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Based on interview and record review, the facility failed to ensure the document titled Patient Rights and Responsibilities was provided to patients or patient representatives in a timely manner.

As a result, there was a potential the patients or their representatives did not understand their rights upon admission which may affect care.

Findings:

A review of records was conducted. Multiple patients/patient representatives received the Patient Rights and Responsibilities document one to five days after the admission date.

On 10/23/24 at 3:39 P.M., an interview with the Chief Nursing Office (CNO) was conducted. The CNO stated the Patient Rights and Responsibilities should have been given to patients/patient representatives upon admission.

On 10/24/24 at 1:42 P.M., an interview with the Admission Coordinator (AC) was conducted. The AC stated the Patient Rights and Responsibilities documents was part of the admissions packet.

Per the facility's policy and procedure titled Patient Rights issued 10/1/23, "PURPOSE: To ensure that each patient/family admitted to Hospital is aware of their guaranteed rights and their responsibilities. POLICY:..Each patient/family admitted to the Hospital will receive a copy of the Patients Right's policy upon admission."

Based on interview and record review, the facility failed to ensure staff followed policy and procedure when obtaining the Consent to Admission and Treatment, Authorization to Release Information and Assignment of Insurance Benefits (CTAT).

As a result, there was a potential treatments were performed without consents.

Findings:

A review of records was conducted. Multiple CTATs were obtained verbally from the patient representatives but there were no follow-up documentation of attempts to obtain the written consent. The CTAT ...Verbal Authorization indicated, "Document 3 attempts to secure written Consent from the Patient Representative ..."

On 10/23/24 at 11:27 A.M., an interview with the Chief Nursing Officer (CNO) was conducted. The CNO stated when the staff obtained an initial verbal consent, the staff needed to document on the CTAT they made three attempts to obtain signatures.

On 10/24/24 at 1:42 P.M., an interview with the Admission Coordinator (AC) was conducted. The AC stated the admissions staff should have reached out to the patient's family members over the phone or ask them to come to the facility to obtain the signatures.

Per the facility's policy and procedure titled Obtaining Consent to Treat revised 4/15/24, "VERBAL CONSENTS ...The verbal consent should be viewed as a temporary solution until an original signature on the Consent Form can be obtained from the patient or the Responsible Party is obtained ...It is critical to maintain documentation of all attempts to do so on the Consent Form."

Based on interview and record review, the hospital failed to ensure staff followed facility Policy and Procedures when:

1. Pain medication was not administered for patients assessed with severe pain (Patients 20 and 30 )

2. Pain reassessments were not conducted or conducted in a timely after pain medication administration (Patients 9, 20 and 26)

3. Medications given during a Change of Condition (COC, a decline in a patient's health) were not documented accurately (Patient 1),

4. An inaccurate dose of pain medication was given (Patient 5), and

5. A charge nurse did not perform her role during a COC (Patient 1).

These failures had the potential to impact the patient's health and safety, or result in a prolonged hospitalization.

Findings:

1a. Patient 20 was admitted to the facility on 10/11/24 with diagnoses which included respiratory failure per the facility's facesheet.

On 10/23/24, a joint review of records was conducted with the Chief Nursing Officer (CNO). Per Patient 20's pain monitoring flowsheet, Patient 20 had a pain level of 9/10 (Numeric Rating Scale 0-10) on 10/23/24 at 2:30 P.M. There was no documentation of an intervention to relieve Patient 20's severe pain.

On 10/23/24 at 3:31 P.M., an interview with the CNO was conducted. The CNO stated pain medications should be given to patients with severe pain. The CNO stated Patient 20 should have been given the prescribed medication for severe pain.

Per the facility's policy and procedure titled Pain Management, Assessment and Intervention Protocol issued 12/1/00, "...POLICY...The following basic principles comprise the pain management approach:..2...The following standard will be utilized on all patients. Patients at Hospital will be either without pain or experience pain that is managed effectively according to their reported pain goal.

1b. Patient 30 was admitted to the facility on 9/16/24 with diagnoses which included aspiration pneumonia (an infection caused by inhalation of food particles into the lungs) per the facility's flowsheet.

On 10/24/24, a joint review of records was conducted with the CNO. Per Patient 30's pain monitoring flowsheet, Patient 30 had a pain severity of 6 or "severe" per the Critical Care Pain Observation Tool (CPOT-behavior pain scale). There was no documentation of an intervention to relieve Patient 30's severe pain.

On 10/24/24 at 3:30 P.M., an interview with the CNO was conducted. The CNO stated Patient 30 should have been given a pain medication to relieve Patient 30's severe pain.

