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Based on observation, interview and record review, the facility failed to ensure nursing staff followed standards of practice for patient care, when:

1. For Patients 2, 4, 5, 17, 18, 19, and 21, oral care was not provided every six hours (Refer to A0144);

2. For Patients 1 and 4, Percutaneous Endoscopic Gastrostomy (PEG- feeding tube) assessments were not completed every shift (Refer to A0144);

3. For Patient 1, a midline catheter (a device used to infuse medications) was not re-assessed for necessity after four weeks (Refer to A144);

4. For Patient's 1 and 2, a midline catheter (a device used to infuse medication) site was not assessed daily and dressing changes were not performed every seven days (Refer to A 0144);

5. For Patient 8, the hemodialysis catheter (flexible tube inserted into a vein in the neck, chest, or upper leg for dialysis) was used to infuse medication (Refer to A0144);

6. For Patient 21, the Central Venous site was not assessed daily, and dressing changes were not performed every seven days (Refer to A0144);

7. For Patients 4 and 21, the Sepsis Management (involves a combination, appropriate treatment, and control of the source of infection) was not activated timely (Refer to A0144);

8. For Patient 4, vital signs were not done every two hours as required in the Intensive Care Unit (Refer to A0144);

9. For Patient 4, abdominal distention was not reported to the physician (Refer to A0144);

10. For Patient 21, nail care was not provided (Refer to A0144);

12. For Patient 8, soft wrist restraints were initiated without a physician's order (Refer to A0168);

13. For Patient 10, an ongoing assessment for restraints was not conducted (Refer to A0174).

The cumulative effects of these systemic failures resulted in the facility's inability to ensure the provision of quality health care, in compliance with the Condition of Participation for Patient's Rights was met.

On September 19, 2024, at 3:39 p.m., the survey team identified significant concerns in the facility's Medical Surgical Telemetry (MSTU) and Intensive Care Unit ICU). Due to the seriousness of the situation, an IJ was called in the presence of the hospital's Chief Executive Officer (CEO), Chief Operating Officer (COO), Rancho Director for Quality (RDQ), Director for Nursing Clinical Services (DNCS), and Director for Quality (DQ). The facility's CEO, COO, DNCS, RDQ, and QD were verbally notified regarding the concerns of the facility's failure to ensure patients receive care in a safe setting.

On September 20, 2024, at 9:39 a.m., the COO provided a Corrective Action Plan (CAP). The CAP was found to not be acceptable.

On September 23, 2024, at 2:42 p.m., the COO provided a revised CAP. The CAP indicated the following:

1. The Nursing Leadership team reviewed the following policies on September 19, 2024, and no modifications were recommended.

a. H-PC 04-015 Oral Hygiene for Airway Assisted Patients;

b. H-PC 04-009 Routine Bathing;

c. H-PC 05-006 Administration of Enteral Nutrition;

d. H-PC 05-010 Mid line Catheter Site Placement, Maintenance and Dressing Change;

e. H-PC 03-007 Sepsis: Early Recognition and Management;

f. H-PC 02-001 Interdisciplinary Assessment and Re-Assessment; and

g. H-IM 01-001 General Documentation Guidelines;

2. All patients were assessed by nursing for the need of oral care, perineal care (pericare, the practice of washing the genital and anal areas of the body) and bathing needs. Care was provided to patients identified as needing oral care, peri care or bathing. Medical records were reviewed by clinical leadership to verify the current worklist includes oral care, peri care and bathing. Any missing elements were added onto the worklist within the electronic medical record for nurses, certified nursing assistant (CNA) and/or respiratory therapist (RT). Bathing and/or pericare to occur daily (by CNA, LVN, RN) and as needed for patients who are soiled, incontinent or upon patient request. For patients who are hemodynamically unstable based on RN assessment, bathing may be paused until hemodynamic status improves. Oral care to occur daily (by CNA, LVN, RN, RT) and as needed or upon patient request. For patients with artificial airway or patients receiving continuous BiPAP (bilevel positive airway pressure, a noninvasive breathing machine that helps people breathe by delivering pressurized air through a mask) therapy by mask, oral care will occur at six-hour intervals (by Nursing, and Respiratory Therapy);

3. All patient records with current physician orders for lactate (a chemical produced in the body when cells break down food for energy, high levels of which could indicate low levels of oxygen in the blood and sepsis [a life threatening infection]) laboratory specimen collection associated with a positive sepsis protocol meeting SIRS (Systemic Inflammatory Response Syndrome, criteria used to identify the body's defense response to harmful stressors) criteria were verified and placed on the worklist for collection every six hours. Additionally, a sepsis screening was completed on each patient to ensure that any early signs of sepsis were identified and sepsis protocol activated, including lab orders, as appropriate;

4. All patients with midlines (a long, flexible tube inserted into a vein in the upper arm to deliver medication or fluids directly into the bloodstream) were reviewed for the date of insertion. The physician was contacted for an order to replace midline with an insertion date greater than 30 days. All patients with line dressing were assessed for intact dressings as well as labeled with date and time. The dressings were changed as appropriate;

5. Education began with nursing (RN, LVN, CNAs, RTs) that were on duty. The remaining staff will be trained within 30 days of acceptance of plan. Any required staff that have not completed the training within the 30 days will not work until training has been completed. The education included:

a. Interdisciplinary assessment and reassessment policy (policy H-PC-02-001);

b. Change of condition to include notification of provider and instructions for completing documentation in Protouch (an electronic medical record used by the facility);

c. A change of condition is anything that is not anticipated or is an unexpected change from previous status. A change of condition includes changes in status, such as a transfer to a higher or lower level of care, change in GI status, early signs and symptoms of sepsis and abnormal vital signs;

d. Vital sign requirements for Intensive Care Unit (unit for critically ill patients) level patients; and

e. Proper assessment of gastrointestinal (refers to the organs that process food and liquids) status includes abdominal assessment and percutaneous endoscopic gastrostomy (PEG, a feeding tube through the stomach wall and skin) tube or gastrostomy (G tube, an artificial opening in the stomach) tube assessment every shift.

On September 23, 2024, at 2:51 p.m., the CAP was reviewed and accepted, and the DNCS and the DQM were notified.

On September 24, 2024, at 9:30 a.m., through observations, interviews, and record review, the CAP was verified onsite to have been fully implemented.

On September 24 , 2024, at 10:25 a.m., the IJ was removed in the presence of the DNCS and the DQ.

Based on interview and record review, the facility failed to ensure qualified and competent Registered Nurses (RN's) were assigned to provide care for patient's in the Medical/ Surgical/Telemetry Unit, and Intensive Care Unit (ICU, a unit for critically ill patients) requiring cardiac monitoring (continuous or intermittent monitoring of the heart's activity to assess a patient's condition). Additionally, the facility failed to follow their policies and procedures on weight management and waste disposal when:

1. 62 of 66 RN's (RN's 1 to 9, 11 to 14, 16, 18, and 20 to 66) did not complete a cardiac arrhythmia (irregular heart rate and rhythm) interpretation course for the certification required to care for patients requiring cardiac monitoring, and who were providing care for patients placed on a cardiac monitor (a device which shows the heart rate and rhythm on a monitor with a capability of printing them on strips) (Refer to A0397);

2. 44 of 66 RN's (RN's 2 to 9, 11 to 13, 20, 21, 25 to 41, 46, 50, 53, 55 to 59, and 61 to 66) did not complete the cardiac rhythm interpretation test required to care for patients requiring cardiac monitoring, and who were providing care for patients on the cardiac monitor (Refer to A0397);

3. Two RN's (RNs 2 and 50), who were providing care to patients in the ICU, had no ICU competency validation and unit orientation completed (Refer to A0397);

4. Six of eight Nursing and House supervisors (NSRN 58, 59, 60, 61, 62, and 65) who are responsible to oversee all the units in the facility during a shift, and who take over the care of patients in the ICU when the ICU RN responds to emergency situations, had no ICU nursing orientation or competency (Refer to A0397);

5. The Director of Nursing Clinical Services (DNCS) did not meet the qualification for the position based on the DNCS job description (Refer to A0397);

6. For Patient 29 and 30 who were on enteral feeding were not re-weighed after a significant weight loss/gain (Refer to A0398); and

7. The facility did not ensure sharps were properly stored or disposed of (Refer to A0398).

The cumulative effects of these systemic failures resulted in the facility's inability to ensure the provision of quality health care, in compliance with the Condition of Participation for Nursing Services were met.

On September 18, 2024, at 1:12 p.m., the survey team identified significant concerns in the facility's Medical Surgical Telemetry (MSTU) and Intensive Care Unit (ICU). Due to the seriousness of the situation, an immediate jeopardy (IJ, a situation which had the potential to cause harm to the health and safety of the patients) was called in the presence of the facility's Chief Executive Officer (CEO), Chief Operating Officer (COO), Rancho Director for Quality (RDQ), Director for Nursing Clinical Services (DNCS), Director for Quality (DQ), and Clinical Analyst (CA). The facility's CEO, COO, DNCS, RDQ, and QD were verbally notified regarding the concerns of the facility's failure to ensure qualified and competent Registered Nurses (RNs), for 62 of 66 RNs, were assigned to provide care to patients requiring cardiac monitoring.

On September 20, 2024, at 9:39 a.m., the COO provided a Corrective Action Plan (CAP). The CAP was found to not be acceptable.

On September 20, 2024, at 3:28 p.m., the COO provided a revised CAP. The CAP indicated the following:

1. The Nursing Leadership team reviewed the facility policy and procedure titled, "Continuous Cardiac Monitoring H-PC 7-015," and no modifications to policy were recommended.

2. All RN files were reviewed by the Nursing Leadership to develop a list of RN team members who have taken a course in cardiac interpretation and have passed the (name of facility) cardiac rhythm interpretation test.

3. All patients currently on continuous cardiac monitoring were assessed by a competent Registered Nurse (RN) with evidence of cardiac rhythm interpretation competency. Rhythm interpretation, vital signs and plan of care reviewed with bedside nurse. Documentation of rhythm interpretation, vital signs, and any interventions are to be documented in the change of condition and will continue to be charted under change of condition for a period of 30 days.

4. All Patients with continued cardiac monitoring will be assessed each shift by a competent Registered Nurse (RN) with evidence of cardiac rhythm interpretation competency by a) rhythm interpretation, vital signs and plan of care, b) review with bedside nurse and c) assessment and interventions as indicated until education can be completed to obtain the sufficient number of licensed nurses with competency in cardiac rhythm interpretation.

