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Based on observation, interview and document review, it was determined the facility's Quality Assurance and Performance Improvement (QAPI) program failed to take action to ensure sustained improvement over time. Specifically, the QAPI program failed to correct known issues with nursing services and medication errors identified during the complaint survey ending May 10, 2022.

The findings include:

Tag - A-0398

Deficiency identified during the current complaint survey

Based on observation, interview, and document review, it was determined the facility staff failed to adhere to the policies and procedures of the hospital by not performing and/or documenting hygiene, activity, and mobility.


Deficiency identified during the complaint survey ending May 10, 2022

Based on interviews and document review, it was determined the facility's nursing staff failed to:

follow the physicians order for ten (10) minute blood pressure checks and the administration of insulin for a decompensating patient (Patient #11),

conduct wound care as ordered for five (5) days for one (1) patient (Patient #4), and

remove a Peripherally Inserted Central Line Catheter (PICC) for one (1) patient prior to discharge.


Tag A-0405

Deficiency identified during the current complaint survey

Based on interview and document review, it was determined the facility staff failed to administer medication according to the orders of the practitioner for one (1) our of six (6) patients.


Deficiency identified during the complaint survey ending May 10, 2022

Based on interview and document review, it was determined that the facility's nursing staff failed to:

Ensure that nursing staff were adequately trained in the prevention of adverse medication events for eleven (11) documented errors in medication administration practices.

Based on observation, interview, and document review, it was determined the facility staff failed to adhere to the policies and procedures of the hospital by not performing and/or documenting hygiene, activity, and mobility.

The findings include:

The surveyors toured the second and third floors of the facility on 9/26/2022. During this tour the surveyors were able to interview the family members of four (4) different patients.

On 9/27/2022 through 9/29/2022, the surveyor reviewed Patient #2's medical record of the patient's hospital admission from 8/11/2022 through 9/26/2022. The medical record provided the following evidence.

As per the medical record, Patient #2 was admitted to the facility "on a tracheostomy collar for continuity of respiratory care, weaning and management of multi-comorbitdities plus nutritional therapy and rehabilitation... The patient has limited response. Opens and tracks with [patient's] eyes; otherwise no meaningful response..." The patient was receiving nutrition via PEG (percutaneous endoscopic gastrostomy) feeding tube (feeding tube placed through the skin and directly into the stomach, needed when unable to eat or drink). On observation by the surveyors, Patient #2 was bedridden, non-responsive, and required total care from the facility staff for turning, bathing, and incontinence care.

As per the documentation, Patient #2 was not bathed for nineteen (19) days of forty-four (44) days reviewed, from 8/11/2022 through 9/26/2022. On multiple occasions, a bath was not documented for two (2) to three (3) days in a row. There was no documentation of a bath for Patient #2 for a four (4) day period, from 8/25/2022 through 8/28/2022.

As per the documentation, Patient #2 was only cleaned up after incontinence two (2) times from 8/11/2022 and 8/27/2022.

As per the documentation from 8/12/2022 through 8/31/2022, Patient #2 was repositioned/turned the following times:

zero (0) times on three (3) days,
one (1) time on five (5) days,
two (2) times on four (4) days,
three (3) times on one (1) day,
four (4) times on one (1) day,
five (5) times on one (1) day,
and six (6) times on two (2) days.

As per the documentation from 9/14/2022 through 9/29/2022, Patient #6 refused a full bath on 9/16/2022 at 6:49 a.m. and a partial bath on 9/16/2022 at 8:17 p.m., and AM/PM and oral care performed on 9/27/2022 at 8:45 a.m. There was no other documentation in the medical record that the patient received a bath of any kind.

As per the documentation from 9/14/2022 through 9/29/2022, Patient #2 was repositioned/turned the following times:

one (1) time on two (2) days,
two (2) times on seven (7) days,
three (3) times on two (2) day,
four (4) times on one (1) day,
and five (5) times on one (1) day.

On 9/26/2022 at 2:20 p.m., the surveyors interviewed a family member of Patient #3. Patient #3's family member shared the following concerns with the surveyors: the staff was not turning the patient as frequently as they should and the patient acquired a bedsore that started after the patient arrived at this facility. The family member denied that the patient had been left in feces or urine. The family member stated that Patient #3 does get bathed.

