HospitalInspections.org

Based on observation interview and record review the facility failed to protect and promote each patient's rights when:

1. Three of four patients (Pt 3, Pt 18 and Pt 22) preferred language was other than English and did not receive communication or information in a language of their preference, in accordance with hospital policy and procedure (P&P). Informed consents (A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) were not in the patient's preferred language and an interpreter was not utilized to translate the informed consent (Pt 22). There was minimal to no documentation an
interpreter was used during Pt 3 and Pt 18's hospitalization in accordance with hospital policy (Refer to A117).

2. Pt 1's family submitted a grievance and the hospital did not track and monitor the complaint/grievance process for each patient in order to achieve prompt response in accordance with the hospital's policy and procedure. The hospital did not develop and implement a log or other process to track the progress for prompt resolution of each patient complaint/grievance (Refer to A118).

3. Licensed Nurse (LN)s did not implement every two hour monitoring for one of three patients (Pt 25) to determine if the restraints (a device that restricts movement) could be
released in accordance with hospital policy and procedure (P&P) (Refer to A154 finding #1).

4. LNs failed to obtain a physician order (PO) for renewal of non violent physical restraints (preventing movement of body and limbs) for one of three patients (Pt 24) while patient remained in non-violent physical restraints , in accordance with hospital P&P (Refer to A154 finding #2).

The cumulative effect of these systemic problems resulted in failure to ensure patients were cared for in a safe manner, and their rights were protected and promoted at all times.

Based on observation, interview and record review, the hospital failed to consider the right of patients to receive communication in preferred language for three of four sampled patients (Pt 3, Pt 18 and Pt 22) whose preferred language was not English, patient care and services were not communicated in the preferred language, interpreter service was not used, informed consents (A process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) were not in the patient's preferred language
in accordance with hospital policy and procedure.

These failures had the potential for ineffective communication, misunderstandings, and possible patient harm .

Findings:

1. During a concurrent interview and record review on 10/24/24 at 10:50 a.m. with Manager (Mgr) 6, Pt 22's "History & Physical [H&P an assessment from physician including medical history and exam]," dated 9/17/24 and the "Face Sheet [FS a document that contains a summary of a patients' personal information]," dated 9/17/24, were reviewed. "The "H&P" indicated, Pt 22 had a past medical history (PMH) of left sided craniotomy (a surgical procedure that involves removing a section of the skull to access the brain), behavioral issues secondary to traumatic brain injury (TBI a brain injury caused by an external force, such as a blow to the head. TBIs can range from mild to severe, and can affect how a person thinks, feels, acts, and moves), seizure disorder (a chronic brain condition that causes recurring seizures [a temporary episode of abnormal electrical activity in the brain that causes sudden change of behavior, movement, or consciousness]) due to TBI, and high blood pressure. Pt 22's "H&P" indicated, " ... presented to the ER [Emergency Room] on 9/5/24 for a 5150 hold [California law that allows for the involuntary psychiatric detention of a person for up to 72 hours] ... Patient has been in the ER close to 2 weeks, been
trying to get placement ...". Mgr 6 stated the "Face Sheet (FS )" indicated Pt 22's preferred language was Portuguese. Pt 22 was transferred to the inpatient Medical Surgical (MS- a hospital unit where patients are treated for a variety of conditions) Unit on 9/17/24 at 6:55 p.m.

During a concurrent interview and record review on 10/24/24 at 11 a.m. with Mgr 6, Pt 22's "Interpreter Services Form [ISF]" dated 10/19/24 at 8:34 a.m. was reviewed. The "ISF" indicated the Licensed Nurse (LN) utilized a video interpreter for medication pass (the process through which medication is administered to patients) and physical
assessment. The "ISF" indicated the LN documented Interpreter Name, Interpreter identification number and Interpreter Agency Name . Mgr 6 stated LNs should complete the "ISF" when an interpreter was used to communicate with Pt 22. Mgr 6 stated no other "ISF" forms were in Pt 22's medical record. Mgr 6 stated LNs should have used interpreter services to communicate with Pt 22 and should have documented the interpreters name and identification number on the "ISF" form.