5. At least 2 RNs, with the support of a Nursing Supervisor who are competent in cardiac interpretation, will be assigned to continually monitor and provide interpretation of cardiac status of all patients requiring cardiac monitoring. This process will continue until a sufficient number of RNs, based on the number of patients with continuous cardiac monitoring, have completed the competency for cardiac rhythm interpretation; and

6. A Lippincott [a publisher of medical and nursing books] based education plan was identified. Initial implementation of education and testing began to ensure qualified and competent licensed nurses are assigned to provide care to patients requiring cardiac monitoring.

On September 20, 2024, at 4:10 p.m., the CAP for the IJ was reviewed and accepted. The DNCS and the Director of Quality Management (DQM) were notified.

On September 23, 2024, at 11:40 a.m., through observations, interviews, and record review, the CAP was verified onsite to have been fully implemented.

On September 23, 2024, at 1:10 p.m., the IJ was removed in the presence of the COO, the DNCS, and the DQ.

Based on interview and record review, facility failed to ensure the grievance process was implemented, for one of 31 sample patients (Patient 18), in accordance with the facility's policy and procedure (P&P).

This failure had the potential to cause harm and delay of care to the patient.

Findings:

A review of Patient 18's record was conducted on September 19, 2024, at 10:40 a.m., with the Clinical Analyst (CA).

A facility document titled, "History and Physical," dated July 19, 2024, at 12:32 a.m., was reviewed. The document indicated Patient 18 was admitted to the facility on July 17, 2024, with diagnoses which included acute (occuring for less than six months) and chronic (occuring for more than six months) respiratory failure (difficulty breathing) with hypoxia (not enough oxygen in the body) or hypercapnia (too much carbon dioxide in the blood) and inhalation injury (damage to the respiratory system or lungs caused by breathing in toxic substances, extreme heat, or other irritants) sustained in a house fire.

On September 18, 2024, at 11:48 a.m., an interview was conducted with the Director of Quality Management (DQM). The DQM stated RN 56 is a house supervisor who works at the facility on weekends. The DQM stated RN 56 gave out his personal email which is not part of the policy. The DQM stated the staff member can take a grievance and put it in the event reporting system and the policy is for that person to attempt to solve the concern. The DQM stated, if the staff are unable to solve the concern, they are to escalate the concern up the chain of command (a ladder of authority where those in charge of an organization). The DQM further stated if the name of the complainant is not on the list, then she did not receive the grievance.

On September 22, 2024, at 6:31 a.m., an interview was conducted with RN 56. RN 56 stated he did sit with the family to discuss their concerns. RN 56 stated he gave out his personal email address because the facility computers were down at that time and his personal email was working. RN 56 stated he sent the complaintant's email to his supervisor. RN 56 further stated he did not enter the grievance in the Event Reporting System (system used by the facility to report patients' grievances) in accordance with the facility's P&P.

The facility was unable to provide documentation the complaint was entered in the Event Reporting System in accordance with the facility's P&P.

A review of facility P&P titled, "Procedure-Patient Complaint and Grievance Process," dated June 2022, was conducted. The P&P indicated, "...When reasonably possible, the person who receives a complaint should address and resolve it...It is the supervisor's responsibility to handle unresolved complaints or grievances promptly and effectively...Initiate an initial investigation if it has not already been started, including interviews of individuals with information about the issue...Initiate the complaint and grievance entry in to the Event Reporting System...Every effort should be made to complete entries by end of the shift...Escalate (if the complaint is not resolved immediately)...every issue, concern, or expression of dissatisfaction that you cannot resolve should be escalated to a supervisor, manager, or administrator..."

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Based on observation, interview, and record review the facility failed to follow their policies and procedures for 11 of 31 patients (Patients 1, 2, 4, 5, 8, 16, 17, 18, 19, 20, and 22) when:

1. For Patients 2, 4, 5, 17, 18, 19, 20, and 22, oral care was not provided every six hours;

2. For Patients 1, 2, 4, 7, 16, and 17, Percutaneous Endoscopic Gastrostomy (PEG- feeding tube) assessments were not completed every shift;

3. For Patient 1's midline catheter (a device used to infuse medications) was not re-assessed for necessity after four weeks;

4. For Patients 1, and 2, midline catheter sites were not assessed daily, and dressings were not changed every seven days;

5. Patient 8's hemodialysis catheter (flexible tube inserted into a vein in the neck, chest, or upper leg for dialysis) was used to infuse medication;

6. For Patient 17 and 22's Central Venous Catheter (thin flexible tube inserted into a vein, usually below the right collarbone, and guided into a large vein above the right side of the heart) site was not assessed daily and dressing changes were not done every seven days;

7. For Patient 4, the Sepsis Management (involves a combination, appropriate treatment, and control of the source of infection) was not activated timely;

8. Patient 4, an Intensive Care Unit (ICU) patient, vitals signs were not done every two hours;

9. Patient 4's abdominal distention was not reported to the physician;

10. Patient 22 was not provided nail care;

11. Patients 19, and 20's PEG Feeding container and water flush was not labeled;

12. Patient 16's change of condition was not reported to the physician; and

13. Patient 18 was not provided a daily bath.


These failures had the potential to cause infection, delay patient care, and cause patient harm or death.

Findings:

1a. On September 16, 2024, at 8:47 a.m., a tour of the facility was conducted with the Director of Nursing Clinical Services (DNCS) and Director Quality Management (DQM).

During the tour of Patient 2's room, Patient 2's mouth was observed with dried mucus on the teeth, white residue around the mouth, and dry flakey lips.

An interview was conducted on September 16, 2024, at 11:12 a.m., with Registered Nurse (RN) 4. RN 4 stated oral care is done every shift and when needed. RN 4 stated it is a shared responsibility of Nursing staff and Respiratory Therapy staff. RN 4 further stated Patient 2 needed oral care to be done.

A review of Patient 2's medical record was conducted on September 17, 2024, at 1:10 p.m., with the Education Manager (EM).

The facility document titled, "History and Physical", dated, August 24, 2024, indicated, "...DATE OF ADMISSION: August 24, 2024... A/P [Assessment/Plan]: Chronic with acute respiratory failure [condition that makes it difficult to breath] which is multifocal from pneumonia [lung infection], Congestive heart failure [heart can't pump enough blood], and aspiration..."

The facility document titled, "Oral Care", dated September 11, 2024, through September 18, 2024, was reviewed with the EM, and indicated oral care was not performed every six hours per the facility policy.

An interview was conducted with the EM on September 17, 2024, at 1:30 p.m. The EM stated oral care should be done every six hours per the facility policy.

b. A review of Patient 4's medical record was conducted on September 18, 2024, at 10:30 a.m., with the Rancho Director of Quality (RDQ).

The facility document titled, "History and Physical" dated February 23, 2024, indicated, Patient 4 was admitted to the facility on February 22, 2024, with a diagnosis of Acute hypoxic respiratory failure (condition where there is not enough oxygen in the blood), Status epilepticus (prolonged seizure), and status post trach (tracheostomy - opening in the neck) and on a ventilator.

The facility document titled "Oral Care" dated February 22, 2024, through February 27, 2024, indicated:

- February 22, 2024, - no documented evidence oral care was provided;

- February 23, 2024, - documentation showed oral care was provided once at 4:24 a.m.;

- February 24, 2024, - documentation showed care was provided at 3:36 a.m., 3 p.m., and 10:56 p.m.;

- February 25, 2024, - documentation showed oral care was provided at 4: 59 a.m.;

- February 26, 2024, - documentation showed oral care was provided at 5:53 p.m., and 8:22 p.m.; and

- February 27, 2024, - there was no documented evidence that oral care was provided.

An interview was conducted on September 18, 2024, at 11:00 a.m., with the RDQ. The RDQ stated oral care was not provided for Patient 4, per the facility policy.

c. A review of Patient 5's medical record was conducted on September 18, 2024, at 3:05 p.m., with the RDQ.

The facility document titled "HISTORY AND PHYSICAL", dated June 17, 2024, indicated, Patient 5 was admitted to the facility on June 16, 2024, with a diagnosis of respiratory failure with hypoxia (not enough oxygen in the brain) and pneumonia (infection of the lungs).

The facility document titled, "Oral care" dated June 23, 2024, through June 30, 2024, indicated oral care was not provided for Patient 5 every six hours.

An interview was conducted on September 18, 2024, at 3:35 p.m., with the RDQ. The RDQ stated oral care was not provided for Patient 5 every six hours per facility policy.

d. A review of Patient 17's medical record was conducted on September 17, 2024 at 2:08 p.m.., with the CA.

A facility document titled, "History and Physical," dated April 29, 2024, at 10:58 a.m. was reviewed. The document indicated Patient 16 was admitted April 28, 2024, with a diagnosis of respiratory failure (difficult to breath) unspecified with hypoxia (not enough oxygen in the brain) or hypercapnia (too much carbon dioxide in the blood).

The facility document titled "Oral Care" dated April 29 through May 6, 2024, indicated oral care was not provided every 6 hours.

An interview was conducted on September 17, 2024, at 3:15 p.m., with the CA. CA stated the RN and the Respiratory Therapist are to complete oral care every 6 hours. The CA stated the staff did not follow the hospital policy.

e. A review of Patient 18's medical record was conducted on September 18, 2024, at 1:59 p.m. with the CA.

The facility document titled, "History and Physical," dated July 18, 2024, at 12:32 a.m., was reviewed. The document indicated Patient 18 was admitted to the facility on July 17, 2024, with a diagnosis of acute and chronic respiratory failure unspecified with hypoxia or hypercapnia, and inhalation injury sustained in a house fire.

The facility document titled, "Nurses Notes Provide Oral Care-Registered Nurse [RN]Work List," dated July 17, 2024, to August 27, 2024, indicated Patient 18 did not receive oral care every six hours per the facility policy.

An interview was conducted on September 18, 2024, at 2:05 p.m., with the CA. The CA stated the RN and the RT are to complete oral care every six hours. The CA stated the staff did not follow the facility's policy.

f. A review of Patient 19's medical record was conducted on September 19, 2024, at 10:32 a.m., with the CA.

The facility document titled, "History and Physical," dated August 30, 2024, at 8:53 p.m., indicated Patient 19 was admitted to the facility on August 29, 2024, with a diagnosis of respiratory failure (difficult to breath) unspecified with hypoxia (not enough oxygen in the brain) or hypercapnia (too much carbon dioxide in the blood).

There was no documented evidence Patient 19 was provided oral care by the Respiratory Therapist (RT) on:

August 30, 2024, no documentation of oral care by RT;

August 31, 2024, no documentation of oral care by RT;

September 1, 2024, no documentation of oral care by RT; and

September 2, 2024, no documentation of oral care by RT.

