collect data. Based on the results, the DQD stated, there was no identification of issues.

A follow-up interview on January 26, 2024, at 10:20 AM, with the DQD, the DQD stated, the medication administration data came from each nursing department combined since the pharmacy department has not conducted any med pass observation.

During an interview on January 26, 2024, at 10:25 AM, in the conference room, with the DQD and Registered Nurse 6 (RN 6), RN 6 stated, she had some opportunities to observe med pass and identified issues from the nursing staff; however, she did not report to anyone.

During an interview on January 26, 2024, at 11:10 AM, in the conference room, with the facility's administration. The survey team brought up some issues identified during survey related to inappropriate medication administration observation during med pass and there was no data collection of medication administration audits. The Chief Executive Officer (CEO) confirmed and stated, the facility had stopped the pharmacy department to conduct the med pass observation, so the GB was not aware of the issues involving the med pass.

A review of the facility's document titled, "Amended & [and] Restated Governing Board Bylaw," reviewed September 6, 2023, indicated, " ...the primary purpose of the Hospital is to provide quality health care in a cost effective manner with the maintenance of high standards of care, the availability of resources, and the expectations of the Practitioners and the community served by the Hospital ... supporting the Hospital's Performance Improvement Programs and its initiatives and the Hospital's Patient Safety Program ..."

Based on interview and record review, the facility failed to ensure patient received a reasonable treatment requested for service for one of 30 sampled patients (Patient 9) when the nursing staff delayed in starting the blood transfusion in the Medical Surgical Telemetry [monitoring of heart activity] (MST) Unit.

This failure had resulted in delay of patient's care which could potentially compromise and negatively affect Patient 9's condition and lead to actual harm or death.

Findings:

A review of Patient 9's "History and Physical" (H&P), dated January 20, 2024, the H&P indicated, Patient 9 was admitted into the facility for vaginal bleeding.

A review of Patient 9's "Hemoglobin [Hgb-cells that carry oxygen to body] - History," dated January 20, 2024, from 3:00 AM through January 21, 2024, at 5:25 AM, indicated as follow:

On January 20, 2024, at 3:35 AM: Hgb 7.2 grams per deciliter (g/dL-the amount of Hgb in blood with normal range for female is 12 to 16 g/dL)
On January 20, 2024, at 3:35 AM: Hgb 8.0 g/dL
On January 21, 2024, at 5:25 AM: Hgb 6.5 g/dL

During an interview on January 25, 2024, at 2:40 PM, in the conference room, with Registered Nurse 6 (RN 6), RN 6 stated, the process of giving the blood transfusion included the nursing staff notified a physician to obtain an order with the critical level of Hgb. RN 6 stated, the nursing staff should attempt to start the blood transfusion within one (1) hour after received a call from the blood bank of the readiness of blood.

A review of Patient 9's "Critical Value Lab Reporting," dated January 21, 2024, indicated, the critical value for Hgb of 6.5 was reported to a physician on January 21, 2024, at 8:35 AM.

A follow-up concurrent interview and record review on January 25, 2024, at 3:15 PM, with RN 6, Patient 9's "RBC [Red Blood Cell-blood components to help delivery oxygen to the body] - No Active Bleeding," dated January 21, 2024, at 9:33 AM, was reviewed. The "RBC - No Active Bleeding" indicated, Patient 9 was ordered to receive the blood transfusion for Hgb less than 7 g/dL. RN 6 verified and confirmed the order date and time.

During a concurrent interview and record review on January 25, 2024, at 3:20 PM, in the conference room, with Laboratory Manager 1 (LM 1), Patient 9's laboratory report, dated January 21, 2024, was reviewed. LM 1 verified and stated, the laboratory staff notified the nursing staff on January 21, 2024, around 12:00 PM, that the blood was ready to be picked up.

During an interview on January 25, 2024, at 3:30 PM, with RN 6, RN 6 stated, she was unable to provide any documented evidence to show the nursing staff notified a physician regarding the delayed in starting the blood transfusion on January 21, 2024.

A follow-up concurrent interview and record review on January 25, 2024, at 3:35 PM, with RN 6, Patient 9's "Blood or Blood Component Transfusion," dated January 21, 2024, was reviewed. The "Blood or Blood Component Transfusion" indicated, the blood transfusion was started at 3:15 PM. RN 6 verified and confirmed, it took about six (6) hours after received a physician order before started the blood transfusion. RN 6 stated, it was a delayed of care.

A review of the facility's policies and procedures (P&P) titled, "Patient Rights and Responsibilities," dated September 2023, indicated, "Policy: [Hospital Name] shall identify each and every patient's Rights and Responsibilities by doing the following: ... 3. Developing and implementing hospital-wide policies and procedures that address the Patient Rights and Responsibilities ... Patient Bill of Rights. You have the right to: ... 9. Reasonable responses to any reasonable requests made for service ..."

Based on interview, and record review, the facility failed to ensure patient's representative was informed and involved in the plan of care after an unwitnessed fall for one of 30 sampled patients (Patient 14).

This failure resulted in Patient 14's family not receiving the information needed to promptly participate in the plan of care, which caused Patient 14's family to distrust the health care team and had the potential to interfere with Patient 14's overall medical care.

Findings:

During a review of Patient 14's "History and Physical" (H&P), dated December 6, 2023, the H&P indicated Patient 14 was admitted with diagnoses including Non-ST-Elevation Myocardial Infarction (NSTEMI - heart attack), pneumonia (infection in the lung) and history of dementia (disease affecting the brain's ability to think, remember and reason).

During an interview on January 24, 2024, at 9:28 AM, with Patient 14's daughter, Patient 14's daughter stated, her father had been admitted to the facility in December 2023. Patient 14's daughter stated, she had communicated with the facility staff that she was to be involved in all medical decisions and visited father daily during the hospitalization. Patient 14's daughter stated she was not informed about her father's fall or updated on his health status until the morning after the fall.

During a review of Patient 14's "Admission/Registration" dated December 12/05/2023, the "Admission/Registration" indicated, " ...PERSON TO NOTIFY ... [name of Patient 14's daughter] ... [Patient 14's daughter's phone number] ...".

During a review of Patient 14's "Nurse Notes" dated December 7, 2023 at 12:30 AM, the "Nurses Note" indicated, "Patient had an unwitnessed fall. Pt found on floor, awake, and alert X 1. Pt placed back into bed. Bed alarm on. Pt agitated and confused. Vital signs stable post fall, no complaints of pain ...skin tear to L forearm noted ...". A further review of the "Nurses Note" at 1:00 AM, indicated, "Patient further assessed. Equal strength to bilateral upper extremities and bilateral lower extremities. Patient denies pain upon movement of all limbs. Pt verbally responsive, denies pain at this time. No s/s [signs or symptoms] of distress."

During a concurrent interview and record review on January 24, 2024, at 2:30 PM, with the Chief Nursing Officer (CNO), Patient 14's "electronic medical record" was reviewed. The CNO was unable to find any documented evidence indicating the of notification of family after Patient 14's fall. The CNO stated, she was unable to find any documentation regarding family notification.

During a concurrent interview and record review on January 25, 2024, at 9:45 AM, with Registered Nurse 9 (RN 9), the facility's Policy and Procedure (P&P) titled, "Fall Reduction/Injury Prevention Policy", dated June 2023, was reviewed. The P&P indicated, " ...Policy ... to outline documentation and communication procedures ... Post Fall Management: ... 7.15 Notify the family ...". RN 9 stated, she would follow the policy and procedure if a patient had a fall, even if the fall occurred in the middle of the night. RN 9 stated family should be notified immediately of the fall and would be notified of the current plan regarding injuries sustained and new interventions to prevent further falls. RN 9 further stated family could be offered to come to the facility to help sit with patient to prevent fall, especially if the patient is confused or has a history of dementia.

During a review of Patient 14's "Social Services Notes" dated December 7, 2023 at 2:53 PM, the "Social Services Notes" indicated, " ...Patients daughter [name of daughter] provides all MDM [Medical Decision Making] ...".

During a review of the facility's policy and procedure titled, "Patient Rights and Responsibilities" dated September 2023, the P&P indicated, " ...Addendum A Patient Bill of Rights: You have a right to: ... 2. His or her representative has a right to make informed decisions regarding his or her care. The patient's rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment ...".

