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Based on document review and interview, nursing services failed to notify provider of abnormal blood pressures and positive drug screen, failed to reassess patients after obtaining abnormal blood pressures for 5 of 10 patient medical records (MRs) reviewed (P1, P5, P6, P7, and P8); failed to complete routine observation rounds for 9 of 10 patient MRs reviewed (P1, P2, P4, P5, P6, P7, P8, P9, P10); and failed to complete documentation after a patient death for 1 of 10 patient MRs reviewed (P1).

The cumulative effects of these systemic problems resulted in the facility's inability to provide nursing care in a safe manner.

Based on document review and interview, nursing services failed to notify provider of abnormal blood pressures and positive drug screen, failed to reassess patients after obtaining abnormal blood pressures for 5 of 10 patient medical records (MRs) reviewed (P1, P5, P6, P7, and P8); failed to complete routine observation rounds for 9 of 10 patient MRs reviewed (P1, P2, P4, P5, P6, P7, P8, P9, P10); and failed to complete documentation after a patient death for 1 of 10 patient MRs reviewed (P1).


Findings include:

1. Facility policy titled, "Vital Signs", PC-86, Revision Date: 03/2023, indicated 1. Purpose: a: To monitor a patients/clients physical status. Policy:
a. It is the policy of the facility to obtain vital signs at regular intervals and to report vital signs that are out of normal range to the appropriate clinician.
d. If abnormal vital signs are obtained, the RN, LPN or MHT to measure a second time unless doing so may impact the patient's/client's immediate survival.

2. Facility policy titled, "Levels of Observation and Precautions - ObservSMART", PC 40, last revised 10/28/2024, indicates under b. Observations i. Routine Observation: 1. Q-15-minute observation: minimum patient observation of at least every fifteen (15) minutes. All patients will be monitored every 15 minutes unless a higher level of observation is ordered.

3. Facility policy titled, "Death of a Patient/Client", RM.05, Revision date: 03/2023, indicated under page 2. n. The Registered Nurse will complete a progress note which includes: i. Circumstance of death and any treatment provided prior to death. ii. Name of clinician who pronounced death and the date and time pronounced. iii. Date and time of notification to the patient/client attending physician. iv. Name of family or caregiver date and time contacted. v. Name of funeral home contacted and date and time contacted. vi. Date and time organ procurement contacted. vii. Date and time coroners office contacted. viii. Date and time hospital leadership was notified.

4. Review of P1 medical record indicated:
a. Patient was admitted to the facility on 11/14/2024 for detoxification. MR lacked documentation of completed 15 minute checks while a patient at F1.
b. Initial Medical Screen dated 11/14/2024 at 0550 hours indicated vital signs blood pressure 175/112 (normal range 120/80). MR lacked documentation the provider was notified of the elevated blood pressure or further assessment of the blood pressure.
c. The MR indicated the patient had a positive drug screen with cocaine and fentanyl present in his/her system. The MR lacked documentation that the provider was notified of positive findings.
c. P1 medical record lacked documentation of patient death on 11/14/2024 that included circumstance of death, date and time of notification to: clinician who pronounced the death, clinical provider, funeral home, organ procurement agency, coroners office, and hospital leadership.

5. Review of P2 medical record indicated the patient was admitted on 11/15/2024 and discharged 11/19/2024 for detoxification treatment. MR lacked documentation of 15 minute checks on patient including, but not limited to: 11/15/2024 at 1829 hours, 1852 hours, 1913 hours, 1927 hours, 1947 hours, and 2004 hours all were greater than 15 minutes observation of P2.

6. Review of P4 medical record indicated the patient was admitted on 11/14/2024 and discharged 11/20/2024 for detoxification treatment. MR lacked documentation of completed 15 minute checks on patient including, but not limited to: 11/14/2024 at 1509 hours, 1529 hours, 1559 hours, 1628 hours, 1733 hours, and 1751 hours all were greater than 15 minutes observation of P4.