During an interview on 9/26/2022 at 2:47 p.m., the family member of Patient #2 stated that the staff "do not clean [the patient] like [the patient] should be" cleaned, and sometimes it is not done at all. The family member stated that "yesterday [the patient] smelled awful" and the family member had to "rinse the rag three (3) times" to wash the patient, and the patient's hands and feet "are dirty, sweaty, and sour". As per the family member: the patient is "lying in feces" every day. The family member heard the nursing director state that the nursing director "could not hang blood". The family member's concerns also included; the oral secretion suction tube was laying on the floor; the leg compression devices were "very dirty"; the room sink was "brownish" and the nurse was going to bathe the patient with water filled in the sink; there was blood on the patient's face and sheet and the staff never came back to change the sheet; the patient acquired a sacral bed sore that "started here"; the family member does not like how the staff "handle" the patient; and other employees tell the family member that the night shift is "mean". The surveyor observed a pillow under the patient's left arm that contained what looked like "coffee stains", and the sink in the patient's room looked to be stained a light brown. The family member showed the surveyor the "bald spot" on the patient's head, that appeared to be hair moved from that spot due to the patient lying on the pillow.

During an interview on 9/26/2022 at 3:28 p.m., the family member of Patient #6 stated that the patient did not have any bed sores, but the patient was in the facility for four (4) days before the first bath was given.

During an interview on 9/27/2022 at 2:18 p.m., Staff Member (SM) 21 stated that the nurses give patients "baths every other day" and "wipe them off" on in between days. SM21 stated that Patient #2 is bathed, cleaned up, and positioned in bed, and is given the same care as other patients, and SM21 had no concerns about the care provided to the patients.

On 9/28/2022 at 11:26, the surveyors went to visit the family member of Patient #2 in the patient's room. The family member now stated that Patient #2 came into this facility with a small sacral wound, but it has gotten worse since being at this facility. The surveyor observed the patient's sacral wound, which appeared to be a stage four (4) wound, packed with gauze and partially covered with a bandage that was coming off. The family member showed the surveyors a photo of a compression device that appeared dirty. The family member stated that the patient just had a bowel movement and the family member told the doctor that was in the room that the patient need to be cleaned up, and asked the doctor to notify the nursing staff. The nursing staff came into the room to clean and change the patient fourteen (14) minutes after the surveyors had entered the room and became aware of the patient's incontinence. The family member stated that: an employee told the family member that night shift isn't very attentive and the facility is "short-staffed"; the facility hired fourteen (14) certified nursing assistants (CNAs) and thirteen (13) of them quit the same day' and that medications are given on time, but cleaning up stool and bathing "are not happening".

During an interview on 9/29/2022 at 10:10 a.m., after reviewing the medical record for Patient #2, SM2 agreed that the documentation related to incontinence, cleaning, bathing, and repositioning is lacking and not happening as per the facility's policy.

During an interview on 9/29/2022 at 11:00 a.m., SM8 stated that "we don't have enough" staff, since June 2021 through April 2022. SM8 stated that staff should document all care given, including a.m./p.m. care, bed bath, shower, pericare, etc... in ADL (activities of daily living) flow sheet or make a note, and some staff do both. Staff should document if the patient is incontinent, cleaned up, repositioned, and should document the position the patient was placed, every two (2) hours. SM8 stated that if the facility is short staffed, it can be a challenge to reposition patients every two (2) hours.

On 9/29/2022 at 2:45 p.m., Patient #2's family member peered into the conference room and waved for the surveyor to come out into the hall to speak with the family member. The family member stated that the family member had to "bathe" Patient #2 around 2:00 p.m. this day, after the patient had been on dialysis from about 8:00 a.m. to 12:00 p.m. The surveyor went to the patient's room with the family member and observed a soiled gown, pillow, and disposable under pad that had been removed from the patient's bed prior to being bathed by the family member. When the surveyor entered the room, two (2) staff members were in the process of bathing the patient.

