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Based on interviews and record review, the facility failed to maintain a current nursing care plan when:

1. Patient (Pt) 6 had hemodialysis (a procedure that removes waste products and excess fluid from the blood when kidneys are no longer functioning properly) ordered on 10/15/24, started on 10/16/24 and did not have a care plan reflecting Pt 6 needs for dialysis until 10/17/24.

2. Patient (Pt) 15 had an order for comfort care dated 10/2/24, and did not have a care plan reflecting Pt 15's needs for comfort care until 10/8/24.

These failures had the potential for Pt 6 and Pt 15 to not receive needed care.
Findings:

1. During a review of Pt 6's "History & Physical (H&P)", dated 10/13/24, the "H&P" indicated Pt 6 was a 65-year-old with a history of coronary artery disease (CAD, narrowed blood supply to the heart due to plaque buildup), diabetes (when the body does not produce enough insulin to regulate blood sugar), chronic kidney disease stage IV (CKD, the stage before complete kidney failure)and septic shock (a life-threatening condition when infection leads to dangerously low blood pressure).

During an observation on 10/16/24 at 1150 in Pt 6's room, Pt 6 was receiving hemodialysis performed by Registered Nurse (RN) 1.

During a concurrent interview and record review on 10/17/24 at 9:20 a.m. with the Director of Nursing (DON), pt 6's "Care Plan (CP)" (undated) was reviewed. The "CP" did not include a plan of care for CKD or hemodialysis. The DON stated she did not see a plan of care for CKD or hemodialysis for Pt 6.

During a review of Pt 6's "Dialysis Order Set (DOS)", dated 10/15/24, the "DOS" was signed by the physician on 10/16/24.

During an interview on 10/18/24 at 9:13 p.m. with House Supervisor (HS) 1, HS 1 stated hemodialysis was added to Pt 6's "CP" on 10/17/24 after it was viewed by the DON at 9:20 a.m.

During a review of the facility's policy and procedure titled, "Nursing Care Plan (NCP)", dated 8/2024, the "NCP" indicated, " ... Nursing care plans will be completed for every patient to assist in compliance ... Nursing care plan begins with the assessment of the patient ... with attention to the key diagnosis and medication ...".



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2. During a review of Pt 15's "History & Physical (H&P", dated 5/10/24, the "H&P" indicated, " ...Patient is a 48-year-old female who initially presented to outside hospital with gunshot wound to abdomen ...found to have multiple small bowel injuries ...patient was found on the floor pulseless code blue (patient in critical condition and needs immediate medical attention) ...patient most likely has anoxic brain injury (brain is deprived of oxygen causing brain cells to die in about 4 minutes) ...overall prognosis is extremely poor ...".

During a review of Pt 15's clinical document titled, "Physician Orders for Life-Sustaining Treatment (POLST)", dated 10/2/24, indicated, " ...Comfort Focused Treatment - primary goal of maximizing comfort ...no artificial means of nutrition ...".

During a review of Pt 15's clinical document titled, "Problem List (Nursing Care Plan (NCP))", dated 10/8/24, the "NCP" indicated, " ...Problem ...Comfort Care ...Pt will be treated as he/she & family have determined for end of life care ...Pt will experience a comfortable death as pain free as possible ...".

During a concurrent interview and record review with house supervisor (HS) 1, on 10/18/24 at 1:22 p.m., HS 1 stated Pt 15's comfort care was started on 10/2/24. HS 1 acknowledged Pt 15's "NCP" for comfort care was not added until 10/8/24. HS 1 explained the "NCP" for comfort care should have been initiated a soon as Pt 15 was put on comfort care. HS 1 explained the importance was to ensure nurses were aware of what type of care to provide, and consistency in care and communication. HS 1 further explained the risk of not having the "NCP" was Pt 15 could potentially receive medications that had been discontinued and could get unnecessary labs and pokes (blood draw).

During a review of the facility's policy and procedure titled, "Nursing Care Plan (NCP)", dated 8/2024, the "NCP" indicated, " ... Nursing are plans will be completed for every patient to assist in compliance ... Nursing care plan begins with the assessment of the patient ... with attention to the key diagnosis and medication ...".

Based on interviews and record review, the facility failed to follow their policies and procedures when 5 of 27 patients (Patient [Pt] 3, Pt 5, Pt 7, Pt 24, Pt 12) had no documentation of patient repositioning in the medical record at least every two hours per policy.

These failures place patients at risk for skin related injuries.