An interview was conducted on September 19, 2024, at 3:23 p.m., with the CA. CA stated oral care should have been performed every six hours by the RN and the RT. CA further stated there is no documentation the RT completed the oral care.

An interview was conducted on September 19, 2024, at 3:25 p.m., with RT 2. RT 2 stated the order set in the computer should include oral care. If it is on the work list, they have to clear the workload. RT 2 stated the RT should have performed oral care every six hours. The RT 2 further stated if it is not found in the documentation, then the RT did not complete the oral care.

g. On September 16, 2024, at 9:35 a.m., Patient 20 was observed lying in bed. Patient 20s mouth was observed to be dry with a thick tan matter on the teeth, gums, and lips.

On September 16, 2024, at 9:41 a.m., an interview was conducted with the DQM. The DQM stated oral care is to be completed every six hours by the RN and RT. The DQM stated based on Patient 20's mouth, she did not think it is good oral care.

A review of Patient 20's medical record was conducted on September 20, 2024, at 9:19 a.m., with the CA.

The facility document titled, "History and Physical," dated September 8, 2024, at 7:12 p.m., indicated Patient 20 was admitted to the facility on September 7, 2024, with a diagnosis of Acute (less than 6 months) and chronic (greater than 6 months) respiratory failure (difficult to breath) unspecified with hypoxia (not enough oxygen in the brain) or hypercapnia (too much carbon dioxide in the blood).

h. On September 16, 2024, at 10:37 a.m., an observation of Patient 22's room was conducted with the DNCS, DQM and RN 5. Patient 22's mouth was observed to be dry with cracked lips and thick white build up on teeth. RN 5 stated he was Patient 22's nurse for the day, and did not know when the last time Patient 22 had oral care performed.

A review of Patient 22's medical record was conducted on September 23, 2024, at 2 p.m., with the CA.

The facility document titled, "History and Physical," dated August 18, 2024, at 5:40 p.m., indicated Patient 22 was admitted to the facility on August 17, 2024, with a diagnosis of acute (under 6 months) respiratory failure unspecified with hypoxia ( not enough oxygen in the brain) or hypercapnia (too much carbon dioxide ion the blood).

The facility document titled, "Nurses Notes Provide Oral Care-Registered Nurse [RN] Work List," dated September 16, 2024, to September 19, 2024, indicated Patient 22 did not receive oral care every six hours per the facility policy.

An interview was conducted on September 23, 2024, at 2:10 p.m., with the CA. CA stated the RN, and the RT are to complete oral care every six hours. CA stated the staff did not follow the facility's policy.

A review of the facility P&P titled, "Core: Oral Hygiene for Airway Assisted Patients," dated June 2021, indicated,"...A combined Respiratory Therapy and Nursing approach will allow for oral hygiene scheduled at 6-hour intervals in order to maintain an oral environment free from bacteria often associated with Ventilator associated pneumonia (respiratory disorder)..."

2 a. A review of Patient 16's medical record was conducted on September 17, 2024, at 11:40 a.m., with the CA.

The facility document titled, "History and Physical," dated February 14, 2024, at 7:15 p.m., indicated Patient 16 was admitted to the facility on February 13, 2024, with a diagnosis of respiratory failure unspecified with hypoxia (not enough blood in the brain) or hypercapnia (too much carbon dioxide in the blood).


The facility document titled, "Nurses Notes" dated February 13, 2024, through February 15, 2024, contained no documented evidence Patient 16's percutaneous endoscopic gastrostomy (PEG-feeding tube through the stomach) feeding tube was completely assessed, and no dressing change was performed for the PEG tube, on the day shift (7a.m. to 7p.m.) and night shift (7p.m. to 7 a.m.).

An interview was conducted on September 17, 2024, at 11:50 a.m., with the CA. CA stated she was unable to find documentation Patient 16's PEG tube was assessed for February 13, 2024, through February 15, 2024. CA stated the PEG tube should be assessed once every shift and as needed.

An interview was conducted on September 17, 2024, at 1:47 p.m., with the EM. EM stated the PEG tubes are to be assessed once a shift for the feeding infusion, and dressing changes.

An interview was conducted on September 17, 2024, at 1:50 p.m., with the DQM. DQM stated there is no policy for the PEG tube assessment and cleaning. The DQM stated they currently use the "Gastrostomy" information from their online resource as the procedure for the facility.

b. On September 16, 2024, a tour of the facility was conducted with the DNCS and DQM.

On September 16, 2024, at 10:25 a.m., in Patient 1's room, Patient 1 was observed to be sitting in bed and had a PEG tube in the left upper abdominal quadrant with feeding infusing.

A review of Patient 1's medical record was conducted on September 17, 2024 at 10:50 a.m., with EM.

The facility document titled," History and Physical" indicated, Patient 1 was admitted to the facility on May 18, 2024, with a diagnosis of acute hypoxic respiratory failure, opiate (pain medication) drug overdose and pneumonia.

The facility's untitled document dated August 25, 2024, indicated, "...*** okay to use G tube*** Verified by KUB [kidney, ureter, and bladder - procedure to scan the kidneys and stomach] x1, start 08/25/2024 [August 25, 2024] 08:20 [8:20 a.m.]..."

Patient 1's PEG feeding tube assessments dated September 10, 2024, through September 16, 2024, indicated:

- September 10, 2024, no documented evidence Patient 1's PEG feeding tube was assessed on the day shift (7a.m. to 7p.m.) and night shift (7p.m. to 7 a.m.)

- September 11, 2024, there was no documented evidence Patient 1's PEG feeding tube was assessed on the day shift (7a.m.-7p.m.)

- September 12, 2024, there was no documented evidence Patient 1's PEG feeding tube was assessed on the day shift (7a.m.-7p.m.)

- September 13, 2024, there was no documented evidence Patient 1's PEG feeding tube was assessed on the day shift (7a.m. to 7p.m.) and night shift (7p.m. to 7 a.m.)

- September 14, 2024, there was no documented evidence Patient 1's PEG feeding tube was assessed on the day shift (7a.m. to 7p.m.) and night shift (7p.m. to 7 a.m.)

- September 15, 2024, there was no documented evidence Patient 1's PEG feeding tube was assessed on the day shift (7a.m. to 7p.m.) and

- September 16, 2024, there was no documented evidence Patient 1's PEG feeding tube was assessed on day shift (7a.m. to 7p.m.) and night shift (7p.m. to 7 a.m.).

An interview was conducted on September 17, 2024, at 11:02 a.m., with the EM. The EM stated PEG feeding tube assessments should be done by the RN's every shift.

c. On September 16, 2024, at 11:10 a.m., Patient 2 was observed lying in bed with a PEG tube in his left upper abdominal quadrant.

A review of Patient 2's medical record was conducted on September 17, 2024, at 1:10 p.m., with the EM.

The facility document titled, "History and Physical", dated August 25, 2024, indicated Patient 2 was admitted to the facility on August 25, 2024, with a diagnosis of chronic with acute respiratory failure, renal failure, and diabetic vascular disease.

The facility document titled, "Nursing Admission" dated August 25, 2024, indicated Patient 2 had a PEG feeding tube located in the left upper abdominal quadrant.

Patient 2's Peg feeding tube assessments dated September 10, 2024, through September 16, 2024, indicated:

- September 10, 2024, no documented evidence Patient 2's PEG feeding tube was assessed on the day shift (7a.m. to 7p.m.)

- September 11, 2024, no documented evidence Patient 2's PEG feeding tube was assessed on day (7a.m. to 7p.m.) shift;

- September 12, 2024, no documented evidence Patient 2's PEG feeding tube was assessed on day (7a.m. to 7p.m.) shift;

- September 13, 2024, no documented evidence Patient 2's PEG feeding tube was assessed on day (7a.m. top 7p.m.) and night (7p.m. to 7 a.m.) shift;

- September 14, 2024, no documented evidence Patient 2's PEG feeding tube was assessed on day (7a.m. to 7p.m.) and night (7p.m. to 7 a.m.) shift;

- September 15, 2024, no documented evidence Patient 2's PEG feeding tube was assessed on day (7a.m. to 7p.m.) and night (7p.m. to 7 a.m.) shift; and

- September 16, 2024, no documented evidence Patient 2's PEG feeding tube was assessed on day (7a.m. to 7p.m.) shift.

An interview was conducted on September 17, 2024, at 1:20 p.m., with the EM. EM stated PEG assessments should be done by the RNs every shift.

d. A review of Patient 4's medical record was conducted on September 18, 2024, at 10:30 a.m., with the RDQ.

The facility document titled, "History and Physical" dated February 23, 2024, indicated Patient 4 was admitted to the facility on February 22, 2024, with a diagnosis of Acute hypoxic respiratory failure (condition where there is not enough oxygen in the blood) and Status epilepticus (prolonged seizure).

The facility document titled, "Physician orders", dated February 22, 2024, indicated, "...VERIFY TUBE PLACEMENT AND PATENCY...Start 02/23/2024 [February 23, 2024] 10:00 [10:00 a.m.]...q[every]...(10 22)..."

Patient 4's PEG feeding tube assessments dated February 22, 2024, through February 26, 2024, indicated:

- February 22, 2024, no documented evidence Patient 4's PEG feeding tube was assessed on day (7a.m. to 7p.m.) shift; and

- February 24, 2024, no documented evidence Patient 4's PEG feeding tube was assessed on the night (7p.m. to 7 a.m.) shift.

An interview was conducted on September 18, 2024, at 1:49 p.m., with the RQD. RQD stated the expectation is for the PEG assessments to be done by the RNs every shift, however, that was not done for Patient 4.

e. On September 16, 2024, at 11:39 a.m., in Patient 7's room, Patient 7 was observed sitting in bed with a PEG tube in the left upper abdominal quadrant, with feeding infusing.

A review of Patient 7's medical record was conducted on September 19, 2024, at 10:21 a.m., with the RDQ.

The facility document titled, " HISTORY AND PHYSICAL" dated July 3, 2024, indicated, "DATE OF ADMISSION: July 2, 2024...IMPRESSION...Acute on chronic hypoxic respiratory failure, status post trach [tracheostomy: incision on the windpipe] on a vent [ventilator- machine to help breath]...Dysphagia [difficulty swallowing] with PEG tube dependent..."

The facility's untitled document, dated July 2, 2024, indicated, "...VERIFY TUBE PLACEMENT AND PATENCY q [every] shift, (10, 12), start 07/03/2024 [July 3,2024] 10:00 [a.m.], stop after 90 days, renewable..."