7. Review of P5 medical record indicated:
a. Patient was admitted on 11/14/2024 and discharged 11/20/2024 for detoxification treatment. MR lacked documentation of completed 15 minute checks on patient including, but not limited to: 11/16/2024 at 0429 hours, 0448 hours, 0511 hours, 0527 hours, 1212 hours, and 1245 hours all were greater than 15 minutes observation of P5.
b. Initial Medical Screening Exam dated 11/14/2024 at 1017 hours indicated vital signs blood pressure 153/100 (normal range 120/80). MR lacked documentation the provider was notified of the elevated blood pressure.

8. Review of P6 medical record indicated:
a. Patient was admitted on 11/15/2024 and discharged 11/21/2024 for detoxification treatment. MR lacked documentation of completed 15 minute checks on patient included but not limited to: 11/16/2024 at 0037 hours, 0103 hours, 0428 hours, 0447 hours, 0511 hours, 0526 hours, 0914 hours, 0935 hours and 1005 hours all were greater than 15 minutes observation of P6.
b. Review of Nursing Admission Assessment dated 11/13/2024 at 1045 hours indicated vital signs blood pressure 158/86. MR lacked documentation the provider was notified of the elevated blood pressure.

9. Review of P7 medical record indicated:
a. Patient was admitted on 11/13/2024 and discharged 11/18/2024 for depression and anxiety. MR lacked documentation of completed 15 minute checks on patient, included but not limited to: 11/14/2024 at 1647 hours, 1723 hours, 1735 hours, 1757 hours, 1826 hours, 2136 hours, 2201 hours, and 2337 hours all were greater than 15 minutes observation of P7.
b. Nursing Admission Assessment dated 11/13/2024 at 1747 hours indicated vital signs blood pressure 155/90. MR lacked documentation the provider was notified of the elevated blood pressure.

10. Review of P8 medical record indicated:
a. Patient was admitted on 11/15/2024 and discharged 11/19/2024 for borderline personality and bipolar. MR lacked documentation of 15 minute checks on patient including, but not limited to 11/14/2024 at 1431 hours, 1457 hours, 1651 hours and 1701. MR indicated on 11/16/2024 0313 hours 0331 hours, 0354 hours, 0411 hours, 0427 hours, and 0444 hours all were greater than 15 minutes observation of P8.
b. Initial Medical Screening Exam dated 11/15/2024 at 0955 hours indicated vital signs blood pressure 143/96. MR lacked documentation the provider was notified of the elevated blood pressure.

11. Review of P9 medical record indicated the patient was admitted on 11/14/2024 and discharged 11/20/2024 for psychiatric treatment. MR lacked documentation of 15 minute checks on patient including, but not limited to: 11/16/2024 at 0913 hours, 0933 hours, 1113 hours, 1129 hours, 1241 hours, and 1216 hours all were greater than 15 minutes observation of P9.

12. Review of P10 medical record indicated the patient was admitted on 11/14/2024 and discharged 11/18/2024 for delusions and psychosis. MR lacked documentation of completed 15 minute checks on patient including, but not limited to: 11/16/2024 at 0030 hours, 0047 hours, 0103 hours, 0120 hours, 0152 hours, and 0210 hours all were greater than 15 minutes observation of P10.

13. Interview with A5 (Nursing Manager) on 12/17/20024 at approximately 6:15 p.m. confirmed that patients P1, P5, P6, P7, and P8 had documentation of abnormal blood pressure vital signs documented in their medical records and medical records lacked reassessment and/or notification to provider of abnormal vital signs. A5 confirmed that P1 had no nursing documentation of the death that occurred 11/14/2024.

14. Interview on 12/17/2024 with A1(Quality and Compliance Manager) at 1800 hours, confirmed that the facility failed to complete 15 minute checks for all patient listed above. No further information was brought for review prior to exit.