Per the facility's policy and procedure titled Pain Management, Assessment and Intervention Protocol issued 12/1/00, "...POLICY...The following basic principles comprise the pain management approach:..PROCEDURE: 1. ASSESSMENT:..iv. Research suggests that a...CPOT score >/= 3 indicates significant pain that should be treated."






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2a. Patient 9 was admitted to the hospital on 10/17/24 with diagnoses to include post-surgical wound care, per the hospital Face Sheet.

On 10/24/24, a record review was conducted.

Per Patient 9's Medication Administration Record (MAR), Patient 9 received oxycodone-acetaminophen (a pain medication) on 10/23/24 at 12:31 A.M. for a pain level of 8 (a scale used to estimate pain, where 0 was no pain and 10 was the worst pain possible).
According to the MAR, the nurse returned to reassess the medication's effectiveness on 10/23/24 at 4 A.M.

Per Patient 9's MAR, Patient 9 received oxycodone-acetaminophen on 10/24/24 at 5:10 A.M. for a pain level of 10.
According to the MAR, the nurse returned to reassess the medication's effectiveness on 10/24/24 at 8 A.M.

On 10/24/24 at 3 P.M., an interview was conducted with the CNO. Per the CNO, pain should be reassessed approximately 30 to 60 minutes after medication was given to ensure the medication was effective.

Per a hospital policy, revised 4/1/24 and titled Pain Management, Assessment and Intervention Protocol, "...Re-Assessment...Pain will be reassessed 30-60 minutes following a pain reduction intervention..."


2b.Patient 20 was admitted to the facility on 10/11/24 with diagnoses which included respiratory failure per the facility's facesheet.

On 10/23/24, a joint review of records was conducted with the CNO. Per Patient 20's pain monitoring flowsheet, Patient 20 had a pain level of 8/10 on 10/21/24 at 4:08 P.M.. Patient 20 was on a continuous intravenous (IV) pain medication infusion (administration) at 4:23 P.M. per the Medication Administration Record (MAR). There was no pain reassessment conducted after the pain medication administration.

On 10/23/24 at 3:26 P.M., an interview with the CNO was conducted. The CNO stated the policy for pain level reassessment was 30 minutes after IV pain medication administration.

2c. Patient 26 was admitted to the facility on 9/14/24 with diagnoses which included post-operative wound infection per the facility's facesheet.

On 10/24/24, a joint review of records was conducted with the CNO. Per Patient 26's pain monitoring flowsheet, Patient 26 had a pain level of 8/10 on 10/22/24 at 10:33 P.M. Per the MAR, a pain medication was administered to Patient 26 on 10/22/24 at 10:33 P.M. There was no pain reassessment conducted after the pain medication administration.

3. Patient 1 was admitted to the hospital on 6/2/24 with diagnoses to include pneumonia (a lung infection), and endocarditis (an infection of the heart's inner lining), per the physician's History and Physical note.

On 10/21/24 at 11 A.M., an interview was conducted with the Director of Quality Management (DQM). The DQM stated Patient 1 had a COC on 6/7/24, and staff reported to the room to assess his condition and provide emergency care. The DQM provided a list of staff who responded to the COC.

On 10/22/24 at 10 AM., and based on the list of staff present at the 6/7/24 COC, an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated she was a charge nurse on 6/7/24, but she was not present during the COC for Patient 1. LN 1 stated she normally reported to COCs but on 6/7/24, she was busy with a patient in a procedure room. LN 1 stated she and other charge nurses report to COCs when they were available, but for Patient 1, she was not available.

On 10/22/24 at 10:08 A.M., an interview was conducted with LN 2. LN 2 stated she was a charge nurse on 6/7/24, and she reported to the COC for Patient 1.LN 2 stated when she arrived in Patient 1's room, other staff were caring for him, so she took the role of transcribing (documenting staff present, medications administered, and timing). LN 2 stated the morning assignment sheet listed the roles for each charge nurse for any COCs that day, but the roles could change. Per LN 2, she was assigned in the morning to use the Automatic External Defibrillator (AED, a device to shock the heart into normal rhythm) for any COCs throughout the day, but when she arrived, someone else had taken the role so LN 2 transcribed instead. LN 2 stated she did not administer any medications to Patient 1. After the COC was done, LN 2 stated she left the room and went to a different part of the hospital. LN 2 stated she was supposed to immediately enter the transcribed information into the electronic medical record (EMR), but she did not have time to do that.

On 10/22/24 at 11:39 A.M., an interview was conducted with LN 3. LN 3 stated he was assigned as the primary nurse for Patient 1 on 6/7/24. LN 3 stated he was on a break when the COC was called, and he went to Patient 1s room immediately after. LN 3 stated several nurses were already in the room, so he did not participate in the COC. LN 3 stated he did not administer any medications to Patient 1 during the COC.