During an interview on 9/29/2022 at 3:15 p.m., SM7 denied any concerns related to patients not being cleaned up or ADLs being completed. SM7 stated that SM7 has not had time to audit records since starting at this facility, but will do it eventually. SM7 stated that Patient #2 is getting bathed and receiving oral care, and it should be documented daily. SM7 confirmed giving Patient #2 Tylenol this day around 1:00 p.m., after the patient's dialysis, and the patient was not soiled at that time.

During an interview on 9/29/2022 at 4:30 p.m., SM22 stated that staffing in general is short and many people have left, but they do their best to staff appropriately, and it's not at the point where it would affect patient care. SM22 stated that the staff do the best they can related to incontinence care, positioning, and bathing, and it can be a challenge due to staffing, but it is not to the point of neglect. SM22 stated that many of the patients require "total care", so it can be a challenge to prevent pressure ulcers (bedsores). As per SM22, orders a being followed properly by staff, and the nurses are well-trained and knowledgeable.

On 9/29/2022 at 5:13 p.m., SM18 stated: that SM18 received appropriate training; the facility is "staffed pretty well if everyone shows up"; staff try their hardest to respond to patient's needs "as fast as we can"; staff document everything they do and "if it's not charted, then it's not done"; patients are repositioned every two (2) hours and staff refer to the "repositioning clock" on the wall; repositioning is documented on a flow sheet with the position specified; night shift bathes patients on even days and day shift bathes patients on odd days; and hourly patient checks are done by the nurses or CNAs and documented.

A review of the facility's policy titled "Nursing: Hourly Rounding" states in part: Policy: The practice of [the facility] will be that staff will round on all patients hourly as an effective process to anticipate patient needs and allows those needs to be met in an efficient and timely manner. The frequency of patient rounding may be increased based on the condition and needs of the patient but should be minimally performed hourly. Procedure: Roles and Responsibilities. All [Facility] employees including Nursing, RT [respiratory therapist], CNAs and Rehab are expected to participate in the purposeful, patient rounding initiative. Purposeful Patient Rounding: Patient rounding will occur every hour. Key Points: If the patient is sleeping, continue to observe and perform detailed rounding ensuring that call light is within reach and personal possessions are within reach. When patient is admitted to the hospital the RN will explain and document that the team will be rounding on an hourly basis. General guideline is that the RN/LPN [licensed practical nurse] round on the odd hours and the CNA will round on the even hours. RT and Rehab will ask patient when they are working with the patient if they are in pain, need the bathroom and ensure that all personal items are within reach prior to leaving the patient's room. RT/Rehab will communicate to primary nurse should pain medication be needed. Purposeful and scheduled patient rounding will be patient focused and will address the [four] 4 P's. Pain, Potty, Position, Possessions. The [four] 4 P's are to be addressed at a minimum. Other patient needs should be addressed at this time as well...Potty: Offer to assist the patient with toileting needs. Actively addressing toileting needs during patient to anticipate that someone will be there to assist them regularly. Positioning: Assist patient to a comfortable position. In addition to offering patients to be repositioned every hour patients will be turned and repositioned every [two] 2 hours and documented in the medical record...Documentation: A Hourly Rounding form will be placed on the bathroom door each day. Prior to leaving the patient room the staff will document with the time and initials that they have made rounds. The hourly rounding form will not be part of the medical record but a means of communication to the patient and family to enhance the patient experience. Documentation regarding turns and pain medication will be documented in the Medical Record.

A review of the facility's policy titled "Nursing and Respiratory: Guidelines for Nursing and Respiratory Care" states in part: Policy: To ensure quality patient care, certain standards of care be upheld. The following table outlines basic nursing tasks and designates the minimum frequency with which these tasks be performed to maintain quality care. Procedure: A specific physician order will supersede the minimum frequencies noted below...Hygiene Patient bathed/hair combed/shaved - Daily...Bed linen changed - Daily and PRN [as needed]. Draw sheets, incontinent pads, gown changed - Daily and PRN. Oral care - Every AM before breakfast, every HS [night] and PRN. Oral care for NPO [nothing by mouth], tube feedings, trach mist - Every [four] 4 hours; Unconscious or intubated patients - Every [two-four] 2-4 hours and PRN; Ventilated patients and non-ventilated patient with artificial airway - Every [twelve] 12 hours with Chlorheidine [sic] solution; Washcloth and mouthwash offered - After each meal and PRN...Activity and Mobility: Bedfast patient turned and documented - Every [two] 2 hours and as per physician order...Signatures: Documentation of staff signature (full name) with credentials and initials - Every shift by all staff who provide care for the patient; on all pages with documentation by the staff member or electronic signature for hospital with Electronic Medical Record (EMR).