During a concurrent interview and record review on 10/24/24 at 11:15 a.m. with Mgr 6, Pt 22's "Electronic Medical Record [EMR a digital version of a patient's medical history, including diagnoses, medications, tests, allergies, immunizations, and treatment plans]" was reviewed. The "Nursing Narrative [a type of nursing documentation used to provide clear, detailed information about a patient]" document from 10/19/24 at 6:19 p.m. indicated " ... Pt a/o [alert and oriented] x 1(to self only knows name), bedbound [confined to bed], but ROM (Range of Motion amount of movement a joint or body part can make around a fixed point or joint) on L [left side] performed ... Swallowed pills whole and very cooperative w/[with] RN using translator. Pt able to converse w/ translator ... although responses were confused when RN tried to [assess] orientation ..." Mgr 6 stated no other "Nursing Narratives" were in Pt 22's "EMR" indicating LNs used interpreter services to communicate with Pt 22. Mgr 6 stated no other documentation was in Pt 22's "EMR" indicating LNs communicated with Pt 22 in English only and not in the preferred language of Portuguese . Mgr 6 stated LNs should have used interpreter services so Pt 22 knew his plan of care.

Mgr 6 stated Pt 22's "EMR" indicated he was often confused due to his brain injury and utilizing interpreting services to speak with him in his preferred language could help with confusion and could potentially decrease agitation (disruptive movement or vocal outbursts).

During an interview on 10/24/24 at 2:59 p.m. with Registered Nurse (RN)13, RN 13 stated she was Pt 22's Primary Nurse for the day . RN 13 stated Pt 22 understood commands in English and Spanish as well as his preferred language of Portuguese. RN 13 stated she did not know if there was any documentation in Pt 22's "EMR" indicating Pt 22 understood any other languages besides Portuguese. RN 13 stated she did not utilize interpreter services to communicate with Pt 22. RN 13 stated she should document in Pt 22's "EMR" when communicating with him in languages not documented as his preferred language. Pt 22's "EMR" did not indicate any LN documentation of other languages being used to communicate with Pt 22 other than English.

During a concurrent observation and interview on 10/24/24 at 3:05 p.m. with Pt 22 in his hospital room, Pt 22 was observed lying in his hospital bed on his back with his eyes open staring at the wall. Pt 22 had his side rails (horizontal bars attached to the side of a bed that can help people get in and out of bed, turn, or pull themselves up) padded and his call light was next to him on the bed. The Director of Medical Surgical (DMS), and a Medical Surgical Charge Nurse entered the room for observation of patient interview. Pt 22 was asked in English if he spoke English and if he was in any pain. Pt 22 did not respond to questions but made eye contact with interviewer. Pt 22 was then asked in Spanish if he was thirsty or if he was in pain. Pt 22 continued to make eye contact and responded no to
both questions. Pt 22 did not respond when asked if he spoke English in either Spanish or English.

During an interview on 10/25/24 at 1:10 p.m. with Family Member (FM) 2, FM 2 were contacted regarding his language preferences. FM 2 stated her father did not speak English but could understand some Spanish as it was very similar to Portuguese. FM 2 stated she interpreted for her father when she was at the hospital, but she was not there all the time. FM 2 stated she believed LNs should communicate with her father in his preferred language of Portuguese. FM 2 stated LNs had called her on the telephone in the past to have her talk to her father and try to calm him when he was agitated. FM 2 stated communicating with him in his preferred language may help to prevent his confusion and agitation.

During an interview on 10/25/24 at 2:54 p.m. with the DMS , she stated she was not aware Pt 22 did not speak English. The DMS stated LNs reported to her Pt 22 spoke English. The DMS stated Pt 22 had not spoken to her in English. The DMS stated her expectation was for LNs to utilize interpreting services for patients in their preferred language. The DMS stated speaking to patients in their preferred language allows patients to feel more comfortable in their surroundings.