Findings:

1. During a review of Pt 7's "History & Physical (H&P)", dated 9/12/24, the "H&P" indicated Pt 7 was 33-year-old with a history of alcoholism and methamphetamine abuse resulting in an intracranial hemorrhage (bleeding in the brain) and obstructive hydrocephalus (when the flow of cerebrospinal fluid [CSF, fluid surrounding the brain and spinal cord] is blocked in the brain) and a stroke. The "H&P" indicated Pt 7 could not follow directions, had tracheostomy and was ventilator (a machine that helps a person breathe by moving air into and out of their lungs) dependent.

During a concurrent interview and record review on 10/17/24 at 10:10 a.m. with the Director of Nursing (DON), Pt 7's "Physical Assessment (PA, contains documentation of patient assessments and activity)", dated 10/10/24 to 10/17/24, was reviewed. The "PA" indicated no documentation of Pt 7's position/repositioning on 10/10/24 from 12:00 a.m. to 6:00 a.m. the "PA" indicated, " ... 06:47 [6:47 a.m.] ... 12 HOUR CHART CHECK COMPLETE ... Turning schedules completed q2 hr [every two hours] ...". The DON stated the nurses complete an end of shift retrospective documentation (12-hour chart check) indicating the patients were repositioned every two hours and the actual documentation is written is on a white dry-erase board in the patient's room for families to see. The DON stated nurse's aides could document patient's position/repositioning in the patient's permanent medical record under the "PA". The DON stated there was no documentation of Pt 7's position/repositioning between 10/10/24 at 4:00 p.m. to 10/11/24 at 11:11 a.m. except the 12-hour chart check at 6:47 a.m. The "PA" indicated Pt 7 was repositioned on 10/13/24 at 8:00 p.m. and 10/14/24 at 1:47 a.m. The "PA" indicated, " ... 07:03 [7:03 a.m.] ... 12 HOUR CHART CHECK COMPLETE: Chart documentation for Shift Completed. I&O's [intake and output], BM's [bowel movements] & Vital signs are documented, Problem List/Care Plans addressed ..." The DON stated there was no shift documentation of every two-hour repositioning on the 12-hour chart check. The "PA" indicated no position/repositioning of Pt 7 between 10/14/24 at 4:00 p.m. and 10/15/24 at 8:00 a.m. and the 12-hour chart check on 10/14/24 at 6:00 p.m. did not address repositioning.

During an interview on 10/18/24 at 8:10 a.m. with the DON, the DON stated the white board was not part of the patient's permanent record. The DON stated the 12-hour chart check was not an adequate reflection of when each patient was repositioned and how patient was positioned. The DON stated the facility needed to change the charting to allow the nurses to document when they reposition a patient.


2. During a review of Patient (Pt) 24's "H&P", dated 10/10/24, the "H&P" indicated Pt 24 was a 76 year old with acute respiratory failure secondary to amyotropic lateral sclerosis (ALS, a fatal disease that attacks nerve cells in the brain and spinal cord) with generalized weakness in his arms and legs, and is ventilator ( a medical device that helps patients breathe by moving air into and out of their lungs) dependent.

During a concurrent interview and record review on 10/17/24 at 2:45 p.m. with House Supervisor (HS) 2, Pt 24's "PA", dated 10/14/24 to 10/16/24, were reviewed. The "PA" indicated Pt 24 was repositioned on 10/14/24 at 4:00 p.m. HS 2 stated the next documented repositioning was on 10/15/24 at 8:00 a.m. The "PA" indicated Pt 24 was repositioned on 10/15/24 at 4:00 p.m. HS 2 stated the next documented repositioning was on 10/15/24 at 10:00 p.m. and the next documented repositioning was on 10/16/24 at 4:00 a.m. HS 2 stated the next documented repositioning was on 10/16/24 at 8:00 a.m.

3. During a review of Pt 5's "H&P", dated 8/27/24, indicated Pt 5 was a 45-year-old with a past medical history of quadriplegia (paralyzed in the arms and legs) due to a gunshot wound to the neck.

During a review Pt 5's "PA", dated 9/19/24 to 9/20/24, was reviewed. The "PA" indicated Pt 5 was repositioned on 9/19/24 at 4:00 a.m. and the next documented repositioning was on 9/19/24 at 8:00 a.m. The "PA" indicated Pt 5 was repositioned on 9/19/24 at 4:00 p.m. and the next documented repositioning was on 9/19/24 at 8:00 p.m. The "PA" indicated Pt 5 was repositioned on 9/20/24 at 4:00 p.m. and the next documented repositioning was at 10:00 p.m.

4. During a review of Pt 3's "H&P", dated 8/30/24, the "H&P" indicated Pt 3 was a 59-year-old with a history of a stroke and a spinal cord abscess, with no sensation in the legs and left arm.