Patient 7's Peg feeding tube assessments dated from September 1, 2024, through September 15, 2024, indicated;

- September 1, 2024, no documented evidence Patient 7's PEG feeding tube was assessed on day (7a.m. to 7 p.m.) and night (7 p.m. to 7 a.m.) shift;

- September 2, 2024, no documented evidence Patient 7's PEG feeding tube was assessed on day (7a.m. to 7 p.m.) and night (7 p.m. to 7 a.m.) shift;

- September 3, 2024, no documented evidence Patient 7's PEG feeding tube was assessed on day (7a.m. to 7 p.m.) and night (7 p.m. to 7 a.m.) shift;

- September 4, 2024, no documented evidence Patient 7's PEG feeding tube was assessed on day (7a.m. to 7 p.m.) and night (7 p.m. to 7 a.m.) shift;

- September 5, 2024, no documented evidence Patient 7's PEG feeding tube was assessed on day (7a.m. to 7 p.m.) shift;

- September 6, 2024, no documented evidence Patient 7's PEG feeding tube was assessed on day (7a.m. to 7 p.m.) shift;

- September 7, 2024, no documented evidence Patient 7's PEG feeding tube was assessed on day (7a.m. to 7 p.m.) and night (7 p.m. to 7 a.m.) shift;

- September 8, 2024, no documented evidence Patient 7's PEG feeding tube was assessed on day (7a.m. to 7 p.m.) and night (7 p.m. to 7 a.m.) shift;

- September 9, 2024, no documented evidence Patient 7's PEG feeding tube was assessed on day (7a.m. to 7 p.m.) shift;

- September 10, 2024, no documented evidence patient 7's PEG feeding tube was assessed on night (7 p.m. to 7 a.m.) shift;

- September 11, 2024, no documented evidence Patient 7's PEG feeding tube was assessed on day (7a.m. to 7 p.m.) and night (7 p.m. to 7 a.m.) shift;

- September 12, 2024, no documented evidence Patient 7's PEG feeding tube was assessed on day (7a.m. to 7 p.m.) and night (7 p.m. to 7 a.m.) shift;

- September 13, 2024, no documented evidence Patient 7's PEG feeding tube was assessed on day (7a.m. to 7 p.m.) shift;

- September 14, 2024, no documented evidence Patient 7's PEG feeding tube was assessed on day (7a.m. to 7 p.m.) and night (7 p.m. to 7 a.m.) shift; and

- September 15, 2024, no documented evidence Patient 7's PEG feeding tube was assessed on day (7a.m. to 7 p.m.) and night (7 p.m. to 7 a.m.) shift.

An interview was conducted on September 19, 2024, at 10:45 a.m., with the RDQ. The RDQ stated PEG tube assessments should be done every shift but were not done for Patient 7.

f. A review of Patient 17's medical record was conducted on September 17, 2024, at 2:40 p.m., with the CA.

The facility document titled, "History and Physical," dated April 29, 2024, at 10:58 a.m., indicated Patient 17 was admitted to the facility on April 29, 2024, with a diagnosis of respiratory failure unspecified with hypoxia or hypercapnia.

- May 2, 2024, no documented evidence Patient 17's PEG feeding tube was assessed on the night (7 p.m. to 7 a.m.) shift;

- May 3, 2024, no documented evidence Patient 17's PEG feeding tube was assessed on the day (7a.m. to 7 p.m.) shift;

- May 5, 2024, no documented evidence Patient 17's PEG feeding tube was assessed on the day (7a.m. to 7 p.m.) and night (7 p.m. to 7 a.m.) shifts; and

- May 6, 2024, no documented evidence Patient 17's PEG feeding tube was assessed on the day (7a.m. to 7 p.m.) shift.

An interview was conducted on September 17, 2024, at 2:45 p.m., with the CA. CA stated Patient 17's PEG tube should have been assessed once every shift and as needed. CA stated the staff did not follow the facility policy.

A review of the facility's P&P titled, "Core: Administration of Enteral Nutrition," dated June 2023, indicated, "...Assess for GI intolerance to enteral tube feeding by assessing for abdominal distention, monitoring for complaints of abdominal pain, and observing for passage of flatus and stool every shift and PRN..."

A review of facility document titled, "Gastrostomy" dated October 9, 2023, indicated,"...Monitor the gastrostomy site for signs of skin irritation and infection...Wash the area around the tube daily with soap and water or normal saline solution...Keep the gastrostomy site clean and dry...Changing the Dressing...Change your dressing daily or whenever it's wet or soiled...clean...the skin around the tube with mild soap and warm water..."

3. A tour of the Medical Surgical Telemetry Unit (MSTU) was conducted on September 16, 2023, at 9:55 a.m., with the DNCS and DQM.

During the tour, in Patient 1's room, Patient 1 was observed sitting in bed, with a midline catheter (a long, flexible tube inserted into a vein in the upper arm to administer medication) in the left upper arm.

An interview was conducted on September 16, 2024, at 1:30 p.m., with RN4. RN4 stated Patient 1's midline is being used to infuse medications.

A review of Patient 1's medical record was conducted on September 17, 2024, at 10:50 a.m., with the EM.

The facility document titled, "History and Physical" dated May 19, 2024, indicated Patient 1 was admitted to the facility on May 18, 2024, with a diagnosis of acute hypoxic respiratory failure, opiate drug overdose and pneumonia.

The facility document titled, "Orders" dated June 26, 2024, indicated, "...Midline catheter insertion: x1, start 06/26/2024 [June 26, 2024] 15:34 [3:34 p.m.]..."

An interview was conducted with the DNCS on September 17, 2024, at 1:13 p.m. The DNCS stated she is not sure when a midline catheter should be discontinued.

A concurrent interview and record review was conducted on September 19, 2024, at 7:40 a.m., with the Chief Operation Officer (COO). The facility education board was reviewed. Education board information indicated, "INS Infusion Nursing Society Selecting a Standards for Infusion Care...Infusion Therapy Device Selection...Peripheral...Therapy Duration...>4 weeks consider PICC (Peripherally Inserted Central Catheter) or non-tunneled (short tracked catheter)..." The COO stated he is not an expert on midline catheters so he does not know when a midline should be changed or discontinued.

4.a. On September 16, 2024, at 10:25 a.m., in Patient 1's room, Patient 1 was observed sitting in bed, with a midline catheter in Patient 1's left upper arm.

An interview was conducted on September 16, 2024, at 1:30 p.m. with RN 4. RN 4 stated the midline is being used to infuse medications.

A review of Patient 1's medical record was conducted on September 17, 2024, at 10:50 a.m., with the EM,

The facility document titled, " History and Physical" dated May 19, 2024, indicated Patient 1 was admitted to the facility on May 18, 2024, with a diagnosis of acute hypoxic, respiratory failure, opiate drug overdose and pneumonia.

The facility document titled, "Orders" dated June 26, 2024, indicated, "...Midline catheter insertion: x1, start 06/26/2024 [June 26,2024] 15:34 [3:34 p.m.]..." During a concurrent interview, the EM stated there was no documented evidence that the midline was changed or discontinued.

The facility document titled, " Intravenous Lines" dated September 10, 2024, through September 15, 2024, had no documented evidence Patient 1's midline catheter dressing was changed every seven days. EM stated midline line dressing should be changed every seven (7) seven days per policy.

The facility document titled, "Nurses Notes: Peripheral Venous line: left upper arm, 5 fr [French] midline ..", dated September 10, 2024, through September 15, 2024, had no documented evidence Patient 1's midline catheter was assessed on September 13, 2024, nor September 14, 2024.

An interview was conducted on September 17, 2024, at 10:55 a.m., with the EM. EM stated there was no documented evidence Patient 1's midline catheter was changed or discontinued. EM stated midline catheter dressings should be changed every seven days, and assessed daily per the facility policy.

b. On September 16, 2024, at 11:10 a.m., in Patient 2's room, Patient 2 was observed sitting in bed with a midline catheter in Patient 2's right upper arm.

A review of Patient 2's medical record was conducted on September 17, 2024, at 1:10 p.m., with the EM.

The facility document titled, "History and Physical", dated August 25, 2024, indicated Patient 2 was admitted to the facility on August 25, 2024, with a diagnosis of chronic with acute respiratory failure, renal failure, (kidney disease) and diabetic vascular disease (diabetes (high blood sugar) caused blockages).

The facility document titled, "Orders" dated June 26, 2024, indicated, "Change midline dressing: q [every] 7d [days], (10), start 09/01/2024 [September 1, 2024] 10:00 (a.m.), stop after 90 days, renewable...".

The facility document titled, "Intravenous Lines" dated September 8, 2024, through September 17, 2024, had no documented evidence Patient 2's midline dressing was changed. The EM stated midline line dressing should be changed every seven (7) seven days per policy.

The facility document titled, "Intravenous Lines" dated September 10, 2024, through September 17, 2024, had no documented evidence Patient 2's midline catheter was assessed on September 13, 2024, and September 16, 2024.

An interview was conducted on September 16, 2024, at 11:25 a.m., with the EM. EM stated midline line dressings should be changed every seven days and midline catheter sites should be assessed daily per facility policy.

A review of facility's policy and procedure (P&P) titled, "Midline Catheter Site Placement, Maintenance and Dressing Change", dated June 2023, indicated, "...Policy: the policy of [Name of Facility] is to ensure the following...Midline catheter should be utilized for anticipative infusion therapy provided for 1-4 weeks...Ongoing daily assessment and with dressing change of IV [intravenous, within a vein] sites. Assess for complications (signs of infection and/or pain of site) and measurement as indicated...Midline catheter site care and dressing changes will be performed every seven days..."

A review of the Infusion Therapy Standards of Practice ninth (9th) Edition (2024), indicated, "Section Five: Vascular Access Device Selection...VASCULAR ACCESS DEVICE PLANNING AND SITE SELECTION... INS [Infusion Nursing Society] categorizes 3 types of PIVCs [Peripheral intravenous catheters]...Midline peripheral catheter...Standard...The appropriate vascular access device (VAD), peripheral or central, is selected based on the prescribed therapy or treatment regimen, anticipated duration of therapy...General Information for Vascular Access Device and Site Selection...Anticipated duration of therapy...(5-14 days): Insert a midline catheter in hospitalized adult patients when all the above elements indicate peripherally compatible therapy...(>15 days) Consider insertion of a peripherally inserted central catheter [PICC - catheter use for long term medication treatment]..."