Based on observation, interview, and record review, the facility failed to provide care in a safe setting when:

1. For a universe of three (3) patients admitted to the Intensive Care Unit (ICU) on January 22, 2024, the clean supply cart contained needles was not locked in the ICU.

2. For two patients of 30 sampled patients (Patient 15 and 16), two patient medications were removed from the medication room at the same time, taken into a contact precaution (actions to prevent spread of germs by direct or indirect contact) room, Patient 16's room and left unattended.

These failures had the potential to cause unsafe access from unauthorized personnel to needle supplies and medications which could potentially cause harms and injuries from unsafe handling of sharp objects and misused of medication.

Findings:

1. During an observation on January 22, 2024, at 10:55 AM, in the ICU, observed an unlocked blue medical supply cart contained medication supplies including needles.

During an interview on January 22, 2024, at 11:00 AM, in the ICU, with the Director of Medical Surgical Telemetry Unit (DMST), the DMST stated, needles or sharps items should be kept in a locked area for safety and unauthorized personnel should not be able to access them. The DMST stated, there was no specific policy regarding locking unused needle supplies.

A follow-up concurrent observation and interview on January 22, 2024, at 11:05 AM, in the ICU, with the DMST and Registered Nurse 2 (RN 2), observed an unlocked blue cart contained needles. The DMST and RN 2 verified and confirmed an unlocked cart with needles. RN 2 stated, a cart should be locked, and the staff must have been too busy and forgot to lock it.

A review of the facility's Registered Nurse Job Description, undated, indicated, "The Registered Nurse is responsible for the delivery of safe patient care ... maintains a safe environment, functioning with an awareness and application of safety issues identified within the unit/facility, i.e., suction and oxygen immediately available at all ICU bedsides ..."

A review of the facility's policies and procedures (P&P) titled, "Patient Rights and Responsibilities," dated September 2023, indicated, "Policy: [Hospital Name] shall identify each and every patient's Rights and Responsibilities by doing the following: ... 3. Developing and implementing hospital-wide policies and procedures that address the Patient Rights and Responsibilities ... Patient Bill of Rights. You have the right to: ... 14. The right to receive care in a safe setting ..."


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2. During a review of Patient 15's "History and Physical" (H&P), dated January 21, 2024, the H&P indicated, Patient 15 was admitted to the hospital with the diagnoses of sepsis (the body's response to infection that can damage vital organs) secondary to lower extremity wound, diabetes with hyperglycemia (the body does not make enough insulin or use insulin [hormone produced by the body to use sugar for energy] to well resulting in high blood sugar), and hyponatremia (when the concentration of sodium in the blood is too low).

During a review of Patient 16's H&P, dated January 21, 2024, the H&P indicated, Patient 16 was admitted to the hospital with the diagnoses of hypoxemic respiratory failure related to multifocal pneumonia (not enough oxygen is provided to the blood and body because of an infection in more than one area of the lungs), sepsis (the body's response to infection that can damage vital organs), and recent flu infection (a viral infection which can include the respiratory system).

During an observation on January 23, 2024, at 9:05 AM, in the hallway outside of Patient 16's room, RN 8's Workstation on Wheels (WOW) was observed with two paper cups with medicines, handwritten room numbers were left unattended.

Patient 15's cup contained the following medications:

Lovenox (to treat or prevent blood clots in the vein) 40 Milli grams (mg - unit of measureent) injection syringe,
Protonix (medicine to treat/ reduce acid in stomach) 40 mg tablet
prednisone (steroid to treat inflammation) 20 mg x 3 tablets.

Patient 16's cup contained the following medications:

Lovenox 40 mg injection syringe
Protonix 40 mg tablet
prednisone 20 mg x2 tablets
Abilify (anti depressant) 10 mg tablet
Lexapro (medicine to treat mood disorder) 20 mg tablet
Buspar (anxiety medicine) 5 mg x3 tablets
Lamictal (seizure [a condition that causes abnormalities in muscle tone or movements] medicine) 200 mg tablet
Nicotine transdermal patch (medicine used to help quit smoking or to treat withdrawal from smoking) .

During a concurrent observation and interview on January 23, 2024, at 9:10 AM, with RN 8, outside of Patient 16's room, RN 8 stated he had already gotten the patient medications and his next patient medication for 9:00 AM, medication pass. RN 8 stated he had removed both Patient 15 and Patient 16's medication from the medication room.

During a concurrent observation and interview on January 23, 2024, at 9:40 AM, with RN 8, RN 8 donned (put on) gloves, mask, and gown prior to entering Patient 16's room. RN 8 stated Patient 16 was on contact precautions because of pneumonia and pending laboratory test results. RN 8 entered into Patient 16's room with Patient 15's medications.

During an observation on January 23, 2024, at 9:45 AM, in Patient 16's room, RN 8 excused himself from the room to get requested pain medication and alcohol swabs for Patient 16. Both Patient 15 and Patient 16 medications were left on RN 8's WOW in Patient 16's room unattended by staff.

During an interview on January 23, 2024, at 10:35 AM, with RN 8, RN 8 stated he removed both Patient 15 and Patient 16's medications at the same time to save time and be more efficient with medication pass. RN 8 stated having both patient's medications on the workstation at the same time could increase the chance of making an error and giving the wrong medication to the wrong patient.

During a concurrent interview and record review on January 25, 2024, at 11:15 AM, with the Director of Pharmacy Department (DPD), the facility's P&P titled, "Automated Dispensing Machines-Removing Medications", dated March 2023, was reviewed. The P&P indicated, "Policy: Medications will be removed from the automated dispensing machine for only one patient at a time ...". The DPD stated, nursing should only remove one patient medications for medication administration, removing multiple patients' medications was not a safe medication practice and could lead to a medication error.

During an interview on January 26, 2023, at 10:50 AM, with the Infection Control Preventionist (ICP), the ICP stated medications should not be taken into another patient's room, especially if patient is on contact precautions. The ICP stated, this practice could spread infection.

A review of the facility's P&P titled, "Medication Administration", dated March 2023, indicated, " ...No medication will be left at the patient's bedside except for the following: nitroglycerin, sublingual tabs, respiratory inhalers and external preps for topical application ...Personnel administering the medications must remain with the patient until all oral medication has been swallowed ...Medications will be prepared immediately prior to administration ...".
A review of the facility's P&P titled, "Patient Rights and Responsibilities" dated September 2023. Indicated, " ...Addendum A Patient Bill of Rights ...4. The right to receive care in a safe setting ...".

Based on interview and record review, the hospital did not ensure an effective and ongoing hospital wide program for a universe of 34 patients admitted on January 22, 2024, when the facility failed to monitor, collecting data and analyze the process of the medication administration, implementation of transmission-based precaution (used to help stop the spread of germs from person to another), and the utilization of Personal Protective Equipment (PPE- disposable equipment worn to decrease exposure to germs).

This failure had resulted in the missed opportunities to identify issues and created changes to improve patients' health outcomes and had the potential to cause a preventable adverse patient outcome that could negatively affect patients' health and safety.

Findings:

During an interview on January 26, 2024, at 8:55 AM, in the conference room, with the Director of Pharmacy Department (DPD) and Pharmacist 1 (Pharm 1), the DPD stated, the department had not observed, tracked, or collected data regarding the "medication pass [med pass-a process of giving medication to patient]."

A follow-up interview and record review on January 26, 2024, at 9:00 AM, with the DPD and Pharm 1, the facility's document titled, "Performance Improvement Quality Council/Committee," dated November 30, 2023, was reviewed. The "Performance Improvement Quality Council/Committee" indicated, the "medication administration" received 100 percent (%) with no issues identified. There was no documentation of data collection and analysis, description for mitigation plans or person responsible. The DPD verified and stated, the data did not come from the pharmacy department. The DPD further stated, there were no opportunities of med pass to observe in the year of 2023 from the pharmacy department.

A follow-up interview and record review on January 26, 2024, at 9:20 AM, with the DPD, the facility's document titled, "2023 Performance Improvement Dashboard [Hospital Name]," undated, was reviewed. The "2023 Performance Improvement Dashboard [Hospital Name]" indicated, "medication pass audits" goal was set at 95% and no opportunities were listed. The DPD stated, as discussed, there was no opportunities to identify issues.

A review of the facility's document titled, "2023 Performance Improvement Dashboard [Hospital Name]," undated, indicated, there was no indicators or data regarding the transmission-based precautions or PPE.