During an interview on 10/28/24 at 1:17 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she assisted with care for Pt 22 on multiple occasions. CNA 1 stated Pt 22 responds to "simple commands" in English, such as questions about needing to be changed or if he was hungry. CNA 1 stated for more complex communication she would utilize Pt 22's daughter on the telephone or utilize family if at bedside. CNA 1 stated she did not document the interpreting assistance by family in Pt 22's "EMR".

During an interview on 10/28/24 at 3:12 p.m. with RN 14, RN 14 stated she was Pt 22's primary nurse on 10/19/24 and used interpreter services to communicate with him. RN 14 stated she received in report from the off going nurse Pt 22 did not speak English, and he was cognitively impaired (problems with ability to think, learn, remember, use judgement, and make decisions). RN 14 stated the off going LN reported Pt 22 only spoke Portuguese, and the family was not at bedside to interpret. RN 14 stated hospital policy was to use the medical interpreter service for assessments, new medications, education, or any procedures. RN 14 stated without using the interpreter service during her assessment she would be unable to determine how cognitively impaired Pt 22 was. RN 14 stated when she used the interpreter, Pt 22 was disoriented, but spoke in complete full sentences. RN 14 stated when she asked Pt 22 if he knew where he was, he knew he was in a hospital, but he thought he was in a "Mental Hospital in Portugal". RN 14 stated Pt 22 had a history of aggression with staff members. RN 14 stated it was possible Pt 22 became more agitated not only due to his TBI, but possibly due to frustrations of not understanding the languages being spoken. RN 14 stated the whole day of her shift Pt 22 was very pleasant and had no behavior issues. RN 14 stated LNs should communicate with patients in their preferred language. RN 14 stated LNs should document in the "EMR" when using a family member to interpret. RN 14 stated "if you don't chart it, it wasn't done".

During an interview on 10/28/24 at 2:57 p.m. with the Director of Patient Access (DPA), the DPA stated, the Patient Access staff completed the preferred language form in a patient's "EMR". The DPA stated a language preference was determined at time of arrival to the hospital. The DPA stated LNs could contact Patient Access staff to change the preferred language if incorrect in the "EMR".

During an interview on 10/29/24 at 11:25 a.m. with the Chief Nursing Officer (CNO), the CNO stated, LNs should be communicating with patients in their preferred language. The CNO stated LNs should be using the hospital resources available, including the video interpreting services or telephone interpreting services. The CNO stated her expectation was for LNs to follow hospital P&P for interpreting services.
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During a review of the hospital's policy and procedure (P&P) titled, "Interpreters", dated 2/19/19, indicated, " ... [name of hospital] staff will arrange to use the on demand video remote interpretation (VRI) service or language interpretation line at no cost to facilitate effective communication with a patient ... who is not fluent in English and/or when patient or patient representative has communicated his or her primary language is not English (the documented primary language is considered the patient's preferred language for receiving information) ... [name of hospital] prohibits the use of outside interpreters other than the VRI or the contracted language line ... If the patient's documented primary language is considered the patient's preferred language for receiving information but the patient is fluent in more than one language and that language is English then the patient may elect to receive the information in English. The nurse shall document this in the medical record ... A patient may, after being informed of the availability of the interpreter service, choose to have an adult family member as an interpreter ...the patient must provide written permission to have access to the patient's personal health information ... When the interpretation is of a medical nature, The VRI ... or language line is utilized ... when the interpretation is of a general nature (basic care no medical decision) any available employee, visitor, or volunteer may be utilized ... If the patient is unable to provide written consent, verbal consent is acceptable ... Staff will document in the patient's medical record when interpreter service are made available to the patient and when an interpreter service [names of services] is utilized. Whenever an interpreter service is used the name of the outside service must be indicated in the medical record along with the interpreter Identification (ID ) ... If the patient elects to have a family member interpret, the [hospital] Staff must document the name of the person who acted as the interpreter and that person's relationship to the patient ... Translation of documents ... Documents requiring patient's signature whenever possible will be in the language the patient speaks. If the document is not available in their primary language the interpreter service should be used and the information recorded in the document ... Consents are available in English and Spanish, other languages require the use of the interpreter service ... The name of the interpreter or the interpreter ID number must be documented on the consent ... Discharge instructions will be provide in the patient's primary language ..."