5. A tour of the ICU was conducted on September 16, 2024, at 8:47 a.m., with the DNCS.

During the tour on September 16, 2024, at 9:12 a.m., in Patient 8's room, Patient 8 was observed in bed with Total Parenteral Nutrition (TPN- a method of feeding that provides nutrients to a patient intravenous [through the vein]) infusing using Patient 8's hemodialysis (treatment for kidney failure) catheter in Patient 8's right groin.

An interview was conducted on September 16, 2024, at 9:15 a.m., with the DNCS. DNCS stated the hemodialysis catheter has a triple lumen, wherein one lumen can be used for infusing the TPN.

An interview was conducted on September 16, 2024, at 11:15 p.m., with Physician 1. Physician 1 stated hemodialysis catheters should not be used for medication infusion.

An interview was conducted on September 16, 2024, at 1:25 p.m., with Dialysis Nurse (DN). The DN stated, hemodialysis catheters should not be used for infusing any medications unless it is an emergency.

A review of Patient 8's medical record was conducted on September 20, 2024, at 9:23 a.m., with the RDQ.

The facility document titled, "History and Physical", dated September 14, 2024, indicated Patient 8 was admitted to the facility on September 14, 2024, with a diagnosis of Chronic hypoxic respiratory failure and acute pulmonary embolism.

The untitled facility document indicated, "...Amino Acid [molecules that combine to form protein] 4.25%/dextrose [fluid with sugar]5%...2000 ml [milliliters, unit of measurement]...50ml/hr. cont....start date 09/16/2024 [September 16, 2024]...Stop date...09/20/2024 [September 20, 2024]..."

The facility document titled "Orders" had no documented evidence of a physician's order to use Patient 8's hemodialysis catheter for TPN infusion.

A review of the P&P titled, "CORE: Hemodialysis Catheter Care and Maintenance", dated June 2022, indicated, "...Policy...It is the policy of [Name of Facility] to ensure the following...The hemodialysis catheter is not used for routine administration of parenteral [intravenous solution] except upon physician or other authorized prescriber's written order..."

6. a. A review of Patient 17's medical record was conducted on September 17, 2024, at 2:08 pm., with the CA.

The facility document titled, "History and Physical," dated April 29, 2024, indicated Patient 17 was admitted to the facility on April 28, 2024, with a diagnosis of respiratory failure unspecified with hypoxia, or hypercapnia.

The facility documents titled, "Central Venous [CV] Line" dated May 3, 2024, through May 5, 2024, indicated no documented evidence Patient 17's CV dressing was changed.

The facility documents titled, "Central Venous Line" dated May 5, 2024, through May 10, 2024, indicated no documented evidence Patient 17's CV dressing was changed.

The facility documents titled, "Central Venous Line" dated May 11, 2024, through May 14, 2024, indicated no documented evidence Patient 17's CV dressing was changed.

An interview was conducted on September 17, 2024, at 2:21 p.m., with the CA. CA stated Patient 17's CV line dressing should have been changed every seven days and the nurse should have documented the dressing change if it was completed. CA stated there was no documentation of Patient 17's CV line dressing was change.

b. Observations in Patient 22's room were conducted on September 16, 19, and 23, 2024. Patient 22 was observed lying in bed with a Central line in the left upper arm with a dressing dated September 9,

Based on observation, interview, and record review, facility failed to ensure the facility's policy and procedure (P&P) was implemented, for one of 31 sample patients (Patient 8), when soft wrist restraints (a device designed to limit the movement of wrists) were initiated on Patient 8 without a physician's order.

This failure had the potential for patient harm and injury for Patient 8.

Findings:

A tour of the Intensive Care Unit (ICU, unit for critically ill patients) was conducted with the Director for Nursing Clinical Services (DNCS) on September 16, 2024, at 8:47 a.m.

An observation was conducted with the DNCS and Registered Nurse (RN) 8 at the ICU on September 16, 2024, at 9:17 a.m. Patient 8 was observed to have soft wrist restraints on both wrists. During a concurrent interview at the time of the observation, RN 8 stated the soft wrist restraints were placed on Patient 8's wrists because the patient was pulling his nasogastric tube (NGT, a feeding tube).

An observation and interview were conducted on September 18, 2024, at 9:17 a.m. with the DNCS and RN 16. Observed patient on bilateral wrist restraints. RN 16 stated Patient 8 was on bilateral wrist restraints because he removed his NGT twice yesterday.

An observation was conducted on September 20, 2024, at 6:38 a.m. with the DNCS and Patient 8 was observed to still be in bilateral soft wrist restraints.

A review of Patient 8's record was conducted on September 20, 2024, at 9:23 a.m., with the Rancho Quality Director (RQD). A facility document titled, "History and Physical" dated September 14, 2024, was reviewed. The document indicated, "... DATE OF ADMISSION: September 14, 2024... IMPRESSION...Chronic hypoxic respiratory failure (condition where there is not enough oxygen in the blood)...Acute pulmonary (lungs) embolism (blood clot)..."

An observation and interview were conducted on September 22, 2024, at 6:01 a.m., with RN 21. Patient 8 was observed to have soft wrist restraints on both wrists. RN 21 stated Patient 8 has pulled his NGT several times.

An observation was conducted on September 23, 2024, at 4:05 p.m., at the ICU with RN 61. Patient 8 was observed to be more awake and alert, and had soft wrist restraints on both wrists. RN 61 stated Patient 8 was still on restraints for pulling on his NGT.

A concurrent interview and review of Patient 8's record were conducted on September 24, 2024, at 11:10 a.m., with the Education Manager (EM). There was no documented evidence a physician's order was obtained for the use of soft wrist restraints on Patient 8 from September 16 to 18, 2024. The EM stated there was no documentation an order for the restraints was given by the physician for the use of soft wrist restraints on Patient 8 from September 16 to 18, 2024. The EM also stated a physician's order is needed for restraints per facility policy.

An interview was conducted on September 24, 2024, at 11:20 a.m., with RN 62. RN 62 stated a physician's order is needed when restraints are placed on patients.

An interview was conducted on September 24, 2024, at 1:08 p.m., with the Chief Operating Officer (COO). The COO stated based on his record review, there was no documentation a physician's order was obtained for Patient 8's restraints from September 16 to 18, 2024.

A review of the facility's policy and procedure (P & P) titled, "CORE: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion," dated June 2023, was conducted. The P&P indicated, "...For current inpatient initial restraint order from the attending physician or other licensed practitioner (LP) is required immediately or within a few minutes from initiating restraints..."

Based on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) for restraints when an ongoing assessment for a patient on restraints (devices or methods that restrict a patient's movement without their consent) was not conducted, for one of 31 sample patients (Patient 10).

This failure had the potential to cause harm, injury, and/or death to Patient 10.

Findings:

A tour of the Medical Surgical Telemetry Unit (MSTU) was conducted on September 16, 2023, at 9:55 a.m., with the Director for Nursing Clinical Services (DNCS) and Director of Quality Management (DQM).

An observation was conducted with the DNCS on September 16, 2024, at 10:36 a.m., in Patient 10's room. Patient 10 was observed lying in bed with eyes closed and did not move nor open his eyes when the surveyor and facility staff introduced themselves while they were entering the room. Patient 10 was observed to have soft wrist restraints (restraint designed to limit the movement of both wrists) on both wrists. Patient 10 continued to have his eyes closed when observation was being done on the percutaneous endoscopic gastrostomy (PEG, a feeding tube) tube attached to him.

An observation was conducted on September 19, 2024, at 10 a.m., in Patient 10's room. Patient 10 was observed to be still with his eyes closed and was observed to have wrist restraints on both wrists. Patient 10 was observed to not move nor wake up when his name was called and his shoulder was tapped.

An observation was conducted on September 20, 2024, at 7:29 a.m., in Patient 10's room. Registered Nurses (RN) 43 and 48 were observed attempting to stimulate Patient 10 to elicit a response or to wake him up. Patient 10 was observed to not be responding after the RNs called the patient's name and tapped his shoulders. Patient 10 was observed to have a soft wrist restraint on the left wrist.

An interview was conducted with Respiratory Therapist (RT) 2 on September 20, 2024, at 7:31 a.m., at Patient 10's bedside. RT 2 stated she has not seen Patient 10 awake nor moving while she provided care for him. RT 2 stated Patient 10 had a soft wrist restraint on his left wrist but not on the right wrist.

An interview was conducted with Certified Nurse Assistant (CNA) 1 on September 22, 2024, at 7:07 a.m. CNA 1 stated the restraints were placed on Patient 10 because the patient was picking on his colostomy (an opening into the colon, a part of the intestine, from the outside of the body) bag and was attempting to remove his tracheostomy (an opening through the neck for breathing) tube. CNA 1 stated she observed Patient 10 was not moving and was sleeping more this week .

A concurrent interview and review of Patient 10's record was conducted with the Education Manager (EM) on September 24, 2024, at 10:30 a.m. A facility document titled, "Restraint Care Plan (Non-Violent, Non -Self Destructive Behavior)," from September 9, 2024, to September 20, 2024, was reviewed. There was no documented response provided for the section which asked, "...Is the need for restraint resolved?..." The EM stated there was no documented response to the question, "Is the need for restraints resolved?" on the dates of September 15, 16, 17, 18, and 20, 2024.

A review of the facility's P&P titled, "CORE: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion," dated June 2023, was conducted. The P&P indicated, "...Ongoing Assessment (at least daily) by an RN of the patient's behavior, whether the unsafe situation is resolved and whether the criteria for discontinuing the restraints are met..."

Based on interview and record review, the facility failed to ensure qualified and competent Registered Nurses (RN's) were assigned to provide care for patients in the Medical/Surgical/ Telemetry Unit (MSTU), and Intensive Care Units (ICU, a unit for critically ill patients), requiring cardiac monitoring (continuous or intermittent monitoring of the heart's activity to assess a patient's condition) when:

1. 62 of 66 RNs (RNs 1 to 9, 11 to 14, 16, 18, and 20 to 66) did not complete a cardiac arrhythmia (irregular heart rate and rhythm) interpretation course for the certification required to care for patients needing cardiac monitoring, and who were providing care for patients on the cardiac monitor (a device which shows the heart rate and rhythm on a monitor with a capability of printing them on strips);

2. 44 of 66 RNs (RNs 2 to 9, 11 to 13, 20, 21, 25 to 41, 46, 50, 53, 55 to 59, and 61 to 66) did not complete the cardiac rhythm interpretation test required to care for patients needing cardiac monitoring, and who were providing care for patients on the cardiac monitor;

3. Two RNs (RNs 2 and 50), who were providing care to patients in the ICU, had no ICU competency validation and unit orientation completed;

4. Six of eight Nursing and House supervisors (NSRN 58, 59, 60, 61, and 62) who are responsible to oversee all the units in the facility during a shift and who take over the care of patients in the ICU when the ICU RN responds to emergency situations, had no ICU nursing orientation or competency; and

5. The Director of Nursing Clinical Services (DNCS) did not meet the qualification for the position based on the DNCS job description.