During a concurrent interview and record review on January 26, 2024, at 10:05 AM, in the conference room, with the Infection Control Preventionist (ICP), the "Job Description" for "Infection Control Preventionist", dated July 2021, was reviewed. The "Job Description" indicated, " ...Job Summary: The Infection Control Preventionist is responsible for surveillance, prevention and control of infection ... Assists with policy and procedure development and implementation ...Acts as primary education consultant to hospital employees, physicians, Patients, volunteers and visitors in safe Infection Control/Prevention practices. Coordinates all hospital infection control activities with the infection control committee, Medical Staff and hospital employees..." The ICP stated, there was no system in place for monitoring the implementation of transmission-based precautions and PPE.

During an interview on January 26, 2024, at 10:45 AM, in the conference, with the Director of Quality Department (DQD), the DQD stated, there was no data collection from the pharmacy or nursing department to show the appropriate medication administration practice such as the proper administration technique used. The DQD further stated, there was no data from the infection control regarding the monitoring or tracking of PPE usage.

A review of the facility's document titled, "Amended & [and] Restated Governing Board Bylaw," reviewed September 6, 2023, indicated, " ...the primary purpose of the Hospital is to provide quality health care in a cost effective manner with the maintenance of high standards of care, the availability of resources, and the expectations of the Practitioners and the community served by the Hospital ... supporting the Hospital's Performance Improvement Programs and its initiatives and the Hospital's Patient Safety Program ..."

Based on interview, and record review, the hospital failed to maintain an effective and ongoing hospital wide, data driven Quality Assessment and Performance Improvement (QAPI) program for a universe of 34 patients admitted on January 22, 2024, when the facility failed to identify the collected data of the issues regarding nursing assessment, documentation, medication administration, and infection control practices to improve patient outcomes.

This failure resulted in the hospital inability to focus on problem prone areas to ensure the provision of quality nursing and patient safety and had the potential to cause adverse health outcomes which could interfere with patients' medical care and jeopardize the health and safety of the patients.

Findings:

During an interview on January 26, 2024, at 8:55 AM, in the conference room, with the Director of Pharmacy Department (DPD) and Pharmacist 1 (Pharm 1), the DPD stated, the department had not observed, tracked, or collected data regarding the "medication pass [med pass-a process of giving medication to patient]" observation.

A follow-up interview and record review on January 26, 2024, at 9:00 AM, with the DPD and Pharm 1, the facility's document titled, "Performance Improvement Quality Council/Committee," dated November 30, 2023, was reviewed. The "Performance Improvement Quality Council/Committee" indicated, the "medication administration" received 100 percent (%) with no issues identified. The DPD verified and stated, the data did not come from the pharmacy department. The DPD further stated, there were no opportunities of med pass to observe in the year of 2023 from the pharmacy department.

During a concurrent interview and record review on January 26, 2024, at 9:45 AM, in the conference, with the Director of Quality Department (DQD), the facility's document titled, "Performance Improvement Quality Council/Committee," dated November 30, 2023, was reviewed. The "Performance Improvement Quality Council/Committee" indicated, the nursing assessment, documentation, and medication administration received 100% with no issues identified. The DQD verified and confirmed the results. The survey team brought up some issues identified during survey such as missing nursing assessment and documentation for an Intensive Care Unit (ICU) patient who was on a titratable (the process of adjusting the dose of a medication for the maximum benefit without adverse effects) medication, and the inappropriate medication administration observation during med pass in the Medical Surgical Telemetry [monitoring of heart activity] (MST) Unit. The DQD stated, each service area would be responsible to conduct its own audit and his department would collect data. Based on the results, the DQD stated, there was no identification of issues.

During an interview on January 26, 2024, at 9:50 AM, in the conference room, with the Infection Control Preventionist (ICP), the ICP stated, in December 2023, hand hygiene was identified with 90% compliance from the goal of 100%. The survey team brought up some issues identified during survey such as missing hand washing, wrong implementation of transmission-based precaution (used to help stop the spread of germs from person to another), and not utilize Personal Protective Equipment (PPE- disposable equipment worn to decrease exposure to germs) appropriately. The ICP stated, there was no tracking regarding the implementation of transmission-based precaution with the usage of at this facility, so the issues were not identified.

A follow-up concurrent interview and record review on January 26, 2024, at 10:05 AM, with the DQD, the facility's document titled, "Medical Record Review Abstraction Form," undated, was reviewed. The "Medical Record Review Abstraction Form" did not include the nursing assessment or documentation for the titratable medication. The DQD confirmed and stated, the pharmacy department would track patients who were on the titratable medication.

A follow-up concurrent interview and record review on January 26, 2024, at 10:15 AM, with the DQD and Pharm 1, the facility's document titled, "Titratable Drips [Medication] Audit Tool," dated from January 8, 2024, through January 16, 2024, was reviewed. The "Titratable Drips Audit Tool" indicated, there were 16 opportunities to review on the titratable medication with seven (7) incidents of the nursing staff missed the components for appropriate documentation. Pharm 1 verified and stated, he used this tool to check patients who were on the titratable medication; however, he only reviewed the administration of medication to ensure the nursing staff followed an order. Pharm 1 further stated, he did not check any nursing assessment or documentation to identify issues.

A follow-up interview on January 26, 2024, at 10:20 AM, with the DQD, the DQD stated, the medication administration data came from each nursing department combined since the pharmacy department has not conducted any med pass observation.

During an interview on January 26, 2024, at 10:25 AM, in the conference room, with the DQD and Registered Nurse 6 (RN 6), RN 6 stated, she had some opportunities to observe med pass and identified issues from the nursing staff; however, she did not report to anyone. RN 6 further stated, she discussed infection control practices with staff such as hand hygiene, the transmission-based precaution and PPE, but she did not observe the implementation or practices from the nursing staff.

A follow-up interview on January 26, 2024, at 10:45 AM, with the DQD, the DQD confirmed, the collected data of nursing assessment and documentation did not capture some components of nursing services such as monitoring of titratable medication. The DQD stated, the medication administration data also did not provide the whole process of med pass from the pharmacy department. The DQD further stated, the hand hygiene has not met the set goal of 100% compliance, only achieved about 95%, so the facility still has to address this issue. The DQD confirmed, the facility had missed many opportunities to identify, plan and implement actions to improve patients care for many problems prone areas.

A review of the facility's document titled, "Amended & [and] Restated Governing Board Bylaw," reviewed September 6, 2023, indicated, " ...the primary purpose of the Hospital is to provide quality health care in a cost effective manner with the maintenance of high standards of care, the availability of resources, and the expectations of the Practitioners and the community served by the Hospital ... supporting the Hospital's Performance Improvement Programs and its initiatives and the Hospital's Patient Safety Program ..."

Based on observation, interview, and record review, the facility failed to ensure the nursing staff supervise and evaluate the plan of care for one of 30 sampled patients (Patient 2) when the nursing staff did not follow up or clarify on the STAT (as soon as possible) order for an Electroencephalogram (EEG-a test that record the brain activities) to ensure it was completed as ordered and did not closely monitor Patient 2 in response with seizure (SZ-a condition that causes abnormalities in muscle tone or movements) activity in the Medical Surgical Telemetry [monitoring of heart activity] (MST) Unit.

This failure had resulted in delay of providing an accurate medical diagnosis, creating disbelief from Patient 2's family towards the healthcare team, and inadequate patient monitoring during SZ activity that could interfere with proper treatment plan and compromise Patient 2's safety which could negatively affect Patient 2's health, safety, and lead to actual harm or death.

Findings:

A review of Patient 2's "History and Physical" (H&P), dated January 21, 2024, the H&P indicated, Patient 2 was admitted into the facility for SZ.

During an observation on January 23, 2024, at 11:04 AM, in the MST Unit, Registered Nurse 3 (RN 3) was observed coming out of Patient 2's room, rattling and cranking noise was heard from inside the room. RN 3 walked to the medication room and stated Patient 2 was having a SZ. Inside patient's room, Patient 2 was observed lying in bed with SZ pad around the bed rails. Patient 2's boyfriend was standing next to the bed.

During an interview on January 23, 2024, at 11:05 AM, with Patient 2's boyfriend, Patient 2's boyfriend stated, Patient 2 was admitted for a witnessed SZ and had been having multiples SZ since admission. He further stated, the EEG was completed this morning which he expressed concern of the delayed in obtaining the EEG to give him information about Patient 2's SZ.