During a review of professional reference titled, "Clinicians' Obligations to Use Qualified Medical Interpreters When Caring for Patients with Limited English Proficiency," dated 3/2017, (retrieved from https://journalofethics.ama assn.org/article/clinicians obligations use qualified medical interpreters when caring patients limited english/2017 03) indicated, " ... Access to language services is a required and foundational component of care for patients with limited English proficiency (LEP) ... In the United States, patients with LEP have a legal right to access health care in their preferred language ..."

2. During a concurrent interview and record review on 10/25/24 at 11:03 a.m. with Manager (Mgr) 4, Pt 18's "Face Sheet (FS)," dated 10/11/24 was reviewed. Mgr 4 stated the FS indicated Pt 18's preferred language was Spanish.

During a review of Pt 18's "Consent for Treatment and Conditions for Admission (COA)", dated 10/10/24, the COA indicated the COA was written in English.

During an interview on 10/28/24 at 2:56 p.m. with the Director of Patient Access (DPA), the DPA stated the COA should have been written in the patient's preferred language when the patient stated his preferred language was not English.

During a review of the hospital's policy and procedure (P&P) titled, "Interpreters", dated 2/19/19, indicated, " ... [name of hospital] staff will arrange to use the on demand video remote interpretation (VRI) service or language interpretation line at no cost to facilitate effective communication with a patient ... who is not fluent in English and/or when patient or patient representative has communicated his or her primary language is not English (the documented primary language is considered the patient's preferred language for receiving information) ... [name of hospital] prohibits the use of outside interpreters other than the VRI or the contracted language line ... If the patient's documented primary language is considered the patient's preferred language for receiving information but the patient is fluent in more than one language and that language is English then the patient may elect to receive the information in English. The nurse shall document this in the medical record ... A patient may, after being informed of the availability of the interpreter service, choose to have an adult family member as an interpreter ...the patient must provide written permission to have access to the patient's personal health information ... When the interpretation is of a medical nature, The VRI ... or language line is utilized ... when the interpretation is of a general nature (basic care no medical decision) any available employee, visitor, or volunteer may be utilized ... If the patient is unable to provide written consent, verbal consent is acceptable ... Staff will document in the patient's medical record when interpreter service are made available to the patient and when an interpreter service [names of services] is utilized. Whenever an interpreter service is used the name of the outside service must be indicated in the medical record along with the interpreter ID ... If the patient elects to have a family member interpret, the [hospital] Staff must document the name of the person who acted as the interpreter and that person's relationship to the patient ... Translation of documents
... Documents requiring patient's signature whenever possible will be in the language the patient speaks. If the document is not available in their primary language the interpreter service should be used and the information recorded in the document ... Consents are available in English and Spanish, other languages require the use of the interpreter service ... The name of the interpreter or the interpreter ID number must be documented on the consent ... Discharge instructions will be provide in the patient's primary language ..."

During a review of professional reference titled, "Clinicians' Obligations to Use Qualified Medical Interpreters When Caring for Patients with Limited English Proficiency," dated 3/2017, (retrieved from https://journalofethics.ama assn.org/article/clinicians obligations use qualified medical interpreters when caring patients limited english/2017 03) indicated, " ... Access to language services is a required and foundational component of care for patients with limited English proficiency (LEP) ... In the United States, patients with LEP have a legal right to access health care in their preferred language ..."

3. During a concurrent interview and record review on 10/23/24 at 2:00 p.m. with Manager (Mgr) 6, Pt 3's "FS," dated 10/23/24 and "EMR"" were reviewed. Mgr 6 stated the FS indicated Pt 3's preferred language was Spanish. Mgr 6 stated she was unable to find any record while in the emergency room that nurses or providers spoke to the patient in her preferred language or used interpreter's services. Mgr 6 stated it should be documented how staff communicated to Pt 3.