These failures had the potential to delay patient care, cause harm or injury, and /or death to patients.

Findings:

1. On September 16, 2024, at 8:47 a.m. a tour was conducted in the ICU with the DNCS. Six patients were observed to have electrocardiogram leads (EKG, a procedure to obtain a graphical description of the electrical activity of the heart) on their chests with the cables connected to a cardiac monitor at bedside.

An interview was conducted the Monitor Technician (MT) 1 in the ICU on September 16, 2024, at 8:50 a.m. MT 1 stated there were six ICU patients and 14 Medical/Surgical Telemetry patients with cardiac monitoring. MT 1 stated part of her responsibility is to print and interpret the rhythm strips (thin strips of paper where the heart rate and rhythm are documented by the cardiac monitor machine), then the RNs are responsible for verifying the interpretation and signing the rhythm strips. MT1 also stated printing and rhythm interpretation is done once a shift.

A concurrent interview and review of rhythm strips interpretation were conducted with RN 1 and RN 2 on September 16, 2024, at 10:30 a.m. RN's 1 and 2 were unable to interpret the heart rhythm on the rhythm strip. RN's 1 and 2 both stated they have not received training on cardiac monitoring.

An interview was conducted with the Education Manager (EM) on September 16, 2024, at 2:02 p.m. The EM stated, to his knowledge, it is not a requirement for RN's hired to work in MSTU to complete a cardiac rhythm interpretation course. The EM also stated he is not qualified to teach a cardiac rhythm interpretation course.

A record review was conducted with the Director Nursing Clinical Services (DNCS) on September 16, 2024, 2:37 p.m. A facility document titled, "MED-SURG-TELEMETRY [Medical-Surgical unit, unit where nurses provide care for patients with a wide range of medical and surgical problems and conditions who are needing less than critical care; Tele, unit where patients' heart rates and rhythms are remotely monitored continuously] DAILY ASSIGNMENT SHEET," dated September 16, 2024, was reviewed. The document indicated the following:

- RN 1 was assigned three patients on cardiac monitoring;
- RN 2 was assigned five patients on cardiac monitoring;
- RN 3 was assigned five patients on cardiac monitoring; and
- RN 4 was assigned five patients on cardiac monitoring.

A review of the facility document titled, "ICU STAFFING ASSIGNMENT SHEET," dated September 16, 2024, was conducted on September 16, 2024, at 2:40 p.m. The document indicated RN 5 was assigned two patients on cardiac monitoring.

A review of employee files was conducted with the EM on September 17, 2024, at 9:16 a.m. The employee education files of five RN's (RN's 1, 2, 3, 4, and 5) were reviewed for valid completion of cardiac rhythm interpretation course. There was no documented evidence RN's 1, 2, 3, 4, and 5 had completed the cardiac rhythm interpretation course in accordance with the facility's policy.

A review of cardiac rhythm interpretation course certification was conducted with the DNCS and Rancho Quality Director (RQD) on September 18, 2024, at 9:27 a.m. The cardiac rhythm interpretation course certificates of RN's 1 through 66 were reviewed. Only four of the 66 RN's reviewed (RN's 10, 15, 17, and 19) had completed the cardiac rhythm interpretation course certification.

There was no documented evidence 62 of 66 RNs who provided care to patients on cardiac monitoring had completed the cardiac rhythm interpretation course.

2. An interview was conducted with the EM on September 16, 2024, at 2:10 p.m. The EM stated passing the cardiac rhythm interpretation test is a requirement for RN's working in the MSTU.

An interview and review of the employee education files of five RN's (RN's 1, 2, 3, 4, and 5) for valid completion of cardiac rhythm interpretation test were conducted with the EM on September 17, 2024, at 9:20 a.m. There was no documented evidence RN's 2, 3, 4, and 5 had completed the facility cardiac rhythm interpretation test in accordance with the facility policy.

A review the facility's cardiac rhythm interpretation test completion was conducted with the DNCS and RQD on September 18, 2024, at 9:27 a.m. The cardiac rhythm interpretation test of RN's 1 through 66 was reviewed. Only 22 of the 66 RN's (RN's 1, 10, 14, 15, 16, 17, 18, 19, 22, 23, 24, 42, 43, 44, 45, 47, 48, 49, 51, 52, 54, and 60) reviewed had completed and passed the facility's cardiac rhythm interpretation test.

There was no documented evidence 44 of 66 RN's had completed the facility's cardiac rhythm interpretation test.

The facility policy and procedure (P&P) titled, "Continuous Cardiac Monitoring," dated June 2023, was reviewed with the DNCS and the Chief Operating Officer (COO) on September 18, 2024, at 9:35 a.m. The policy indicated, "...Staff Orientation, Competency, Requirements, and Competency Validation a. In addition to general and nursing department orientation, the following are requirements concerning care for telemetry patients...Cardiac rhythm interpretation qualification...The hospital maintains sufficient number of registered nurses with competency in cardiac rhythm interpretation...A valid certificate of satisfactory completion of a cardiac rhythm interpretation course from another institution is acceptable evidence of course completion, but the staff member must also pass [Facility Name] cardiac rhythm interpretation test..."

During a concurrent interview, the DNCS stated the facility only needs to have a sufficient number of nurses competent in cardiac rhythm interpretation. The DNCS was unable to define what a sufficient number of nurses is.

A review of the American Heart Association (AHA, a nationally recognized organization) Scientific Statement titled, "Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings. A Scientific Statement from the American Heart Association," dated November 7, 2017, was reviewed. The document indicated, "...Endorsed by the American College of Cardiology, American Association of Critical Care Nurses and Pediatric Congenital Electrophysiology Society... BACKGROUND AND PURPOSE: This scientific statement provides an interprofessional, comprehensive review of evidence and recommendations for indications, duration, and implementation of continuous electrocardiographic monitoring of hospitalized patients...Education of Staff: Education is a critical aspect of the process in electrocardiographic monitoring. Adequate education is crucial for correct interpretation of electrocardiographic waveforms and data and proper care of patients undergoing continuous electrocardiographic monitoring. Incorrect interpretation can result in unnecessary diagnostic or surgical interventions...Education about electrocardiographic monitoring should be included in orientation and on an ongoing basis, with both didactic content and clinically based hands-on practice..."

On September 18, 2024, at 1:12 p.m., the survey team identified significant concerns in the facility's Medical Surgical Telemetry (MSTU) and Intensive Care Unit (ICU). Due to the seriousness of the situation, an immediate jeopardy (IJ, a situation which had the potential to cause harm to the health and safety of the patients) was called in the presence of the facility's Chief Executive Officer (CEO), Chief Operating Officer (COO), Rancho Director for Quality (RDQ), Director for Nursing Clinical Services (DNCS), Director for Quality (DQ), and Clinical Analyst (CA). The facility's CEO, COO, DNCS, RDQ, and QD were verbally notified regarding the concerns of the facility's failure to ensure qualified and competent RN's, for 62 of 66 RNs, were assigned to provide care to patients requiring cardiac monitoring.

On September 20, 2024, at 9:39 a.m., the COO provided a Corrective Action Plan (CAP). The CAP was found to not be acceptable.

On September 20,2024, at 3:28 p.m., the COO provided a revised CAP. The CAP indicated the following:

1. The Nursing Leadership team reviewed the facility policy and procedure titled, "Continuous Cardiac Monitoring H-PC 7-015," and no modifications to policy were recommended;

2. All RN files were reviewed by the Nursing Leadership to develop a list of RN team members who have taken a course in cardiac interpretation and have passed the Kindred cardiac rhythm interpretation test;

3. All patients currently on continuous cardiac monitoring were assessed by a competent Registered Nurse with evidence of cardiac rhythm interpretation competency. Rhythm interpretation, vital signs and plan of care reviewed with bedside nurse. Documentation of rhythm interpretation, vital signs, and any interventions are to be documented in the change of condition and will continue to be charted under change of condition for a period of 30 days;

4. All Patients with continued cardiac monitoring will be assessed each shift by a competent Registered Nurse (RN) with evidence of cardiac rhythm interpretation competency by a) rhythm interpretation, vital signs and plan of care, b) review with bedside nurse and c) assessment and interventions as indicated until education can be completed to obtain the sufficient number of licensed nurses with competency in cardiac rhythm interpretation;

5. At least 2 RNs, with the support of a Nursing Supervisor who are competent in cardiac interpretation, will be assigned to continually monitor and provide interpretation of cardiac status of all patients requiring cardiac monitoring. This process will continue until a sufficient number of RNs, based on the number of patients with continuous cardiac monitoring, have completed the competency for cardiac rhythm interpretation; and

6. A Lippincott (a publisher of medical and nursing books) based education plan was identified. Initial implementation of education and testing began on to ensure qualified and competent licensed nurses are assigned to provide care to patients requiring cardiac monitoring;

On September 20, 2024, at 4:10 p.m., the CAP for the IJ was reviewed and was found to be acceptable, and the DNCS and the Director of Quality Management (DQM) were notified.

On September 23, 2024, at 11:40 a.m., through observations, interviews, and record review, the CAP was verified onsite to have been fully implemented.

On September 23, 2024, at 1:10 p.m., the IJ was removed in the presence of the COO, the DNCS, and the DQ.

3a. A review of RN 2's employee file was conducted with the EM on September 17, 2024, at 9:16 a.m. A facility document titled, "Clinical Skills Initial Core Competency Checklist RN Critical Care/High Observation," dated January 15, 2024, indicated, "... areas of need...To learn more on charting drips [medications are administered through the veins over a given amount of time] on the paper...Orientation release date 01/23/2024 [January 23, 2024]...Release from Orientation - yes..." The document indicated it was signed by RN 2, RN 59, who was RN 2's preceptor (an experienced licensed clinician who supervises nurses during their unit orientations), and the DNCS on January 23, 2024.

A review of the facility document titled, "Clinical Skills Initial Core Competency Checklist RN Critical Care/High Observation," dated January 15, 2024, was conducted with RN 59 on September 17, 2024, at 3:38 p.m. During a concurrent interview, RN 59 stated she was the ICU Preceptor when RN 2 was undergoing her orientation at the ICU. RN 59 stated she was instructed by the former DNCS to "just put a date and sign the competency checklist" of RN 2.