A follow-up observation on January 23, 2024, at 11:06 AM, RN 3 was observed back into Patient 2's room with syringes. RN 3 informed Patient 2 and Patient 2's boyfriend that she had an Ativan (a sedation medication that can be used to treat SZ) to give to Patient 2. Upon receiving permission, RN 3 administered medication to Patient 2 through an intravenous (IV-into the vein) catheter.

A follow-up interview on January 23, 2024, at 11:20 AM, RN 3 stated, when she was in the room talking to Patient 2 and her boyfriend, she observed Patient 2's whole body started to shake. RN 3 further stated, she came out of the room to get Ativan to give to patient and there was no other nursing staff in the room with Patient 2.

During an interview on January 23, 2024, at 2:00 PM, in the conference room, with the Chief Nursing Officer (CNO), the CNO stated, there was no specific policy for SZ.

During a concurrent interview and record review on January 23, 2024, at 3:45 PM, in the conference room, with RN 4, Patient 2's "Order" for EEG, dated January 21, 2024, at 4:23 PM, was reviewed. The "Order" indicated, the EEG was ordered as a STAT order. RN 4 verified and confirmed the order status. RN 4 stated, the nursing staff should have called to arrange for the test to be completed as soon as possible. RN 4 further stated, she was unable to provide any documented evidence that the nursing staff followed up on the order to ensure its completion. RN 4 confirmed, an EEG was completed on January 23, 2023, more than 24 hours after the order was placed.

During a concurrent interview and record review on January 24, 2024, at 10:20 AM, in the conference room, with the Director of MST Unit (DMST), Patient 2's "Patient Notes," dated January 23, 2024, at 11:07 AM, was reviewed. The "Patient Notes" indicated, Patient 2 had SZ activity. The DMST stated, there was no specific policy for SZ however, the nursing staff was expected and required to stay with patients during SZ activity. The DMST further stated, the nursing staff should not leave patients to ensure safety, however can request other nursing staff to obtain any necessary items such as medication to assist with the incident.

A review of the facility's Registered Nurse Job Description, undated, indicated, "The Registered Nurse is responsible for the delivery of safe patient care utilizing the nursing process of assessment, planning, implementation and evaluation ... The Registered Nurse is directly responsible and accountable for the care given to their assigned patients ..."

Based on interview and record review, the facility failed to ensure the nursing staff followed the policies and procedures (P&P) for medication administration and storage for two of 30 sampled patients (Patient 3 and 4) in the Medical Surgical Telemetry [monitoring of heart activity] (MST) Unit when:

1. For Patient 3, Enoxaparin (Lovenox-medication to treat or prevent blood clot) syringe was left on the side table.

2. For Patient 4, patient's own medications (POM) were left on the side table.

These failures had the potential for unauthorized personnel to have access to medications and patients to misuse on medications which could negatively affect patients' health, safety, and lead to actual harm or death.

Findings:

1. A review of Patient 3's "History and Physical" (H&P), dated January 18, 2024, the H&P indicated, Patient 3 was admitted into the facility for shortness of breath with past medical history of congestive heart failure (CHF-a condition that heart does not pump blood well to the body).

During an observation on January 22, 2024, at 10:17 AM, in Patient 3's room, Patient 3 was observed lying in bed with an unused syringe of Lovenox 30 milligrams (mg-unit dosing medication) on the side table.

During an interview on January 22, 2024, at 10:23 AM, with Registered Nurse 1 (RN 1), RN 1 stated, he already administered Lovenox to Patient 3.

A follow-up concurrent observation and interview on January 22, 2024, at 10:27 AM, with RN 1, an unused syringe of Lovenox 30 mg was observed on the side table. RN 1 verified and stated, he did not see this syringe when he was previously in the room. RN 1 further stated, he did not know how long this syringe was left here. RN 1 confirmed, medication should not be left unattended at the bedside.

During an interview on January 26, 2024, at 9:05 AM, in the conference room, with the Director of Pharmacy Department (DPD) and Pharmacist 1 (Pharm 1), the DPD stated, the nursing staff might accidentally pull extra doses of medication; however, the extra dose that was not administered to patient should either be wasted or returned. The DPD further stated, per policy, medication should not be left at the bedside.

A review of the facility's P&P titled, "Medication Administration," dated March 2023, the P&P indicated, "Policy: Medications will be administered only upon the order of physicians ... No medication will be left at the patient's bedside ..."

2. A review of Patient 4's H&P, dated January 17, 2024, the H&P indicated, Patient 4 was admitted into the facility for altered mental status (AMS).

During a concurrent observation and interview on January 22, 2024, at 9:35 AM, in Patient 4's room, Patient 4 was observed lying in bed with a bag of medication bottles on the side table. Patient 4 stated, she did not know how or why the medications were there. The bag with medication bottles included as follow:

Memantine (medication to treat memory loss) 5 mg.
Gabapentin (medication to treat seizure [a condition that causes abnormalities in muscle tone or movements]) 300 mg.
Folate (vitamin supplement) 666 micrograms (mcg-unit dosing medication).
Amlodipine (medication to treat high blood pressure) 2.5 mg.
Atorvastatin (medication to treat high cholesterol) 20 mg.
Carvedilol (medication to treat high blood pressure) 12.5 mg.
Levothyroxine (medication for thyroid) 100 mcg.
Fluoxetine (medication to treat depression) 10 mg.
Aspirin (medication to treat minor pain) 81 mg.
Insulin pen (medication to control blood sugar).

During an interview on January 22, 2024, at 9:45 AM, in Patient 4's room, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated, POM needed to be sent to the pharmacy department to check and would be given back to patients upon discharge. LVN 1 further stated, POM should not be kept at the bedside for anyone to be able to access.

A follow-up concurrent observation and interview, on January 22, 2024, at 9:50 AM, with LVN 1, a bag of medication bottles was observed on the side table. LVN 1 verified and stated, she did not see this bag of medication bottles when she was previously in the room. LVN 1 confirmed, medication bottles should have been sent to the pharmacy department and should not be left on the side table.

During an interview on January 26, 2024, at 9:10 AM, in the conference room, with the DPD and Pharm 1, the DPD stated, per policy, POM should not be kept at the bedside but sent to the pharmacy department. The DPD further stated, the nursing staff was responsible to ensure POM was not left inside patients' room.

A review of the facility's P&P titled, "Patient's Own Medications: Use, Storage, Destruction," dated March 2023, the P&P indicated, "Policy: ... The contents of the containers have been examined, positively identified and the integrity evaluated by the hospital's Pharmacist ... The patient will not be allowed to self-medicate or keep his/her own medication at the bedside, with exceptions made under special circumstances, see "Bedside Medication" policy. The medication will be kept in the pharmacy department and will be dispensed on a daily basis, stored in patient's cassette ..."

Based on observation, interview, and record review, the facility failed to ensure the nursing staff administered medications as ordered and followed the acceptable standards of practices during medication administration of 30 sampled patients when:

1. For Patient 1, the nursing staff did not administer Colace (stool softener) appropriately.

2. For Patient 1, the nursing staff did not administer Fluoxetine (Prozac-medication to treat depression) appropriately.

3. For Patient 10, the nursing staff did not check blood pressure (BP) before Hydralazine (medication to treat high blood pressure) administration.

4. For Patient 12, the nursing staff did not check blood sugar (BS) as ordered.

These failures had resulted in preventable medication errors with unsafe medication administration and had the potential to cause adverse health outcomes such as inadequate therapy for treatment, inadequate patient monitoring of BP, and uncontrolled BS, which could negatively affect patients' health, safety, prolonged hospitalization, and lead to actual harm or death.

Findings:

1. A review of Patient 1's "History and Physical" (H&P), dated January 18, 2024, the H&P indicated, Patient 1 was admitted into the facility for hypoxemia (low oxygen in blood) with medical histories including chronic respiratory failure (a condition when lungs cannot get enough oxygen) with tracheostomy (trach - a tube placed into the trachea via the neck to assist with breathing) and ventilator (a machine to assist in delivery of oxygen) dependent, and diabetes (a condition that body cannot control blood sugar).