During a concurrent interview and record review on 10/18/24 at 1:15 p.m. with the DON, Pt 3's "PA", dated 9/8/24 to 9/17/24, was reviewed. The "PA" indicated Pt 3 was repositioned on 9/8/24 at 6:00 p.m. The DON stated the next documented repositioning was on 9/9/24 at 8:00 a.m. The "PA" indicated Pt 3 was repositioned on 9/10/24 at 6:00 p.m. The DON stated the next documented repositioning was on 9/10/24 at 10:00 p.m. The "PA" indicated Pt 3 was repositioned on 9/11/24 at 5:00 a.m. The DON stated the next documented repositioning was on 9/11/24 at 8:00 p.m. The "PA" indicated Pt 3 was repositioned on 9/12/24 at 4:00 a.m. The DON stated the next documented repositioning was on 9/12/24 at 8:00 a.m. The "PA" indicated Pt 3 was repositioned on 9/12/24 at 4:00 p.m. The DON stated the next documented repositioning was on 9/13/24 at 5:00 a.m. and the next on 9/13/24 at 8:00 p.m. The "PA" indicated Pt 3 was repositioned on 9/15/24 at 4:00 a.m. The DON stated the next documented repositioning was on 9/15/24 at 8:00 p.m. The "PA" indicated Pt 3 was repositioned on 9/17/24 at 5:30 a.m. The DON stated the next documented repositioning was on 9/17/24 at 1:00 p.m.

During a review of the facility's policy and procedure titled, "Skin Care, Assessment and Maintenance of (SC)", dated8/2024, "SC" indicated, " ... Purpose ... To maintain optimal skin integrity ... Policy ... all bedfast patients shall be turned every 2 hours ... General Statements ... Documentation will become a permanent part of the patient record ... Decrease Pressure ... Turn and position every two hours ...".

During a review of the facility's policy and procedure titled, "Documentation Standards for Clinical Services DS)", dated 8/2024, "DS" indicated, " ... PURPOSE ... ensuring accurate, consistent, and timely documentation for every patient ... All patient encounters, interventions, and assessments must be documented as soon as practicable after the service is rendered ... Documentation must be clear, concise, and complete, reflecting the patient's status, care provided, response to treatment, and any changes in the care plan . All entries must be made directly into the EHR [electronic health record] ... and must adhere to hospital-specific formats and templates to ensure uniformity .... Document all treatments, interventions, and responses ...".

During the review of a professional reference titled, "Pressure Injuries (PI)", dated 2024, "PI" indicated, " ... Pressure injuries can develop if you must stay in bed or aren't able to move and aren't turned, and positioned correctly, or often enough ...A pressure injury develops when pressure cuts off the blood supply to the skin for a long period of time. Lack of blood flow to the skin leads to skin cells dying ...".



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5. During a review of Pt 12's "History & Physical (H&P)", dated 9/12/24, the H&P indicated Pt 12 was a 30-year-old with a history of testicular cancer with metastasis (The spread of cancer cells from the place where they first formed to another part of the body) to C2 (Second cervical vertebrae of the spine (bones supporting the neck and head)) resulting in quadriparesis (a condition that causes muscle weakness in all four limbs). The H&P further indicated a history with a left femoral (large blood vessel) deep vein thrombosis (DVT a blood clot that forms in a vein deep within the body, usually in the lower leg or thigh).

During a concurrent interview and record review with house supervisor (HS) 1, on 10/18/24, at 11:15 a.m., Pt 12's "PA", dated 10/1/24 to 10/7/24, was reviewed. The PA did not show documented evidence Pt 12's position was changed on the following dates and times:

10/1/24 no documentation for repositioning at 0200, 0400, 0600, 1800;
10/2/24 no documentation for repositioning at 0600, 1800, 2000;
10/3/24 no documentation for repositioning at 0000, 0200, 0400. Patient turned to right side at 1000 & 1200. No documentation for repositioning at 1800 & 2200.
10/4/24 documentation indicated Pt 12 was turned to his right side at 0000 & 0200. No documentation for repositioning at 0400, 0600, 1800 & 2000;
10/5/24 documentation did not indicate Pt 12's position placement at 1800; and
10/6 no documentation for repositioning at 0600, was repositioned to left side at 0400 & 0800. No documentation for repositioning at 1600.

HS 1 explained Pt 12 should have been turned q (every) 2 hours for the dates and times listed above and HS 1 acknowledged that Pt 12 was not turned q 2 hours.