A review of the facility document titled, "ICU staffing Assignment Sheet," dated January 1, 2024, through January 23, 2024, was conducted with the EM on September 18, 2024, at 2:45 p.m. The documents indicated:

- On January 1, 2024, day shift (7 a.m.- 7 p.m.), RN 2 was assigned one ICU patient;
- On January 11, 2024, day shift, RN 2 was assigned two ICU patients;
- On January 14, 2024, day shift, RN 2 was assigned two ICU patients;
- On January 15, 2024, day shift, RN 2 was assigned two ICU patients;
- On January 20,2024, day shift, RN 2 was assigned two ICU patients; and
- On January 23, 2024, day shift, RN 2 was assigned one ICU patient.

During a concurrent interview, the EM stated, if there was no "O [on orientation]" and the name of the Preceptor beside RN 2's name in the ICU assignment sheet, then RN 2 was providing patient care on her own. The EM also stated the former DNCS allowed RN 2 to work in ICU, even while knowing RN 2 failed the cardiac rhythm interpretation test and the ICU critical care examination.

A review of RN 2's employee file was conducted with the EM and DNCS on September 19, 2024, at 11:15 a.m. A facility document titled, "Job Description," dated May 17, 2023, indicated, "...Job Title: Registered Nurse...Experience: Minimum six months' Medical/Surgical experience in acute care setting preferred..."

An interview was conducted with the EM and DNCS on September 19, 2024, at 12:30 p.m. The EM stated it was the former DNCS who oversaw RN 2's orientation. The EM stated he does not know the facility's policy on the duration of the ICU unit orientation. The DNCS stated she does not know the orientation process at this facility.

A review of the facility document titled, "HD Orientation/Annual Guidelines," dated July 2018, was conducted with the EM, the DNCS, and the RDQ on September 19, 2024, at 1:10 p.m. The document indicated, "Orientation Guidelines...Following 8 [eight] hours of General Hospital Orientation, these are the recommendation for Department Orientation...discipline...New Graduate RN/LPN [Licensed Practical Nurse]...Recommendation...360 hours of unit orientation..."

During a concurrent interview, the EM stated he was not aware of these guidelines. The RDQ stated this document is the official guidelines for all [Name of Facility] Hospitals.

An interview was conducted with the EM on September 19, 2024, at 1:13 p.m. The EM stated there was no documentation RN 2 completed the ICU unit orientation prior to January 23, 2024.

An interview was conducted with RN 2 on September 19, 2024, at 2:20 p.m. RN 2 stated she did not completed the 360 hours ICU unit orientation.

b. An interview was conducted with RN 50 on September 22, 2024, at 5:55 a.m. RN 50 stated she started as a medical/surgical nurse at this facility in November 2023. RN 50 stated she did not have any ICU experience prior to working at the facility. RN 50 stated she has not completed any critical care course nor had 360 hours of ICU unit orientation.

An observation was conducted on September 22, 2024, at 6:10 a.m. in Room A in the ICU. RN 50 was observed at the bedside providing care for Patient 12.

A review of facility document titled, "ICU staffing Assignment Sheet," dated September 21, 2024, was conducted on September 22, 2024, at 5:30 a.m. The document indicated, "...1900 [7 p.m.]- 0700 [7 am]...[Room B]...PATIENT [name of Patient 19]...STATUS...ICU...NURSE [name of RN50]...[Room C]...PATIENT [name of Patient12]...NURSE...[name of RN 50]..."

A review of RN 50's employee file was conducted with the EM on September 24, 2024, at 9:05 a.m. There was no documented evidence RN 50 completed a critical care course nor any ICU competencies and ICU unit orientation.

An interview was conducted with the EM on September 24, 2024, at 9:15 a.m. The EM stated the former DNCS was in charge of the ICU training.

4. An interview was conducted with the EM on September 16, 2024, at 2:15 p.m. The EM stated, during a medical emergency or rapid response (a hospital code for a group of healthcare professionals who are called to a patient's bedside to assess and treat a medical emergency), an ICU RN or the Nursing Supervisor (an RN who oversees all the units at the facility) would respond because they have certification for Advance Cardiac Life Support (ACLS, training of healthcare professionals on how to respond to life threatening emergencies and provide the appropriate electrical shock and emergency medication). The EM stated the Nursing Supervisors will take over the care of ICU patients assigned to an ICU RN who would respond to the emergency or rapid response.

An interview was conducted with the DNCS on September 16, 2024, at 2:45 p.m. The DNCS stated the Nursing supervisors will respond to a code (code blue, a hospital code for a patient who requires immediate medical attention or needs to be revived) or rapid response (a team of providers who are called to a patient's bedside to assess and treat a patient who is showing signs of clinical deterioration) because they are ACLS certified or covers ICU patients when ICU RN responds to the code.

On September 16, 2024, at 2:47 p.m., a rapid response was observed to be called on Room D. ICU RN 8 and Nurse Supervisor (NSRN) 62 were observed to respond to the rapid response call.

An interview was conducted with RN 8 on September 16, 2024, at 4 p.m. RN 8 stated NSRN 62 assumed the care for her patients when she (RN 8) responded to the rapid response at 2:47 p.m., on the same day. RN 8 stated she was then informed NSRN 62 responded also to the rapid response with her. RN 8 stated, "Then nobody was watching my patients."

A review was conducted with the EM on September 23, 2024, at 9:25 a.m. The following employee files of the House/Nursing Supervisors were reviewed for their critical care experience or current ICU competencies:

- For NSRN 58, there was no documented evidence of critical care experience and current critical care competencies;
- For NSRN 59, there was no documented evidence of critical care experience, initial ICU unit orientation when hired, and current ICU competencies;
- For NSRN 60, there was no documented evidence of critical care experience, initial ICU unit orientation, and current ICU competencies;
- For NSRN 61, there was no documented evidence of current ICU competencies;
- For NSRN 62, there was no documented evidence of critical care experience, initial ICU unit orientation, and current ICU competencies; and
- For NSRN 65, there was no documented evidence of critical care experience, initial ICU unit orientation, and current ICU competencies.

An interview was conducted with the COO on September 23, 2024, at 11:18 a.m. The COO stated a Nursing Supervisor should have ICU competencies to care for ICU patients.

A review of an undated facility document titled, "Job Description," was conducted with the EM on September 23, 2024, at 11:25 p.m. The document indicated, "...Job Title: Registered Nurse...Experience: Minimum one year training and experience in Critical Care..." During a concurrent interview, the EM stated the document is the ICU RN job description. The EM stated the current Nursing Supervisors do not have a signed ICU job description and did not complete the initial ICU unit orientation.

5. A review of an undated facility document titled, "Job Description," was conducted with the EM on September 24, 2024, at 3:33 p.m. The document indicated it was signed by the DCNS on August 4, 2024. The document indicated ACLS is required upon hire.

An interview was conducted with the DNCS on September 24, 2024, at 3:40 p.m. The DNCS stated she is still on a 90- day probationary period and has until the end of the probationary period to obtain ACLS certification.

An interview was conducted with the COO on September 24, 2024, at 3:45 p.m. The COO stated ACLS certification is a requirement for the DNCS position based on the qualification listed on the job description.

An interview was conducted with the COO on September 24, 2024, at 4 p.m. The COO stated there is no documentation to support the claim of the DCNS that she can obtain her ACLS certification before the 90- day probation ends.

Based on interview and record review, the facility failed to follow their policies and procedures (P&P) for significant weight loss/gain and discarding sharps, for four of 31 patients (Patient 15, 21, 29, 30) when:

1. Patients 29 and 30, who were receiving enteral feeding (method of delivering nutrition to the body through the digestive system) were not re-weighed after a significant weight loss/gain; and

2. For Patients 20 and 28, sharps and needles were left on the patients over bed table and not discarded in the sharps container.

This failure had the potential to delay patient care and cause patient harm.

Findings:

On September 23, 2024, at 8:30 a.m., an unannounced visit was conducted at the facility to investigate a complaint.

1. a. A review of Patient 29's medical record was conducted on September 23, 2024, at 1:07 p.m., with the Radiology Manager (RM).

The undated facility document titled, "Patient Registration Data" indicated Patient 29 was admitted to the facility on September 4, 2024.

The facility document titled, "History and Physical," dated September 10, 2024, indicated, "...with muscular dystrophy [a hereditary condition marked by progressive weakening and wasting of the muscles]...past medical history of mitochondrial DNA depletion syndrome associated with mutation in TKA 2 Gene [genetic condition where mutations in the TK2 gene lead to a deficiency]...Neuromuscular scoliosis [ sideways curvature of the spine that's caused by conditions that affect the muscles, nerves, or brain]...Ventilator dependence [a serious medical condition that occurs when a patient can't breathe independently and requires a ventilator to help them breathe]...Starvation ketosis [a metabolic acidosis that occurs when the body breaks down fat and muscle for energy after prolonged fasting or starvation]..."

The facility untitled document dated September 4, 2024, indicated, "...LVN [Licensed Vocational Nurse]/RN [ Registered Nurse] TO ENTER WT[weight]. IF > [more than] 5 LB [pounds] CHANGE RE-WEIGH & COMMENT "RE-WEIGH & [and] POSSIBLE CAUSES...IF >10% CHANGE, HOYER PT [patient]. RE-ZERO & RE-WEIGH. IF STILL >10% CHANGE, OPEN A COC [change of condition], NOTIFY MD [Medical Doctor]..."

The facility document titled, "Weight," dated September 5, 2024, through September 23, 2024, indicated the following weights in pounds:

-September 5, 2024, (58.50)
-September 9, 2024, (143)
-September 16, 2024, (147)
-September 23, 2024, (145)

The facility document titled, "Nutrition progress note," dated September 7, 2024, at 1:38 p.m., indicated, "...Per MD [medical doctor] notes, pt [patient] visited in room with father at bedside...father shared that pt wt [weight] hasn't changed much...Diet order: Osmolite 1.5 at 30 mL/hr [milliliters an hour, unit of measurement]...Provides 720 mL, 1080 kcals, 45g [grams] protein, 823 mL TF [tube feeing] daily...Current weight: 26.5 kg [kilograms, unit of measurement] (58.5 lbs - bed scale)...Malnutrition status: Pt meets severe malnutrition criteria d/t [due to] severe muscle wasting and severe fat loss...Nutrition risk level...HIGH..."