During an observation on January 23, 2023, at 9:50 AM, in the Medical Surgical Telemetry [monitoring of heart activity] (MST) Unit, Patient 1 was lying in bed with a trach attached to a ventilator, Registered Nurse 3 (RN 3) was observed using a needle to puncture a capsule of Colace 100 milligrams (mg-unit dosing medication), squeezed out the clear gel substance inside the capsule onto Patient 1's apple sauce, and administered to Patient 1.

A follow-up interview on January 23, 2023, at 10:10 AM, RN 3 verified and confirmed of using needle to puncture a capsule of Colace, squeezed out the content inside onto Patient 1's apple sauce, and administered to Patient 1. RN 3 stated, Patient 1 could not swallow capsules, so she gave the substance inside Colace to Patient 1. RN 3 further stated, she did not check with a pharmacist before she administered Colace.

During an interview on January 23, 2023, at 2:05 PM, in the conference room, with Pharmacist 1 (Pharm 1), Pharm 1 stated, the department would provide Colace in liquid form for patients who could not swallow medication. However, the nursing staff needed to inform the pharmacy department and request to change from capsule to liquid form as appropriate. Pharm 1 stated, it was not appropriate to squeeze out the gel inside Colace's capsule to give to patient.

A review of the facility's policies and procedures (P&P) titled, "Medication Administration," dated June 2023, the P&P indicated, "Policy: To safely administer medication in the manner specified by the physician ... If there are any questions regarding the medication, contact the Pharmacist and/or refer to an appropriate medication reference ..."

2. A review of Patient 1's H&P, dated January 18, 2024, the H&P indicated, Patient 1 was admitted into the facility for hypoxemia with medical histories including chronic respiratory failure with a trach and ventilator dependent, and diabetes.

During an observation on January 23, 2023, at 9:50 AM, in the MST Unit, Patient 1 was lying in bed with a trach attached to a ventilator, RN 3 was observed opening a capsule of Prozac 10 mg, poured the white powder inside the capsule onto Patient 1's apple sauce, and administered to Patient 1.

A follow-up interview on January 23, 2023, at 10:10 AM, RN 3 verified and confirmed of opening a capsule of Prozac to get the powder inside, poured the white powder inside the capsule onto Patient 1's apple sauce, and administered to Patient 1. RN 3 stated, she did not check with a pharmacist before she administered Prozac.

During a concurrent interview and record review on January 23, 2023, at 2:55 PM, in the conference room, with Pharm 1, Patient 1's "Medication Administration Record" (MAR) for Prozac, dated January 18, 2024, was reviewed. The MAR indicated, 10 mg or one capsule was ordered to be given. Pharm 1 verified and stated, there was no specific instruction to stop the nursing staff from opening the capsule. However, capsules should not be opened, and the nursing staff should check with the pharmacy department before giving medication outside of the original form. Pharm 1 stated, for Prozac, the nursing staff should not open the capsule since the medication would not be effective to patients.

A review of the facility's P&P titled, "Medication Administration," dated June 2023, the P&P indicated, "Policy: To safely administer medication in the manner specified by the physician ... If there are any questions regarding the medication, contact the Pharmacist and/or refer to an appropriate medication reference ..."

3. A review of Patient 10's H&P, dated January 20, 2024, the H&P indicated, Patient 10 was admitted into the facility for cough with a diagnosis of chronic obstructive pulmonary disease (COPD-a group of disease that cause blockage in airflow) exacerbation on oxygen, and history of high blood pressure.

A review of Patient 10's "Medication Order" for Hydralazine, dated January 20, 2024, indicated, Hydralazine 50 mg was ordered to be given four times daily.

During an interview on January 25, 2024, at 2:25 PM, in the conference room, with RN 6, RN 6 stated, patients' blood pressure should be assessed and documented before any medication that will affect blood pressure was given.

A follow-up concurrent interview and record review on January 25, 2024, at 2:30 PM, with RN 6, Patient 10's MAR for Hydralazine, dated January 21, 2024, from 8:00 AM through 1:00 PM, was reviewed. The MAR indicated as follow:

At 8:36 AM: 50 mg given.
At 12:58 PM: 50 mg given.

RN 6 verified and confirmed Hydralazine administration. RN 6 stated, Hydralazine would affect patients' blood pressure so blood pressure should be assessed before the medication was given.

A follow-up concurrent interview and record review on January 25, 2024, at 2:35 PM, with RN 6, Patient 10's "Vital Signs [VS-a measurements of the body's most basic function such as heart rate and BP]," dated January 21, 2024, from 8:00 AM through 1:00 PM, were reviewed. The VS indicated as follow:

At 8:00 AM: BP 167/87 MAP 113
At 4:00 PM: BP 153/84 MAP 107

RN 6 verified and confirmed the blood pressure measurement. RN 6 stated, there was no blood pressure taken before 12:58 PM dose of Hydralazine given. RN 6 further stated, the nursing staff did not follow the P&P for medication administration.

A review of the facility's P&P titled, "Medication Administration," dated June 2023, the P&P indicated, "Policy: To safely administer medication in the manner specified by the physician ... Prior to giving medications which will affect blood pressure or heart rate, check apical pulse rate and/or blood pressure. Hold medications if patient is bradycardic (less than 60), hypotensive or according to parameters ordered by physician and notify physician if medications held ..."

4. A review of Patient 12's H&P, dated January 17, 2024, the H&P indicated, Patient 12 was admitted into the facility for COPD exacerbation with medical histories including high blood pressure and diabetes.

A review of Patient 12's "Orders" for Blood Glucose (blood sugar or BS) Monitoring, dated January 16, 2024, indicated, monitor of BS was ordered to be completed before meals and at bedtime.

During a concurrent interview and record review on January 25, 2024, at 11:55 AM, in the conference room, with the Chief Nursing Officer (CNO), Patient 12's "POC [Point of Care] Glucose - History" dated January 22, 2024, was reviewed. The "POC Glucose - History" indicated as follow:

At 6:35 AM: BS 107 milligrams per deciliter (mg/dl-a unit measure of BS level with reference value between 70-105 mg/dl)
At 10:03 PM: BS 163 mg/dl

The CNO verified and confirmed BS testing was missing before lunch and dinner time. The CNO stated, she was unable to find any documented evidence to justify the missing BS testing. The CNO further stated, there was no specific policy regarding checking of BS; however, the nursing staff had to follow a physician's order.

During a concurrent interview and record review on January 25, 2024, at 4:15 PM, in the conference room, with RN 7, Patient 12's "POC Glucose - History" dated January 22, 2024, was reviewed. The "POC Glucose - History" indicated, the BS testing was not completed before lunch and dinner time. RN 7 verified and confirmed, she did not check Patient 12's BS since she was busy. RN 7 stated, she knew Patient 12 would refuse the test because Patient 12 refused in the morning; however, she did not ask Patient 12 again during lunch or dinner time.

A review of the facility's Registered Nurse Job Description, undated, indicated, "The Registered Nurse is responsible for the delivery of safe patient care utilizing the nursing process of assessment, planning, implementation and evaluation ... The Registered Nurse is directly responsible and accountable for the care given to their assigned patients ..."

A review of the facility's P&P titled, "Medication Administration," dated June 2023, indicated, "Policy: To safely administer medication in the manner specified by the physician ..."

Based on interview and record review, the facility failed to ensure the nursing staff monitored patients appropriately and as ordered during the continuous intravenous (IV-Into the vein) infusion for one of 30 sampled patients (Patient 5) when the nursing staff did not assess Patient 5's blood pressure (BP) and titrate (the process of adjusting the dose of a medication for the maximum benefit without adverse effects) Norepinephrine (Levophed-a medication to treat life-threatening low BP) appropriately.

This failure had resulted in an unsafe medication administration and monitoring of Patient 5 which could adversely affect Patient 5's responses without proper dosing adjustment and monitoring and could jeopardize Patient 5's health and safety, leading up to actual harm and possible death.

Findings:

A review of Patient 5's "History and Physical" (H&P), dated January 18, 2024, the H&P indicated, Patient 5 was admitted into the facility for decreased responsiveness and seizure (SZ-a condition that causes abnormalities in muscle tone or movements).

During an interview on January 24, 2024, at 1:30 PM, in the conference room, with Pharmacist 1 (Pharm 1), Pharm 1 stated, the nursing staff needed to monitor and assess patients' blood pressure during the titration of medication based on the frequency ordered. Pharm 1 further stated, for example, Levophed was ordered to be titrated every five minutes to achieve BP goal. When the nursing staff needed to titrate Levophed, the nursing staff needed to monitor and document patients' BP every five minutes. Once patients' BP was stable, the nursing staff would follow the unit protocol to monitor BP every two hours.