During a review of Pt 3's "Consent for Treatment and Conditions for Admission (COA)", dated 10/10/24, the COA indicated the COA was written in English.

During an interview on 10/28/24 at 2:56 p.m. with the Director of Patient Access (DPA), the DPA stated the COA should have been written in the patient's preferred language when the patient stated his preferred language was not English.

During an interview on 10/29/24 at 11:25 a.m. with the Chief Nursing Officer (CNO), the CNO stated, LNs should be communicating with patients in their preferred language. The CNO stated LNs should be using the hospital resources available, including the video interpreting services or telephone interpreting services. The CNO stated her expectation was for LNs to follow hospital P&P for interpreting services.

During a review of the hospital's policy and procedure (P&P) titled, "Interpreters", dated 2/19/19, indicated, " ... [name of hospital] staff will arrange to use the on demand video remote interpretation (VRI) service or language interpretation line at no cost to facilitate effective communication with a patient ... who is not fluent in English and/or when patient or patient representative has communicated his or her primary language is not English (the documented primary language is considered the patient's preferred language for receiving information) ... [name of hospital] prohibits the use of outside interpreters other than the VRI or the contracted language line ... If the patient's documented primary language is considered the patient's preferred language for receiving information but the patient is fluent in more than one language and that language is English then the patient may elect to receive the information in English. The nurse shall document this in the medical record ... A patient may, after being informed of the availability of the interpreter service, choose to have an adult family member as an interpreter ...the patient must provide written permission to have access to the patient's personal health information ... When the interpretation is of a medical nature, The VRI ... or language line is utilized ... when the interpretation is of a general nature (basic care no medical decision) any available employee, visitor, or volunteer may be utilized ... If the patient is unable to provide written consent, verbal consent is acceptable ... Staff will document in the patient's medical record when interpreter service are made available to the patient and when an interpreter service [names of services] is utilized. Whenever an interpreter service is used the name of the outside service must be indicated in the medical record along with the interpreter ID ... If the patient elects to have a family member interpret, the [hospital] Staff must document the name of the person who acted as the interpreter and that person's relationship to the patient ... Translation of documents
... Documents requiring patient's signature whenever possible will be in the language the patient speaks. If the document is not available in their primary language the interpreter service should be used and the information recorded in the document ... Consents are available in English and Spanish, other languages require the use of the interpreter service ... The name of the interpreter or the interpreter ID number must be documented on the consent ... Discharge instructions will be provide in the patient's primary language ..."

During a review of professional reference titled, "Clinicians' Obligations to Use Qualified Medical Interpreters When Caring for Patients with Limited English Proficiency," dated 3/2017, (retrieved from https://journalofethics.ama assn.org/article/clinicians obligations use qualified medical interpreters when caring patients limited english/2017 03) indicated, " ... Access to language services is a required and foundational component of care for patients with limited English proficiency (LEP) ... In the United States, patients with LEP have a legal right to access health care in their preferred language ..."

Based on interview and record review, the hospital failed to have a process for prompt resolution of grievances for one of 32 patients (Pt 1), when Pt 1's family submitted a grievance, and the hospital did not track and monitor the complaint/grievance process for Pt 1 in order to achieve prompt response in accordance with the hospital's policy and procedure. The hospital did not develop and implement a log or other process to track the progress for prompt resolution of Pt 1's complaint/grievance.

These failures resulted in not ensuring the rights of Pt 1 and all patients who complaint/grieve, not provide a prompt resolution of complaints/grievances to determine whether the quality of care concerns that were experienced were effectively investigated and resolved and the potential for increased risk of injury and harm to patients.