The facility document titled, "Nutrition progress note," dated September 16, 2024, at 6:04 p.m. indicated, "...During last week's ICT [inter care team] discussion, pt family states pt's usual body weight is 80 lbs. Suspected weight inaccuracy. Please re-weigh patient using appropriate procedure in order to obtain accurate weight...Anthropometrics: NOTE SUSPECTED WEIGHT INACCURACY. PLEASE RE-WEIGH ACCORDING TO PROCEDURE...Per wt hx [history]...09/16/2024 [September 16, 2024]...66.6 kg/147 lbs. (bed scale)...09/09/2024 [September 9, 2024]...64.9 kg/143 (unspecified scale)...09/05/2024 [September 5, 2024]...26.5 kg/58.5 lbs (bed scale)*admission...UTA [unable to assess] wt status d/t [due to] limited assessment data and questionable wt accuracy...Intervention...Request re-weigh ASAP [ as soon as possible] d/t large weight discrepancy..."

The facility document titled, "Nutrition progress note, " dated September 18, 2024, at 1:09 p.m., indicated, "...In previous RD [Registered Dietician] assessment note 09/16 [September 16], there had been a request to obtain new patient weight as there is suspected weight inaccuracy. Recommendation for new weight not yet carried out. Patient does not appear to reflect 147 lb weight per EMR [electronic medical record]...Due to suspicion of inaccurate weight, it is not possible to calculate patient's estimated needs...RECOMMENDATIONS WHILE PATIENT REMAINS IN HOSPITAL...Please re-weigh patient, noting scale modality, and noting that the bed was zero'd out and pt was weighed according to policy...Request daily weights..."

An interview was conducted on September 23, 2024, at 1:48 p.m., with the RM. RM stated when Patient 29 was weighed and there was more than a five-pound difference, the nursing staff should have re-weighed the patient and added a note the patient was re-weighed. If the weight was still more than a five-pound difference, or more than a ten percent difference from the last weight, the nurse should have completed a change of condition, notified the physician, and notified the registered dietician. RM stated there was no documented evidence Patient 29 was re-weighed, a change of condition was completed, or the registered dietician was notified.

1 b. A review of Patient 30's medical record was conducted on September 24, 2024, at 9 a.m., with the RM.

The facility document titled, "History and Physical," dated December 20, 2023, indicated Patient 30 was admitted to the facility on December 20, 2023, for altered level consciousness after being found to have fentanyl overdose. Patient 30 was intubated and on the vent.

The facility document titled, "Nursing Admission," dated December 20, 2023, indicated, Patient 30 weighted 220 lbs (pounds, unit of measurement)/ 100 kilograms (kilograms, unit of measurement) per bed scale.

The facility document titled, "Vital signs/I&O/unit labs," dated December 25, 2023, indicated "...weight 200.8, (91.27 kg) bed scale...LVN/RN TO ENTER WT. IF >5 LB CHANGE RE-WEIGH & COMMENT "RE-WEIGH & POSSIBLE CAUSES...IF >10% CHANGE, HOYER PT. RE-ZERO & RE-WEIGH. IF STILL >10% CHANGE, OPEN A COC, NOTIFY MD..." This was 19.2 lbs. less than what Patient 30 weighed on admission.

The facility document titled, "Vital signs/I&O/unit labs," dated December 29, 2023, indicated, "...Weight 193.4 lbs (87.91 kg) bed scale..." This was 26.6 lbs. less than what Patient 30 weighed on admission.

The facility document titled, "Vital signs/I&O/unit labs," dated December 30, 2023, indicated, "...Weight 189 lbs (85.91 kg) bed scale..." This was 31 lbs. less than what Patient 30 weighed on admission.

The facility document titled, "Vital signs/I&O/unit labs," dated January 03, 2024, indicated, "...Weight 186.5 lbs (84.77 kg) bed scale..." This was 33.5 lbs. less than what Patient 30 weighed on admission.

The facility document titled, "Vital signs/I&O/unit labs," dated January 07, 2024, indicated, "...Weight 179 lbs (81.36 kg) bed scale..." This was 41 lbs. less than what Patient 30 weighed on admission.

The facility document titled, "Vital signs/I&O/unit labs," dated January 08, 2024, indicated, "...Weight 176.9 lbs (80.41 kg) bed scale..." This was 43.1 lbs. less than what Patient 30 weighed on admission.

The facility document titled, "Vital signs/I&O/unit labs," dated January 22, 2024, indicated, "...Weight 180 lbs (81.82 kg) bed scale..."

The facility document titled, "Vital signs/I&O/unit labs," dated January 29, 2024, indicated, "...Weight 169 lbs (76.82 kg) bed scale..." There was no documented evidence Patient 30 was re-weighed when his weight changed 11 lbs. in one week. This was 51 lbs. less than when Patient 30 was admitted.

There was no documented evidence a change of condition was completed by nursing staff for Patient 30's continued loss of weight.

An interview was conducted on September 24, 2024, at 10 a.m., with the RM. RM stated the expectation would have been to re-weigh Patient 30 due to his weight variance of 11 lbs. in one week. The RM stated due to the constant weight loss, the expectation would have been to place a change of condition and notify the physician.

An interview was conducted on September 24, 2024, at 3 p.m., with the Registered Dietician (RD). The RD stated due to the significant loss of weight in a short period of time the expectation would have been to re-weigh Patient 30, if the weight remained low, greater than five pounds or more than ten percent, and nursing staff should have placed a change of condition. The RD further stated nursing staff should have also placed a dietician consult.

A review of the facility policy titled, "CORE: Weight Measurement," dated June 2021, indicated, "...The policy of [name of facility] is to ensure proper measurement of patient weights...Weight is determined by appropriate methods and measuring devices...Timing of weight assessments may be individualized based on a physician's order, nutrition assessment or interdisciplinary team recommendations...Change in weight gain or loss are addressed in the nutrition assessment and the patient's plan as applicable...If patient has a 5 pound or more difference from the most recent weight, the scale shall be re-balanced...and the weight taken again to confirm accuracy..."

A review of the facility policy titled, "CORE: Interdisciplinary Assessment and Re-Assessment," dated June 2023, indicated, "...All patients will have an initial assessment and appropriate follow up assessments upon identified patient-specific needs...The goal of the Assessment/Reassessment process is to provide an interdisciplinary approach for the assessment and ongoing reassessment of individual patient care needs and for planning and implanting patient specific interventions...Data analysis to develop a plan of care...Coordination of care by sharing patient information internally...patient information may include...care, treatment, medications, services, and any recent or anticipated changed to any of these...admitting RN will screen each patient during the initial assessment...Screening for specialized interventions and/or possible referral to other disciplines is completed...and includes...Nutritional status...licensed staff...may update the patient's needs/problems and plan of care based on results of clinical findings...To respond to significant changes in status and /or diagnosis or condition...The registered dietitian identifies patients needing further monitoring...Examples of patients that may need further monitoring include...Receiving enteral or parenteral nutrition...Having significant unintentional weight change...Having non-severe or severe malnutrition...Reassess patient upon significant change of condition in nutritional status...weight change...Reporting/Notification of a Change in Condition...To achieve this goal, nurses as well as physicians must recognize a change in condition...Changes in condition of the patient are determined by assessments using clinical parameters, current and past documented medical condition...When an Assessment Reveals a Change or Suspected Change in Condition...The nurse assigned to the patient or supervising the care of the patient is responsible for notification of and communication to the patient's primary physician...Document change of condition, notification and interventions in the medical record...EMR facilities document under the "Change of Condition" Pathway..."

2. A tour of the Intensive Care Units (ICU) medication room was conducted on September 16, 2024, at 10 a.m., with the Director of Quality Management (DQM) and Director of Pharmacy (DOP). In the ICU medication room, a packaged needle was noted in the trash can. At this time the DOP stated the needle should have been placed in the sharp's container not be in the trash can.

During the tour, in Patient 21's room, the over bed table was observed to have four intravenous angio catheter needle (type of needle used for Intravenous access) 22-gauge kits, and Vanish Point blood collection set (type of safety needle for blood collection) 23 gauge. At this time the DMQ stated the nursing staff should have disposed of the sharps in the sharp's container and should not have left them on the over bed table.

During the tour, in Patient 15's room, the over bed table was observed to have two gray capped needles, and two needles in a white plastic container. At this time the DQM stated the needles should have been properly stored or in the sharp's container and not left on Patient 15's over bed table.

A tour of Patient 15's room was conducted on September 22, 2024, at 6:29 a.m., with the Environmental Services Marketing Director (ESMD) and Registered Nurse (RN) 56. Patient 15's over bed table was observed to have an orange cap insulin syringe (type of syringe used for administering medication) in a container. At this time RN 56 stated the syringe should have been placed in the sharp's container and not left on Patient 15's over bed table.

A review of the facility policy and procedure titled, "[Facility Name] Specific Addendum to Regulated Medical Waste Management," dated July 2023, was conducted. The policy indicated, "...sharps waste shall be placed in a sharps container..."

Based on interview and record review the facility failed to follow their "Medical Staff Rules and Regulations," policy and procedure (P&P), and ensure the patient's history and physical (H&P) was completed within 24 hours of admission, for one of 31 patients (Patient 18).

This failure had the potential to cause harm and a delay in patient care.

Findings:

A review of Patient 18's medical record was conducted on September 19, 2024, at 10:40 a.m., with the Clinical Analyst (CA).

The facility document titled, "History and Physical," dated July 19, 2024, at 12:32 a.m., indicated Patient 18 was admitted to the facility on July 17, 2024, with a diagnosis of acute (less than 6 months) and chronic (greater than 6 months) respiratory failure (difficult to breath) unspecified with hypoxia (not enough oxygen in the brain) or hypercapnia (too much carbon dioxide in the blood), inhalation injury (injury affecting the airway) sustained in a house fire. It further indicated, "...Date of admission...July 17, 2024...dictation date [DD] 07/19/2024 [July 19, 2024] at 00:13 [12:13 a.m.] Eastern Standard Time..."

An interview was conducted on September 17, 2024, at 11:48 a.m., with the CA. The CA stated the H&P should have been completed within 24 hours of Patient 18's admission. CA further stated the H&P was not completed according to the policy.

An interview was conducted on September 23, 2024, at 2:12 p.m., with the Health Information Management Technician (HIM T). HIM T stated the H&P was completed on July 19, 2024, which was longer than 24 hours after Patient 18 was admitted to the facility and should have been completed within 24 hours of admission.

A review of the facility's policy and procedure titled, "Medical Staff Rules and Regulations," dated 2022, was conducted. The policy indicated, "...Complete History and Physical...medical History and Physical examination completed and documented...24 hours after admission...The medical history and physical must be placed in the patient's medical record within 24 hours after admission..."