A review of Patient 5's "Medication Order" for Levophed, dated January 18, 2024, indicated to start the medication at 0.1 microgram per kilogram per minute (mcg/kg/min-a unit dosing medication) and titrate by 0.03 mcg/kg/min every 5 mins to achieve goal of mean arteria pressure (MAP) above 65.

During a concurrent interview and record review on January 25, 2024, at 2:00 PM, in the conference room, with Registered Nurse 5 (RN 5), Patient 5's "Medication Administration Record" (MAR) for Levophed, dated January 18, 2024, from 11:00 AM through 3:00 PM was reviewed. The MAR indicated as follow:

At 11:28 AM: the infusion rate set at 0.4 mcg/kg/min.
At 2:00 PM: the infusion rate set at 0.37 mcg/kg/min (decrease 0.03 mcg/kg/min from previous).
At 3:00 PM: the infusion rate set at 0.34 mcg/kg/min (decrease 0.03 mcg/kg/min from previous).

RN 5 verified and confirmed the titration of Levophed.

A follow-up concurrent interview and record review on January 25, 2024, at 2:05 PM, with RN 5, Patient 5's "Vital Signs [VS-a measurements of the body's most basic function such as heart rate and BP]," dated January 18, 2024, from 2:00 PM, through 7:58 PM, were reviewed. The VS indicated as follow:

At 2:00 PM: BP 124/95 MAP 105
At 3:00 PM: BP 128/87 MAP 101 (60 mins from previous)
At 3:36 PM: BP 141/75 (36 mins from previous)

RN 5 verified and confirmed the nursing staff did not check Patient 5's BP appropriately after the titrating of Levophed to ensure that Patient 5 was able to tolerate the adjustment of Levophed.

During an interview on January 26, 2024, at 8:45 AM, in the conference room, with the Director of Pharmacy Department (DPD) and Pharm 1, Pharm 1 stated, he reviewed Patient 5's chart and confirmed Patient 5 was on 2 medications including Levophed and Neo-synephrine to control BP on January 18, 2024, at 5:00 PM.

A follow-up concurrent interview and record review on January 26, 2024, at 8:50 PM, with the DPD and Pharm 1, Patient 5's VS, dated January 18, 2024, at 4:00 PM through 7:58 PM, was reviewed. The VS indicated as follow:

At 4:00 PM: BP 101/80 MAP 87 (24 mins from previous)
At 4:13 PM: BP 124/87 (13 mins from previous)
At 5:00 PM: BP 153/81 MAP 105 (57 mins from previous)
At 7:58 PM: BP 114/74 (2 hours and 58 mins from previous)

The DPD and Pharm 1 verified and stated, Patient 5's BP at 5:00 PM, should be rechecked for accuracy or medication should be titrated down. The DPD further stated, it was unsafe to keep patients on medications when BP was high since patient could have negative effect from medication such as stroke (a condition of losing blood flow to the brain).

A review of the facility's policies and procedures (P&P) titled "Titrating Medications," dated March 2023, the P&P indicated, "Policy: It is the policy of this institution to allow orders for medication titration, which is the progressive increase or decrease of the medication dose in response to the patient's clinical status ... Clinical staff must assess the patient frequently when titrating medications to detect potential problems as early as possible ..."

Based on observation, interview, and record review, the hospital failed to ensure the nursing staff implemented the prevention and control of infection for five (5) of 30 sampled patients (Patient 1, 2, 16, 27, and 29) when

1. For Patient 2, the nursing staff cleaned the intravenous injection (IV-a device that allows medication to be given through a vein) port with a used alcohol wipe after the medication administration.

2. For Patient 1, 27 and 29, the Intravenous infusion tubing (tubing that administers fluids and medication onto a patient's vein) was not labeled and dated.

3. For Patient 16, Registered Nurse 8 (RN 8) did not clean/disinfect the IV port during two medication administration opportunities.

These failures had the potential to result in cross-contamination (the transfer of harmful bacteria) causing a preventable bloodstream infection which can negatively affect patients' health and prolonged hospitalization.

Findings:

1. A review of Patient 2's "History and Physical" (H&P), dated January 21, 2024, the H&P indicated, Patient 2 was admitted into the facility for seizures (SZ-a condition that causes abnormalities in muscle tone or movements).

During an observation on January 23, 2024, at 11:04 AM, in the Medical/Surgical Unit, RN 3 was observed coming out of Patient 2's room, rattling and cranking noise was heard from inside the room. RN 3 walked to the medication room and stated Patient 2 was having SZ. Inside patient's room, Patient 2 was observed lying in bed with SZ pad around the bed rails. Patient 2's boyfriend was standing next to the bed.

During an interview on January 23, 2024, at 11:05 AM, with Patient 2's boyfriend, Patient 2's boyfriend stated, Patient 2 was admitted for a witnessed SZ and had been having multiples SZ since admission. He further stated, the Electroencephalogram (EEG-a test that record the brain activities) was completed this morning which he expressed concern of the delayed in obtaining the EEG to give him information about Patient 2's SZ.

A follow-up observation on January 23, 2024, at 11:06 AM, RN 3 was observed back into Patient 2's room with syringes. RN 3 informed Patient 2 and Patient 2's boyfriend that she had an Ativan (a sedation medication that can be used to treat SZ) to give to Patient 2. Upon receiving permission, RN 3 wiped or disinfected (kill germs) IV port with an alcohol wipe, placed a used alcohol wipe onto Patient 2's bed, administered medication to Patient 2 through IV port, and picked up a previously used alcohol wipe left on Patient 2's bed and wiped IV port.

A follow-up interview on January 23, 2024, at 11:20 AM, with RN 3, RN 3 verified and confirmed using the same alcohol wipe to disinfect Patient 2's IV port before and after medication administration.

During a concurrent interview and record review on January 23, 2024, at 4:00 PM, in the conference room, with RN 4, Patient 2's "Medication Administration Record" (MAR) for Ativan, dated January 23, 2024, at 11:06 AM, was reviewed. The MAR indicated, Patient 2 was given 1 milligrams (mg-unit dosing medication) of Ativan. RN 4 stated, the nursing staff should never use the same alcohol wipe to clean or disinfect IV port before and after the medication administration, it is a single use. RN 4 further stated, using the same alcohol wipe would increase the risk of introducing infection to Patient 2.

A review of the facility's policies and procedures (P&P) titled, "Standard and Transmission Based Precautions," dated March 2023, the P&P indicated, "Policy: It is the policy of [Hospital Name] to provide an effective means of isolation, based on the Center for Disease Control and Prevention (CDC) Guidelines, for Standard and Transmission based precautions ... 7. Patient Care Equipment: ... ensure that single-use items are discarded properly ..."


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2a. During a review of Patient 1's H&P, dated January 19, 2024, the H&P indicated, Patient 1 was admitted with diagnoses including pneumonia (an infection in the lung), Chronic Obstructive Pulmonary disease (COPD- a long-lasting disease where the airways in the lungs are damaged), and diabetes mellitus type 2 (the body does not make enough insulin or does not use insulin well).

During an observation on January 22, 2024, at 10:54 AM, in Patient 1's room, Patient 1 had Vancomycin (antibiotics) 1,000 mg in 250 milliliter (ml-unit of measurement) Dextrose (fluid used to give medications through IV) connected to her IV. The tubing was not labeled.

2b. During a review of Patient 27's H&P, dated January 16, 2024, the H&P indicated, Patient 27 was admitted with diagnoses including small bowel obstruction (a blockage in the small intestine) and ileocecal mass (area of thickening in the in the large intestine).

During an observation on January 22, 2023, at 11:03 AM, in Patient 27's room, there was Total parenteral nutrition (TPN- a special formula given through a vein providing nutrients the body needs) infusing into patients IV. The IV tubing for the TPN was not labeled.

During a concurrent observation and interview on January 22, 2024, at 11:20 AM, with RN 3, RN 3 stated Patient 27's TPN tubing was not labeled but should be labeled because it needs to be changed every 24 hours to prevent infection.