Findings:

During a review of Pt 1's,"History & Physical/ [H&P (H&P the formal document that physicians produce through interview with the patient, physical exam, and the summary of testing either obtained or pending] Admission Notes ", dated 8/22/24, the "H&P " indicated, Pt 1 was admitted on 8/22/24, " ... W/ [with] untreated depression (a constant feeling of sadness and loss of interest)/anxiety (a feeling of fear, dread, and uneasiness) and polysubstance [using multiple illicit drugs] use disorder presents due to 2d [secondary] of alcohol withdrawal sxs [symptoms] ..." Pt 1 was admitted with an order for Clinical Institute Withdrawal Assessment Alcohol Scare Revised (CIWA/AR-an instrument used by medical professionals to assess and diagnose the severity of alcohol withdrawal and administer medications based on the severity).

During an interview on 10/24/24, at 9:58 a.m ., with RN 16, RN 16 stated patients had the right to complain about the care they receive. RN 16 stated patients could talk to the manager of the unit or even go to administration about issues. RN 16 state, she was unaware that complaints from patients while being cared for on the unit were considered grievances and should be responded to.

During a concurrent interview and record review on 10/24/24, at 1:15 p.m., with the Director of Quality (DQ) and the PSO, the complaint/grievance log for August 2024, September 2024 and October 2024 were reviewed. Only one grievance was listed for August 28, 2024 about Pt 1 . The DQ stated, only formal grievances were being tracked. The DQ stated complaints were not being tracked or logged. The DQ stated, they were not following the policy about tracking and trending complaints or handling complaints systematically . The DQ stated, complaints were resolved on the spot by himself or the Patient Safety Officer (PSO). PSO stated the hospital was not tracking the complaints from patients and should have as hospital have done in the past.

During an interview on 10/25/24, at 8:41 a.m., with Pt 1's family member (FM 1), FM 1 stated, Pt 1 had fallen at the hospital and was transferred to another facility due to brain injury. FM 1 stated, he filed a grievance with the hospital Patient Safety Officer (PSO) about the care of Pt 1 as FM 1 felt that the fall was preventable. FM 1 stated, the PSO sent him a letter in response to his complaint about nurses receiving training but did not call him about the complaint resolution.

During an interview on 10/29/24 at 11:25 a.m. with the Chief Nursing Officer (CNO), the CNO stated, the DQ reports to the Chief Executive Officer (CEO) and issues about complaints and grievances process should be reported to him. The CNO stated, she was unsure of the process for complaints and was unable to explain the process for how complaints are handled as per the hospital policy. The CNO stated, she would relay the message to the CEO about the findings of the policy not being followed.

During a review of the hospital's record "Patients' Rights and Responsibilities (PR) [HOSPITAL NAME]" (PR), dated 8/5/2024, the PR indicated, " ... You have the right to... Express concerns regarding any of these rights in accordance with the grievance process... Complaints: Should you need to file a complaint with this hospital. you may by writing or calling: Administrative Offices, [HOSPITAL ADDRESS] ... For those complaints/grievances filed by patients to hospital staff our policy is as follows: For patient complaints, staff present is to resolve the issue and report the patient complaint through the appropriate means for tracking purposes. Patient grievances (those complaints that are made verbally or writing and cannot be resolved immediately by staff present are to be recorded on the Complaint Form. The Unit Director will investigate the complaint and respond in writing to the patient. For most grievances, this written response will be sent to the patient within seven days of the complaint. If additional time is needed, we will notify the patient in writing that we are continuing our investigation and will respond as soon as possible..."

During a review of the hospital's policy and procedure, "Patient Complaints/Grievances", dated 8/28/2024, the record indicated, " ...This policy provides a mechanism for initiation, review, and when possible, prompt resolution of patient complaints concerning the quality of care of service(s) received. ... The Hospital's process for managing Complaints and Grievances incorporate the following objectives: ... C. Provide a planned, systematic mechanism for receiving and promptly acting upon issues expressed by patients and/or patient representatives... D. Provide an on going system for monitoring and trending patient Complaints and Grievances. ... The Hospital Quality Management Department or the Director of Revenue Analysis (DRA) shall incorporate patient Complaints in the Complaint/Grievance data set for aggregation, analysis, and reporting quarterly to the designated Grievance Committee, Hospital Quality Improvement Committee, the Medical Staff Quality Improvement Committee, Medical Executive Committee (MEC), and Governing Board ... The Hospital's Quality Management department will maintain a log that provides response to the patient. ... The DCQI [Director, Clinical Quality Improvement] or the Patient Safety Officer is responsible for ensuring that all individuals adhere to the requirements of this policy that these procedures are implemented and followed at the Hospital and that instances of non compliance with this policy are reported to the Chief Nursing Officer (CNO)... "

