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Based on observation and interview, it was determined that the facility failed to maintain privacy during patient care for one (1) of two (2) Patients (Patient (P) # 3).

The findings include:

On April 12, 2023 at 9:40 a.m., Staff Member (SM) # 5 was observed during patient care and Medication Administration for P # 3.
SM # 5 failed to pull the privacy curtain or shut the door to maintain privacy for P # 3. SM # 5 exposed P # 3 abdomen to administer medications via tube.
During process, SM # 14 asked SM # 5 about the medication cart and then pushed the medication cart into the room and closed the door.

According to the Journal of American Nursing Association, the current Code of Ethics for Nurses (ANA, 2001) is "clear in intent and meaning as it relates to the nurse's role in promoting and advocating for patient's rights related to privacy and confidentiality. The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient" (ANA, 2001). The interpretive statements are explicit in their language regarding privacy and confidentiality, and should be used by nurses to guide clinical practice and to set organizational policy.


On April 12, 2023, the findings were discussed with Staff Members # 1, # 2 and # 4 during the exit interview.

Based on document review and interview, it was determined that the facility failed to ensure Patient care plans were current for two (2) of ten (10) Patients, Patients (P) # 7 and P # 9.

The findings include:

On April 11, 2023 at 9:00 a.m., during clinical record reviews the following were revealed:

P # 7-
The plan of care dated 2/20/2023 for Tracheostomy with Patient goals: Maintain adequate oxygenation or ventilation, Prevent/reverse bronchospasm, maintain patent airway and pulmonary hygiene had a target date of 3/21/23.

The plan of care dated 2/22/23 for Nutritional needs via tube feeding, wt (weight) fluctuations expected r/t (related to) diuretic in place, tolerating TF (tube feed) at goal rate: Pediasure 1.0 at 70 ml/hr continuous with Patient goals: Nutrition related labs will be within normal limits, tolerate tube feedings without residuals or signs of nausea, vomiting or diarrhea, no signs of aspiration, and maintain current body and show weight gain consistent with growth curves without significant weight change had a target date of 3/24/23.

P # 9-
The plan of care dated 4/13/21 for Nocturnal Mechanical Ventilation with Patient goals: maintain patent airway, pulmonary hygiene, patient comfort, maintain adequate oxygenation or ventilation on vent and trach collar and prevent/reverse bronchospasm had a target date of 4/5/23.

In conclusion, the plan of care target dates for P # 7 and P # 9 were not reviewed and updated as required.

On April 12, 2023 a review of the facility policy titled "Care Plans" reads in part "The patients Interdisciplinary Care Plan is reviewed and updated to address progress towards goals and discharge plan, if applicable.

On April 12, 2023, the findings were discussed with Staff Members # 1, # 2 and # 4 during the exit interview.

Based on observation, document review and interview, it was determined that the facility failed to ensure staff administer the right dose of medication by not pouring liquid medication on a flat surface when preparing medication for one (1) of one (1) Patients (Patient (P) # 4).

The findings include:

On April 12, 2023 at 9:40 a.m., Staff Member (SM) # 5 was observed during medication preparation for P # 3.
SM # 5 was observed pouring two (2) separate liquid medications by holding the cup and medication bottle in the air.

According to the Journal of American Nursing Association, to Administer Liquid Medications:
Check consent - ask the client if they are ready to take their medication.
Shake the bottle if required (read instructions).
Measure correct dose.
Pour liquids into a marked beaker- put the beaker on a flat surface, bend knees and keep back straight, pour liquids at eye level.

On April 12, 2023, a review of the facility policy titled "Medication Administration" reads in part "Licensed nurse will observe the five rights of administration when passing medications. Right Patient, Right drug, Right dose, Right time and Right route."

On April 12, 2023, the findings were discussed with Staff Members # 1, # 2 and # 4 during the exit interview.

Based on observations, document review and interview, it was determined that the facility failed to ensure staff maintain infection prevention for two (2) of five (5) Staff Members (Staff Member (SM) # 5 and SM # 6).

The findings include:

On April 12, 2023 at 9:15 a.m., SM # 6 was observed during Patient Care for Patient (P) # 4. SM # 6 donned clean gloves and cleaned cart prior to gathering supplies. SM # 6 removed dirty gloves and failed to perform hand hygiene.
SM # 6 then began to gather supplies from cart without performing hand hygiene.

During the observation, SM # 5 entered the room with gloves on. SM # 5 came to P # 4's bedside and then went the bedside of the other Patient in the room without changing gloves.

SM # 6 removed scissors from pocket to cut gauze during procedure.

SM # 6 used hand sanitizer between glove changes during the procedure but failed to rub hands until sanitizer was dry. SM # 6 stated "It hard to get gloves on when hands on wet."

At 9:40 a.m., SM # 5 was observed during Patient Care for P # 3. SM # 5 turned the water on with dirty hand, washed hands, dried hands and donned gloves then turned the faucet off by touching the dirty knob with clean gloved hand.
SM # 5 used stethoscope from around neck to listen to abdomen of P # 3. SM # 5 then placed the dirty stethoscope back around neck without cleaning and disinfecting the stethoscope.
SM # 5 removed dirty gloves but failed to perform hand hygiene before donned clean gloves after medication administration before eye drop instillation.
SM # 5 removed dirty gloves but failed to perform hand hygiene before donned clean gloves after eye drop instillation before eye ointment instillation.

On April 12, 2023, a review of the facility's policy titled "Handwashing" reads in part "All hospital personnel are expected to wash their hands when arriving at and prior to leaving work, before and after each patient contact, after personal hygiene, and before performing invasive procedures.
Using a second clean dry towel turn the faucet off."
The facility policy titled "Cleaning/disinfecting equipment" reads in part "Clean equipment using a germicidal cloth prior to taking it into the room. Prior to leaving the room, the equipment is to be cleaned using a germicidal cloth."

Directions on hand sanitizer bottle read in part "wet hands thoroughly with product and rub lightly until dry. Do not wipe off or rinse."

On April 12, 2023, the findings were discussed with Staff Members # 1, # 2 and # 4 during the exit interview.