2c. During a review of Patient 29's H&P, dated January 8, 2024, the H&P indicated, Patient 29 was admitted with diagnoses including anemia (not enough red blood cells to transport nutrients and oxygen to organs), right pleural effusion (a buildup of fluids between the lungs and the chest cavity), and chronic kidney disease (progressive loss of kidney function).

During an observation on January 22, 2024, at 10:40 AM, in Resident 29's room, there were IV fluids and a secondary medication Mycamine (a medication used to treat fungal infection) hanging on IV pole and attached to Patient 29's IV. The tubing was not labeled.

During an interview on January 22, 2024, at 10:48 AM, with Chief Nursing Officer (CNO), the CNO stated all IV tubing should be dated and initialed because the tubing needs to be changed at least every four days.

During a concurrent observation and interview on January 22, 2024 at 11:20 AM, with RN 3, RN 3 stated Resident 27's TPN tubing was not labeled, but should be labeled because it needs to be changed every 24 hours to prevent infection.

During a review of the facility's P&P titled, "Intravenous Infusion: Peripheral Lines", dated June 2023, the P&P indicated, "Policy: ... Primary, secondary and extension set tubing are changed every 4 days ... Exceptions: ...Replace tubing used to administer TPN within 24 hours of initiating the infusion ...Intermittent administration of Medication via Direct Line ...1. Prime and date secondary set ...".

3. During a review of Patient 16's H&P, dated January 21, 2024, the H&P indicated, Patient 16 was admitted to the hospital with the diagnoses of hypoxemic respiratory failure related to multifocal pneumonia (not enough oxygen is provided to the blood and body because of an infection in more than one area of the lungs), sepsis (the body's response to infection that can damage vital organs), and recent flu infection (a viral infection which can include the respiratory system).

During an observation on January 23, 2024, at 10:06 AM, in Patient 16's room, RN 8 accessed Patient 16's IV port and administered Protonix (medication used to treat heartburn) 40 mg IVP without disinfecting the IV injection port.

During an observation on January 23, 2024, at 10:21 AM, in Patient 16's room, RN 8 accessed Patient 16's IV port and administered Morphine (medication used to treat severe pain) 1 mg IVP without disinfecting the IV injection port.

During an interview on January 23, 2024, at 10:30 AM, with RN 8, RN 8 stated, he had forgotten to wipe the IV injection port with alcohol wipes before administering both the Protonix and Morphine medications. RN 8 stated the IV injection port is to be cleansed every time medication is given in the IV line is flushed and not cleaning the IV injection port with alcohol could cause bacteria to enter Patient 16's blood stream and cause an infection.

During a review of the facility's P&P titled, "Medication Administration", dated June 2023, the P&P indicated, " ...X. Injectables ...8. Choose appropriate injection site. 9. Cleanse injection site by wiping vigorously with alcohol wipe ...".

Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment to prevent Hospital Acquired Infections (HAI - an infection acquired when receiving health care that was not present during the time of admission) when:

1) Registered Nurse 7 (RN 7) did not clean/disinfect the glucometer (a portable device used to measure blood sugar) properly after use with one of 30 sampled patients (Patient 15) who was on contact isolation precautions (preventative measure to prevent spread of germs from direct and indirect contact).

2) Staff did not wear Personal Protective Equipment (PPE- disposable equipment worn to decrease exposure to germs) per policy and procedure for two of 30 sampled patients (Patient 15 and 16).

These failures had the potential to expose all 32 patients on the Medical surgical/Telemetry (continuus heart montoring) floor which could lead to life threatening infections and prolonged hospitalizations.

Findings:

1. During a review of Patient 15's "History and Physical" (H&P), dated January 21, 2024, the H&P indicated, Patient 15 was admitted to the hospital with the diagnoses of sepsis (the body's response to infection that can damage vital organs) secondary to lower extremity wound, diabetes with hyperglycemia (the body does not make enough insulin or use insulin [hormone produced by the body to use sugar for energy] to well resulting in high blood sugar), and hyponatremia (when the concentration of sodium in the blood is too low).

During an observation on January 24, 2024, at 11:30 AM, outside of Patient 15's room, Registered Nurse7 (RN 7) used the glucometer to obtain Patient 15's blood sugar level. Upon completion of this task, RN 7 took the glucometer out of Patient 15's room and set it on her work station. RN 7 rubbed a used alcohol swab over the top of glucometer and set the glucometer on her workstation outside of Patient 15's room.

During an interview on January 24, 2023, at 11:50 AM, with RN 7, RN 7 stated she was done using the glucometer. RN 7 stated the patient was on contact isolation precautions for Methicillin Resistant Staphylococcus Aureus (MRSA- a germ that is resistant to most antibiotics). RN 7 stated the used alcohol swab was not sufficient to clean the glucometer and she should have used the chlorhexidine (chemical that kills most germs) or bleach wipe to clean the glucometer. RN 7 stated it was important to properly clean the glucometer between patients so infection will not spread from one patient to another.

During an interview on January 25, 2024, at 3:00 PM, with Chief Nursing Officer (CNO), the CNO stated, the glucometer is to be disinfected before and after each patient use with the antiseptic wipes.

During a review of the facility's policy and procedure (P&P) titled, "Point of Care Test (Nursing)", reviewed June 2023, the P&P indicated, " ...Infection and Biohazard Precautions: 9. Cleaning/decontamination procedures should be followed ... 9.1 Meter disinfection for external surfaces should include the use of approved bleach wipes after each patient use, c. Thoroughly wipe the surface of the meter (top, bottom, front and back sides) ...".

2a. During a review of Patient 16's H&P, dated January 21, 2024, the H&P indicated, Patient 16 was admitted to the hospital with the diagnoses of hypoxemic respiratory failure related to multifocal pneumonia (not enough oxygen is provided to the blood and body because of an infection in more than one area of the lungs), sepsis (the body's response to infection that can damage vital organs), and recent flu infection (a viral infection which can include the respiratory system).

During an observation on January 23, 2024, at 9:46 AM, RN 8 exited Patient 16's room and continued to enter the medication supply room to get syringe and alcohol swabs without removing the used PPEs (including gloves and gown).

During an interview on January 23, 2024, at 10:25 AM, RN 8 stated he had forgotten to remove his PPE when exiting the room to retrieve needed supplies for medication administration. RN 8 stated the facility's policy was to remove PPE before exiting the room. RN 8 stated Patient 16 was on contact precautions for pneumonia pending lab results and contact precautions had been implemented. RN 8 further stated if PPE was not removed, it could spread infectious disease from one room to other rooms on the floor.

2b. During a review of Patient 15's H&P, dated January 21, 2024, the H&P indicated, Patient 15 was admitted to the hospital with the diagnoses of sepsis (the body's response to infection that can damage vital organs) secondary to lower extremity wound, diabetes with hyperglycemia (the body does not make enough insulin or use insulin well resulting in high blood sugar), and hyponatremia (when the concentration of sodium in the blood is too low).

During an observation on January 24, 2024, at 11:30 AM, outside of Patient 15's room, a Contact Precaution sign was posted outside the room and a cart with disposable masks, gowns, gloves and antiseptic wipes was located outside the door of the room.

During an observation on January 24, 2024, at 11:31 AM, at patient 15's room, RN 7 performed hand hygiene and donned gloves, she entered Patient 15's room without putting on a gown. RN 7 obtained Patient 15's blood glucose level with glucometer and then exited room.

During an interview on January 24, 2024, at 11:45 AM, with RN 7, RN7 stated Patient 15 was on contact precautions and she should have put on a gown before entering in to Patient 15's room. RN 7 stated the purpose of contact precautions was to prevent the spread of infection.

During a review of the facility's P&P titled, "Standard and Transmission Based Precautions", dated March 2023, the P&P indicated " ... 3. Contact Precautions ...use contact precautions for patients known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact ...or indirect contact ... c. Gown 1) Wear a gown (a clean, non-sterile gown is adequate) when entering the room if you anticipate that your clothing will have substantial contact with the patient, environmental surfaces, or items in the patient's room ...".

Based on interview, and record review, the facility failed to ensure tracking of adherence to infection prevention policies and procedures (P&P) for a universe of 34 patients admitted on January 22, 2024, when the facility failed to have a system in place to audit implementation and interventions for transmission-based precautions (used to help stop the spread of germs from person to another).