During a review of a professional reference, titled the "State Operations Manual" (SOM), dated 2020, the "SOM" indicated, " ... Patient complaints that are considered grievances also include situations where a patient or a patient's representative telephones the hospital with a
complaint regarding the patient's care or with an allegation of abuse or neglect, or failure of the hospital to comply with one or more Condition of Participations (CoPs ) or other CMS requirements. Whenever the patient or the patient's representative requests that his or her complaint be handled as a formal complaint or grievance or when the patient requests a response from the hospital, the complaint is considered a grievance and all the requirements apply. ...Data collected regarding patient grievances, as well as other complaints that are not defined as grievances (as determined by the hospital), must be incorporated in the hospital's Quality Assessment and Performance Improvement (QAPI- a data driven and proactive approach to quality improvement) Program ..."

Based on I nterview and record review, the hospital failed to ensure patients were free from restraints (a device that restricts movement) and to ensure restraints were discontinued at the earliest possible time when:

1. Licensed Nurse (LN)s did not implement every two hour monitoring for one of three patients (Pt 25) to determine if the restraints could be released in accordance with hospital policy and procedure (P&P).

This failure resulted in Pt 25 not being monitored by LNs, which could have caused injuries from restraints and violated Pt 25's right to be released from restraints at the earliest possible time .

2. LNs failed to obtain a physician order (PO) for renewal of non violent physical restraints (preventing movement of body and limbs) for one of three patients (Pt 24) while patient remained in non-violent physical restraints , in accordance with hospital P&P.

This failure resulted in an unauthorized use of restraint on Pt 24 with the potential to result in inappropriate, unnecessary, and prolonged use of physical restraints .

Findings:

1. During a concurrent interview and record review on 10/25/24 at 10 a.m. with Manager (Mgr) 6, Pt 25's "History & Physical [H&P an assessment from physician including medical history and exam]," dated 10/4/24 at 2:44 p.m. was reviewed. The "H&P" indicated Pt 25 had a past medical history of alcohol abuse and was brought in by ambulance from home to the Emergency Department (ED). Mgr 6 stated Pt 25 was admitted to the hospital as an inpatient (a patient who is admitted to a hospital or other facility and stays overnight to receive medical care) for acute kidney injury (A sudden and often reversible decline in kidney function),
rhabdomyolysis (potentially life threatening condition that occurs when muscle tissue breaks down, releasing harmful substances into the bloodstream), acute hypoxic respiratory failure (body doesn't have enough oxygen in the tissues), and acute encephalopathy (brain dysfunction causing confusion) and moved to the Medical Surgical (MS) Telemetry (hospital floor where patients hearts are continuously monitored) Unit on 10/4/24 at 4:39 p.m.

During a concurrent interview and record review on 10/25/24 at 10:05 a.m. with Mgr 6 Pt 25's "Restraint Monitoring Flowsheet (RMF)," dated 10/09/24 to 10/13/24 were reviewed. The "RMF" indicated Pt 25 was on two point (a mechanical restraint that restricts a patient's wrist movement) soft limb (soft materials for arm or leg) restraints that were initiated at 9 a.m. on 10/9/24 in the ED. Mgr 6 stated Pt 25's "RMF" indicated LNs did not document the two hour assessment on 10/12/24 at 10 p.m. Mgr 6 stated hospital expectation and physician orders for non violent restraint monitoring were for LNs to complete a patient assessment at least every two hours. Mgr 6 stated monitoring patients on restraints at least every two hours was important because the patients were "tied down". Mgr 6 stated LNs needed to assess the patient's skin under the restraint area, reposition the patient, offer the patient something to drink, to eat, to change the patient or offer toileting. Mgr 6 stated assessing patient's every two hours also allows LNs to determine if the patient needed to remain restrained.