On 10/22/24, a concurrent interview and document review was conducted with the Chief Nursing Officer (CNO).
Per a Nursing Note, dated 6/7/24 at 1:30 P.M., LN 4 documented she had reported to the COC for Patient 1. LN 4 documented her assessment and interventions of calling for additional staff to assist.
LN 4 did not document she had administered any medications to Patient 1.

Per a Nurses Note, dated 6/7/24 at 5:08 P.M., LN 3 documented he had returned from break and gone to Patient 1s room for the COC. LN 3 did not document any medications given to Patient 1.

Per a Patient Care Timeline, dated 6/7/24 with no time stamp, LN 2 documented the starting and ending time of the COC. LN 2 documented all medications given, and indicated the LN who gave the medications was LN 1.

Per a training guide to COCs, and an attendance sheet, dated January 2024, LN 1, and LN 2 had attended a March/April training session on roles and responsibilities during a COC.

The CNO stated, LN 1s name was on the Patient Care Timeline, but LN 1 had denied being present. The CNO stated it was important to document the details of the COC as soon as possible so the details were accurate. The CNO stated the other staff present at the COC may have administered the medications and LN 2 may have made an error.

On 10/22/24 at 2:32 P.M., a follow-up interview was conducted with LN 2. LN 2 stated the assignment sheet indicated what role staff would fill in the event of a COC. LN 2 stated she did not remember which LN provided the medications to Patient 1 during the COC. LN 2 stated LN 1 had been assigned medications on the assignment sheet, but she did not recall whether she had seen her in Patient 1s room, or administer any medications. LN 2 stated she was delayed entering the information into the EMR. LN 2 stated it was important to document exactly what happened during a COC but she may have made a mistake entering the name into the EMR.

On 10/22/24 at 2:48 P.M. an interview was conducted with LN 5. LN 5 stated she had been present during part of the COC, but she had not administered any medications to Patient 1. LN 5 recalled LN 2 had been the transcriber, and did not recall seeing LN 1 in the room. LN 5 stated during a COC, the physician called out the name of a medication, which would be administered by a nurse and written down by the transcriber. LN 5 stated, the expectation was for medications to be written or transcribed into the EMR in real time (at the same time) ideally.

On 10/23/24 10:08 A.M., an interview was conducted with LN 4. LN 4 stated she was not assigned to Patient 1 on 6/7/24, but a staff member asked her to report to the room. LN 4 stated she went to the room and assessed Patient 1. LN 4 stated a COC was called, and she brought equipment to the room to assist. LN 4 stated she did not administer any medication to Patient 1. LN 4 stated during a COC, it was important to administer the medications as quickly as possible, then document in the EMR.

On 10/23/24 at 10:39 A.M., an interview was conducted with the CNO and the Director of Quality Management (DQM). The CNO stated her expectation was for the transcriber to enter the COC information, including the name of the staff member providing it, into the EMR. The CNO stated being timely was important as it can affect the accuracy of the documentation. The CNO stated training had been done recently, and all charge nurses had attended. The CNO stated documenting the wrong person administering the medications could mean not knowing who administered the medications. Per the CNO, LN 2 should have asked for clarification of roles during the COC before entering staff names into the EMR. The DQM stated all COC documentation was audited to ensure it was complete. Per the DQM, it was important to document accurately for patient safety.

On 10/24/24 at 8:30 A.M., a follow-up interview was conducted with the CNO. The CNO stated the hospital had identified the LN who administered the medication on 6/7/24 to Patient 1. Per the CNO, LN 6 had stated she remembered reporting to the COC for Patient 1, and she had taken the role of administering medication. The CNO stated this information had been added as a late entry into the EMR to correct the wrong documentation.

Per an hospital Guidebook, dated January 2024, staff roles during a COC were: "Recorder...know/have eyes on...keep time...make leader aware what meds are due...repeat back what meds were given..."

Per a hospital policy, revised 7/1/24 and titled Medication Administration, "Purpose: To ensure the safe preparation and administration of medications..."

Per a hospital policy, revised 10/1/24 and titled Change in Patient Condition, "...Assessment, interventions, and physician communication documented on...EMR..."

4. Patient 5 was admitted to the facility on 9/20/24 with diagnoses to include sepsis (a serious reaction to an infection), per the hospital Face Sheet.

On 10/24/24, a record review was conducted.

Per Patient 9's physician's orders, dated 10/10/24, Patient 9 was prescribed oxycodone (a pain medication), one tablet every six hours as needed for severe pain (described per policy as pain level 7-10 out of 10 per hospital policy).

Per Patient 9's MAR, Patient 9 received oxycodone on 10/22/24 for pain level 5 out of 10 (moderate pain per hospital policy).