During a review of the facility's policy and procedure titled, "Documentation Standards for Clinical Services DS)", dated 8/2024, "DS" indicated, " ... PURPOSE ... ensuring accurate, consistent, and timely documentation for every patient ... All patient encounters, interventions, and assessments must be documented as soon as practicable after the service is rendered ... Documentation must be clear, concise, and complete, reflecting the patient's status, care provided, response to treatment, and any changes in the care plan . All entries must be made directly into the EHR [electronic health record] ... and must adhere to hospital-specific formats and templates to ensure uniformity .... Document all treatments, interventions, and responses ...".

During the review of a professional reference titled, "Pressure Injuries (PI)", dated 2024, "PI" indicated, " ... Pressure injuries can develop if you must stay in bed or aren't able to move and aren't turned, and positioned correctly, or often enough ...A pressure injury develops when pressure cuts off the blood supply to the skin for a long period of time. Lack of blood flow to the skin leads to skin cells dying ...".

Based on interviews and record review, the facility failed to follow their policies and procedures when one, patient, Pt 12's, subcutaneous (medication given into the subcutaneous fat under the skin) injectable blood thinning medication, was administered without consistently rotating sites of administration.

This failure placed Pt 12 at risk for excessive bruising, skin trauma, and infection at the injection sites.

Findings:

During a review of Pt 12's "History & Physical (H&P)", dated 9/12/24, the H&P indicated Pt 12 was a 30-year-old with a history of testicular cancer with metastasis (The spread of cancer cells from the place where they first formed to another part of the body) to C2 (Second cervical vertebrae of the spine (bones supporting the neck and head)) resulting in quadriparesis (a condition that causes muscle weakness in all four limbs). The H&P further indicated a history with a left femoral (large blood vessel) deep vein thrombosis (DVT a blood clot that forms in a vein deep within the body, usually in the lower leg or thigh).

During a concurrent interview and record review with house supervisor (HS) 1, on 10/17/24, at 10:45 a.m., Pt 12's "Medication Administration Record (MAR - contains medications administered, site locations, and who administered the medication)", dated 9/12/24 to 10/17/24, was reviewed. The MAR indicated, "Enoxaparin (an anticoagulant (type of medication to prevent blood clots) medication used to prevent DVT's) ...40 MG (Milligrams a unit of measure) INJ (injection) ...0.4 ML (Milliliters a unit of volume) Solution ...Route: SUBCUTANEOUS (under the skin) ...Frequency: BEDTIME ...Times: 2200 (10 PM) ..." The medication was documented as administered in the following sites, on the following dates, and time:

9/12/24 2200 Abdomen
9/13/24 2200 Abdomen
9/18/24 2200 Abdomen
9/19/24 2200 Abdomen
9/20/24 2200 Abdomen
9/26/24 2200 Right Upper Arm
9/27/24 2200 Right Upper Arm
9/29/24 2200 Abdomen
9/30/24 2200 Abdomen
10/3/24 2200 Abdomen
10/4/24 2200 Abdomen
10/5/24 2200 Abdomen
10/7/24 2200 Abdomen
10/8/24 2200 Abdomen
10/9/24 2200 Abdomen
10/10/24 2200 Abdomen
10/11/24 2200 Abdomen
10/12/24 2200 Abdomen
10/13/24 2200 Left Upper Arm
10/14/24 2200 Left Upper Arm
10/15/24 2200 Abdomen
10/16/24 2200 Abdomen

The HS 1 stated the sites of administration on the above dates and times should have been alternated and were not. HS 1 explained by not alternating sites it can cause excessive bruising or skin issues like lipohypertrophy (little indentations). HS 1 further explained the importance of alternating sites was to reduce the chance of excessive trauma, possible infection, and to make sure the patients skin is intact.

During a review of a facility document titled, "Nursing Huddle Topics," dated for the weeks of 7/14/24, 8/11/24, and 9/8/24, the "Nursing Huddle Topics," indicated, "Sub Q (subcutaneous) injections ...Effective immediately all nurses will document the location of abdominal sub q injections in the Nursing Daily Assessment ...Injections should be rotated ...Nurses will look at the previous documentation where the injection was administered so that the site can be rotated ..."

During a review of a professional reference titled, "Highlights of Prescribing Information ...enoxaparin (HPIE) ...", revised 4/2022, "HPIE" indicated, " ...Subcutaneous Injection Technique ...Alternate injection sites between left and right ...abdominal wall ...".