This failure had the potential to expose patients to highly contagious diseases (germs that cause illness) that could compromise the facility's ability to ensure the quality of health care which may result in a life-threatening infection and prolong the hospitalization of the vulnerable patients.

Findings:

During an interview on January 26, 2024, at 10:40 AM, with the Infection Control Preventionist (ICP), the ICP stated, there was no tracking for the use of transmission-based precautions or Personal Protective Equipment (PPE- disposable equipment worn to decrease exposure to germs) use at this facility. The ICP stated it was the expectation that the Registered Nurse (RN) and doctor placed the patient on the appropriate transmission-based precautions and all patient care staff wear the required PPEs per P&P. The ICP stated staff was educated on transmission-based precautions at new hire orientation and annually for patient care staff.

During a concurrent interview and record review on January 26, 2024, at 10:05 AM, with the ICP, the "Job Description" for "Infection Control Preventionist", revised on July 2021, was reviewed. The Job Description indicated, " ...Job Summary: The Infection Control Preventionist is responsible for surveillance, prevention and control of infection ... Assists with policy and procedure development and implementation ...Acts as primary education consultant to hospital employees, physicians, Patients, volunteers and visitors in safe Infection Control/Prevention practices. Coordinates all hospital infection control activities with the infection control committee, Medical Staff and hospital employees...". ICP stated there was no system in place for monitoring transmission-based precautions implemented and use of PPE.

Based on observation, interview and record review, the facility failed to ensure the correct infection prevention practice was implemented for one of 30 sampled patients (Patient 16) when an inadequate and inaccurate transmission-based precaution (used to help stop the spread of germs from person to another) was implemented.

This failure had the potential to put all patients, visitors and staff on the medical surgical/telemetry (continuous heart monitoring) floor (area of hospital) at risk of being exposed to a contagious disease (illness caused by spread of germs).

Findings:

During a review of Patient 16's "History and Physical" (H&P), dated January 21, 2024, the H&P indicated, Patient 16 was admitted to the hospital with the diagnoses of hypoxemic respiratory failure related to multifocal pneumonia (not enough oxygen is provided to the blood and body because of an infection in more than one area of the lungs), sepsis (the body's response to infection that can damage vital organs), and recent flu infection (a viral infection which can include the respiratory system).

During a concurrent observation and interview on January 23, 2024, at 9:50 AM, with Registered Nurse 8 (RN 8), RN 8 donned gloves, mask, and gown prior to entering Patient 16's room. No transmission-based precaution sign was displayed outside Patient 16's room. RN 8 stated, there should be a contact precaution (actions to prevent spread of germs by direct or indirect contact) sign outside the room. RN 8 further stated, Patient 16 was on contact precautions because he has pneumonia and some of his tests are still pending.

During a concurrent interview and record review, on January 23, 2024 at 11:45 AM, with RN 4, Patient 16's pending laboratory tests was reviewed. The QuantiFERON-TB Gold Plus (a laboratory test that can detect tuberculosis [TB- a disease caused by bacteria usually affecting the lungs and can be spread through the air]) indicated, lab was ordered January 22, 2024, and results were currently pending. RN 4 stated, Patient 16 was on transmission-based precautions because of the QuantiFERON-TB Gold Plus test was pending, and he would remain on precautions until negative lab results were available.

During a concurrent interview and record review, on January 26,2024, at 10:45 AM, with the Infection Control Preventionist (ICP) , the facility's policy and procedure (P&P) titled, "Standard and Transmission Based Precautions", dated March 2023 , was reviewed. The P&P indicated, " ...While Standard precautions apply to all patients, Transmission Based Precautions apply to either a confirmed or suspected diagnosis ... Initiation of Transmission Based Precautions: a ... if a situation or diagnosis exists that requires "Transmission Based Precautions", the nurse will implement the appropriate precaution and notify the physician ...2) The nurse is responsible for initiating the appropriate precaution as indicated by laboratory results or physician diagnosis and for notifying the primary physician if not already informed ...3. Identification of patient requiring Transmission Based Precautions: a. Post appropriate isolation sign outside patient's room. B. Identify appropriate isolation precaution needed ... Procedure: 1. Airbourne Precautions (actions to prevent spread of germs by air) ...use Airborne precautions for patients known or suspected to be infected with microorganisms transmitted by airborne droplet nuclei ... such as tuberculosis ...". The ICP stated, Patient 16's Transmission based precaution should have been posted as airborne precautions and contact precaution was not appropriate for a patient pending a TB test result. Patient 16 should have been placed on Airborne Precautions. The ICP further stated every nurse was provided education at new hire orientation regarding transmission-based precautions, but states the nurses need further education.

During a review of the facility's document "Job Description" for "Infection Control Preventionist", revised on July 2021, the "Job Description" indicated, " ...Job Summary: The Infection Control Preventionist is responsible for surveillance, prevention and control of infection ... Assists with policy and procedure development and implementation ...Acts as primary education consultant to hospital employees, physicians, Patients, volunteers and visitors in safe Infection Control/Prevention practices. Coordinates all hospital infection control activities with the infection control committee, Medical Staff and hospital employees...".

Based on observation, interview, and record review, the hospital failed to ensure the implementation of hand washing to prevent and control infection for one of 30 sampled patients (Patient 1) when the nursing staff did not wash her hands after the medication administration.

This failure had the potential to result in cross-contamination (the transfer of harmful bacteria) to other vulnerable patients from a preventable infection which can negatively affect patients' health and prolonged hospitalization.

Findings:

A review of Patient 1's "History and Physical" (H&P), dated January 18, 2024, the H&P indicated, Patient 1 was admitted into the facility for hypoxemia (low oxygen in blood) with medical histories including chronic respiratory failure (a condition when lungs cannot get enough oxygen) with tracheostomy (trach - a tube placed into the trachea via the neck to assist with breathing) and ventilator (a machine to assist in delivery of oxygen) dependent, and diabetes (a condition that body cannot control blood sugar).

During an observation on January 23, 2023, at 9:50 AM, in the Medical/Surgical Unit, Patient 1 was lying in bed with a trach attached to a ventilator. Registered Nurse 3 (RN 3) was observed pouring crushed medications onto Patient 1's apple sauce after received permission from Patient 1. Medications including:

Aldactone (medication to treat fluid retention or blood pressure) 50 milligrams (mg-unit doing medication).
Glucophage (medication to manage blood sugar) 500 mg.
Eliquis (medication to prevent blood clot) 5 mg.
Topamax (medication to prevent seizure or a condition that causes abnormalities in muscle tone or movements) 200 mg.

RN 3 was also observed opening a capsule of Prozac (medication to treat depression disorder) 10 mg and poured the white powder inside the capsule onto Patient 1's apple sauce. RN 3, then, used a needle to puncture a capsule of Colace (stool softener) 100 mg and squeezed out the clear gel substance inside the capsule onto Patient 1's apple sauce. RN 3 gave all medication to Patient 1.

A follow-up observation on January 23, 2023, at 10:05 AM, RN 3 was observed removing her gloves, isolation gown, and threw them into a trash bin. RN 3 wheeled out her computer on wheel (COW) to the hallway and continued to review Patient 1's information without using alcohol based hand rub or performing a hand wash.

A follow-up interview on January 23, 2023, at 10:10 AM, RN 3 verified and stated, she had not washed her hands after she finished Patient 1's medication administration. RN 3 confirmed, she needed to perform hand washing after the medication administration and came out from patients' room to prevent spreading of infection. RN 3 stated, she "forgot" and was "a little nervous."

A review of Patient 1's "Report" for Methicillin-resistant Staphylococcus aureus (MRSA-a group of bacterial infection that become resistant to many medications), dated January 19, 2024, the "Report" indicated Patient 1 had a positive MRSA infection.

A review of the facility's policies and procedures (P&P) titled, "Standard and Transmission Based Precautions," dated March 2023, the P&P indicated, "Policy: It is the policy of [Hospital Name] to provide an effective means of isolation, based on the Center for Disease Control and Prevention (CDC) Guidelines, for Standard and Transmission based precautions ... The following elements will be followed by ALL personnel at ALL times regardless of patient diagnosis: 1. Hands will be washed for a minimum of 15 seconds using soap and warm running water or use alcohol-based waterless hand rub for a minimum of 20-30 seconds (see Hand Washing/Hand Hygiene policy and procedure): before and after caring for each patient, after removing gloves, immediately after possible contact with blood or other body fluids ..."