On 10/24/24 at 4 P.M., a concurrent interview and record review was conducted with the Director of Quality Management (DQM). Per the DQM, the oxycodone should not have been administered for moderate pain. The DQM stated no other medication had been ordered for lower levels of pain. The DQM stated the nurse should not have given the oxycodone, but should have contacted the physician to clarify which medication to use for moderate pain.

Per a facility policy, revised 4/1/24 and titled Pain Management, Assessment and Intervention Protocol, "...The Hospital will conduct audits on the following...i. Pain assessment frequency and quality...Use of pain scale..."

5. Patient 1 was admitted to the hospital on 6/2/24 with diagnoses to include pneumonia (a lung infection), and endocarditis (an infection of the heart's inner lining), per the physician's History and Physical note.

On 10/22/24 at 10:07 A.M., an interview was conducted with the DQM. The DQM stated Patient 1 had a COC on 6/7/24, so staff reported to the room to assess him and provide medications and assistance.

On 10/23/24 at 11:20 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. Per CNA 1, she was assigned to Patient 1 on 6/7/24. CNA 1 stated family of Patient 1 came out of the room for assistance, and she went in to assist them. CNA 1 stated she went to find LN 3 who was assigned to provide care for Patient 1, but he was on break. Per CNA 1, when the primary nurse assigned was on break, the charge nurse, LN 7, was responsible to provide care of his patients. CNA 1 stated she requested LN 7 assess Patient 1. CNA 1 stated LN 7 told her she was too busy, and told her to get another staff person to assist. CNA 1 asked LN 4 to go to Patient 1's room and assess, and both returned to the room.

On 10/23/24 at 11:39 A.M., an interview was conducted with the CNO. Per the CNO, it was LN 7's responsibility to assess Patient 1 during LN 3's break. The CNO stated an she had interviewed LN 7, who confirmed she did not report to the room as requested by CNA 1. The CNO stated CNA 1 had followed the correct procedure for obtaining nursing assistance, but LN 7 had not followed the procedure. LN 7 was not available for interview. Per the CNO, the charge nurses had attended a recent training regarding their role and responsibility during a COC.

On 10/23/24 at 2:48 P.M., an interview was conducted with LN 5. LN 5 stated all charge nurses reported to any COCs. LN 5 stated the LNs were recently trained on the process, and the daily assignment of roles during a COC was available to review each morning.

Per a training guide to COCs, and an attendance sheet, dated January 2024, LN 7 had attended a March/April 2024 training session on roles and responsibilities during a COC.

Per a hospital policy, revised 10/1/24 and titled Change in Patient Condition, "...It is the responsibility of the charge nurse to ensure that the process to assess the patient occurs..."

Based on interview and record review, the hospital failed to ensure nursing staff implemented a facility Policy and Procedure related to blood transfusions for one of 30 sampled patients (Patient 1).

This failure had the potential to impact Patient 1s health and safety, or result in a prolonged hospitalization.

Findings:

Patient 1 was admitted to the facility on 8/26/24.

A record review was conducted on 10/23/24.
Per the medical record, Patient 1 had a consent for a blood transfusion, dated 9/21/24.
The consent form had a Special Instructions section, where a nurse had documented, "Telephone consent obtained from patient's daughter..."
The signature line indicated it was to be signed by the patient or legal guardian. One signature was signed by a Licensed Nurse (LN), followed by a slash. No second signature was evident.
An additional signature line indicated it was to be signed by a witness. An "X" was written on the line with no name, no date, and no time documented.

On 10/23/24 at 1:57 P.M., an interview was conducted with the Director of Quality Management (DQM). Per the DQM, the LN whose name appeared on the blood transfusion consent was a charge nurse. The DQM stated the charge nurse had read the consent to the daughter over the phone to obtain permission from the family to transfuse the blood. The DQM stated phone consents required two nurses' signatures to validate it as accurate. Per the DQM, no second signature had been written, so the consent was not valid. The DQM stated, "That is not the correct way to document a consent done by phone, per our policy."

The charge nurse was not available for interview.

Per a hospital policy, revised 7/1/24 and titled Blood/Blood Components Administration, "Purpose: To establish a policy and procedures for the safe administration of blood and/or blood components...1. Informed Consent must be obtained...Procedure 1. Verify consent signed...

Per a hospital policy, revised 7/1/22 and titled Consents for Medical Treatment, "...Witnesses: any Hospital employee may sign as a witness to a patient's signature. Witnessing a signature indicates that a person saw the patient or patient's designee sign the document or listened to the conversation in the case of a telephone consent. The witness signs, dates and times the consent form...Consent Forms: include, but are not limited to...Agreement for Blood, and/or Blood Products, Transfusion..."