Based on observations, interviews, and record review, the facility failed to maintain its infection prevention and control program when:

1. A clean and sanitary environment was not maintained when white dry deposits were found on a drain plate on a coffee maker used for patients, visitors, and staff; and,

2. A dietary trainee (DT) 1 did not don appropriate personal protective equipment (PPE gown, gloves, mask, face shields) when entering a room with patients on enhanced precautions (patients in room with communicable illnesses) requiring staff to don gloves, mask, and gown.

These failures resulted in potential cross-cross contamination (the physical transfer of harmful bacteria from one person, object or place to another) and spread of infection to patients, visitors and staff.
Findings:

1. During a concurrent observation and interview on 10/16/24 at 12:00 p.m. with the Quality Officer (QO) in the first-floor nourishment room, a coffee maker had dry white deposits on the drain tray. The QO stated the maintenance department completes a deep clean (inside parts) the coffee maker monthly and checks it daily. The QO stated the white deposits could not have happened overnight.

During a concurrent observation and interview on 10/16/24 at 12:05 p.m. with the Facility's Operations Manager (FOM) in the nourishment room, FOM stated Environmental Services (EVS) checks and cleans the outside of the coffee maker daily. The FOM stated a log of the daily cleaning was not maintained.

During a review of the facility's policy and procedure titled, "Infection Prevention and Control System (IPC)", dated 2/5/24, the "IPC" indicated, " ... [Facility Name] maintains an organized, hospital-wide program designed to systematically identify and reduce the risk of acquiring and transmitting infections among patients, visitors, and health care workers ... The hospital (Organization) shall have a process in place, as required and/or recommended by the Centers for Disease Control (CDC) and related professional organizations, to maintain a sanitary environmental for the hospital, patients, staff and others ... EVS ... Daily assignments are given to staff, i.e. which floor/area assignment, which are monitored at random intervals and sites, to ensure efficacy ... Follow up is performed by the EVS supervisor/manager/Director upon completion of the task assigned ... Maintenance/ Plant Ops - Assists in the review of, monitoring of and preventative maintenance of ventilation system and water quality controls. Water Quality Testing is ... monitored quarterly ... Infection Control ... Surveillance activities: Environmental rounds ... Perform random and monthly EOC [environment of care] rounds in conjunction with either Quality or EVS staff ... Assists in audits of food preparation areas, and sanitation processes within the facility ...".

During the review of a professional reference titled, "Hard Water Scaling Linked to Bacteria growth in Homes (HW)", dated 1/9/14, "HW" indicated, " ... research by the School of Sustainable Engineering at Arizona State University has found that hard water scaling normally found in the pipes of homes is an active environment for harmful bacterial growth ... hard water- water containing high levels of calcium and magnesium ... hard water results in scale formation ... and that provides a perfect home for bacteria. This can significantly increase exposure to pathogenic bacteria such as Legionella, which can cause Legionnaires disease [a serious type of pneumonia] ... Colonization of plumbing by disease-causing bacteria is well-documented, especially in hospital buildings and hotels ... Unless the minerals that cause scaling are entirely removed ...people are at risk of bacterial infections ...".




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2. During a concurrent observation and interview, with DT 1, on 10/16/24, at 12:02 p.m., DT 1 was observed entering Room 275 without donning PPE. On the wall, outside of Room 275, there was a green sign indicating, "Enhanced Precautions", with the sign indicating gown, gloves, and a mask are required prior to entering. DT 1 exited Room 275 and explained she had been informed about the process for entering rooms on "Enhanced Precautions", by her supervisor and stated not donning the PPE was her fault.

During an interview with house supervisor (HS) 1, on 10/16/24, at 12:08 p.m., HS 1 stated her expectations were for staff to don gown, gloves, and a mask before entering a room with patients on "Enhanced Precautions". HS 1 explained wearing the correct PPE was important due to the risk for cross-contamination to and to ensure staff and patients are safe.

A review of the facility's policy and procedure titled, "Infection Prevention and Control System (IPC)", dated 2/5/24, the "IPC" indicated, " ...compliance with use of Isolation Precautions Signage & PPE ... compliance with appropriate and well visualized isolation designation on the sign, appropriate availability of an isolation cart and contents to meet the needed PPE standard ...the nursing department will evaluate areas such as: Correct isolation signage posted, Correct disinfection wipes located within the patient room ...adequate PPE supply within vicinity ...".
A review of facility document, posted outside of Room 275, titled, "Green Enhanced Precautions", dated 8/5/23, the "Green Enhanced Precautions", indicated, " ...Stop Check With Nurse Before Entering ...Put On Gown ...Put On Gloves ...Put On A Face Mask ...PPE MUST BE WORN BY ALL WHO ENTER ROOM ...".