A review of the facility's policy titled "Wound Care: Skin Integrity and Pressure Injury Prevention" states in part: Policy: It is the policy of [Facility] that an assessment of care needs for pressure injury prevention and/or management will be made at admission and every shift with emphasis on, but not limited to, prevention strategies, pressure-reducing devices, and general nutritional status. This assessment will be integrated into the care planning process...Care Plan Based on Pressure Injury Assessment/Braden Scale: Mobility, Activity or sensory perception: Pressure Relieve - Turn/reposition schedule, Pressure redistribution device bed/chair...Moisture: Incontinence - Clean as soon as possible after soiling...

Based on interview and document review, it was determined the facility staff failed to administer medication according to the orders of the practitioner for one (1) our of six (6) patients.

The findings include:

On 09/27/22 at 11:20 am, the surveyors initiated a medical record review of Patient # (1-6). Both Staff Member #4 and Staff Member #6 assisted in the record review process of Patient #1's chart.

The surveyor reviewed all reported laboratory results throughout Patient #1's hospitalization, specific to blood ("sugar") glucose. Upon inspection, the surveyor identified a critical lab result recorded on 08/16/22 at 4:00 am from a CMP (Comprehensive Metabolic Panel). The CMP result revealed that Patient #1's blood glucose level was recorded at "11" mg/dL. [Note: Adult blood glucose levels are within normal limits between (65-100) mg/dL.]
The surveyor questioned Staff Member #4 regarding the events surrounding the abnormally low blood glucose reading. The surveyor confirmed that Patient #1 was an insulin-dependent diabetic who had orders for glucose checks by nursing staff before meals. The surveyor requested Staff Member #4 acquire all glucose readings from POC (Point of Contact) glucometer checks. Staff Member #4 supplied the surveyor with the glucometer readings throughout hospitalization.

The surveyor located the entries surrounding the critically low "11" blood glucose level reported by laboratory, and confirmed that the lab performed a full CMP Venous stick as a result of the glucometer being unable to accurately read the abnormally low blood sugar reading. The glucometer readings indicated that the staff member attempted confirm the glucose reading by rechecking the patient's blood sugar only to get the same result.

Just prior to the event, on 08/16/22 at 5:42 pm, the surveyor confirmed through the glucometer record that the patient ' s dinner glucose reading was above normal range at "220" mg/dL before dropping to "11" mg/dL as confirmed by the lab the next morning. Staff Member #21, who reportedly took the glucometer reading then contacted the attending provider for insulin orders as documented.

The surveyor found a nursing note written at this time which read that Patient #1 was "awake in bed, responsive, MD at bedside, labs per order obtained, FSBS [finger stick blood sugar] = <40, Repeat <40, Pt received D50W IVP X1 AMP, receiving IVF D10W @ 50 and NS @ 50 ml/hr, VSS, without dyspnea".

The surveyor reviewed the attending provider's corresponding progress note written on 08/16/22 at 5:51 pm, which reads, "Reg. insulin 10u IVP ordered but inadvertently given SQ by RN". The surveyor confirmed with Staff Member #4 that the acronyms used in the note allegedly refer to Regular Insulin, 10 Units, intravenous VP "push" but was given subcutaneously.

The surveyor reviewed the order set information with Staff Member #4 and confirmed that one-time Regular Insulin, IVP for 10 units was ordered on 08/16/22.

The surveyor received the facility policy titled, "Administration of Medications" (with last revision date of 01/2022). The policy states that the "7'R's" of administering medication will be verified prior to any medication administered: ""Right" patient, "Right" medication, "Right" dose, "Right" time, "Right" route, "Right" documentation, "Right" reason".

The surveyor conducted an interview with Staff Member #4 who confirmed the wrongful medication event did not follow the provider's plan of care as ordered, and was considered a medication error.