During an interview on 10/29/24 at 11:28 a.m. with the Chief Nursing Officer (CNO), the CNO stated LNs should monitor patients on restraints. The CNO stated if LNs did not monitor patients on restraints there was an increased risk of harm to the patient. The CNO stated her expectation was for LNs to follow the hospital P&P and monitor and document assessments for patients on restraints.

During a review of the hospital's P&P titled, "Restraint & Seclusion," dated 11/9/23, indicated, " ... Staff must discontinue Restraint or Seclusion (the act of involuntarily confining a person in a room or area from which they are physically prevented from leaving) at the earliest possible time, regardless of the scheduled expiration of the order ... Monitoring is accomplished by observation, direct face to face interaction with the patient or related direct examination of the patient by trained and competent staff ... Appropriate interval for re assessment is based on the patient needs, condition, and type of Restraint use ... When Restraint or Seclusion is used, there must be documentation in the patient's medical record of the following: ... A description of the patient's behavior and the intervention used
...Individual patient assessments and reassessments, and ... Use of Restraint or Seclusion in the Plan of Care ... Monitoring must include, but not be limited to ... Ability to clear airway ... Patient safety and comfort, during and after Restraint is removed ... Care will not be
compromised by the use of Restraints and shall include ... Provision of nutritional needs ... Systemic [affecting the entire body] release of the restrained limbs.

During a review of professional reference titled, Patient Restraint and Seclusion," dated 11/14/22, (retrieved from https://www.ncbi.nlm.nih.gov/books/NBK565873/ f (nih.gov) indicated, " ... Healthcare workers should know that restraint and seclusion can have significant adverse implications on patients and should be deemed a last resort. Healthcare professionals must follow the 4 basic ethical healthcare principles: autonomy [make decisions and act independently without interference from others], justice, beneficence [the doing of good, promoting the well being of others], and non maleficence [doing no harm]. Per beneficence the act of doing good and non maleficence do no harm; healthcare providers must ensure the administration of restraint is implemented as a last resort ... Healthcare workers must also be sure to appropriately monitor the patient following restraint and seclusion to avoid deleterious [causing harm] effects such as pressure ulcers [localized area of damaged skin or tissue that occurs when pressure is applied to skin for a long time], skin breakdown, abrasions [scraping or wearing away] , asphyxia [body deprived of oxygen, suffocation], strangulation, incontinence [involuntary loss of bladder control], depression, social isolation, and drug overdose or interaction ...Document appropriate clinical indications and prepare a standardized checklist for staff to monitor and supply patient needs effectively. Numerous deaths and adverse patient outcomes have been reported due to inappropriate restraint placement and negligent [failing to take proper care] monitoring. After
restraint placement, patients should be reevaluated every hour and moved regularly ... Once it is safe, the patient should also be evaluated for medical causes of agitation ..."

2. During a review of Pt 24's "H&P" dated 10/18/24 at 2:09 a.m., the "H&P" indicated Pt 24 had a past medical history of recently diagnosed untreated lung cancer, congestive heart failure (CHF heart cannot pump enough blood to meet body's demands), and dementia (a decline in
mental ability, loss of thinking, remembering, and reasoning, that worsens over time). Pt 24 was brought into the ED by family due to an increased decline in mental status, and visual hallucinations (hearing, seeing, smelling, tasting, or feeling things that appear but only exist in
the mind). Pt 24 was admitted to the hospital as an inpatient for metabolic encephalopathy (brain dysfunction causing confusion caused by a chemical imbalance), and CHF on 10/18/24 at 2:12 a.m. Pt 24 was assigned a sitter (a person who takes care of someone) in the ED for safety purposes.

During a concurrent interview and record review on 10/25/24 at 2:05 p.m. with Manager (Mgr) 6, Pt 24's "Physician Orders (PO)" and Restraint Monitoring Flowsheet (RMF)," dated 10/18/24 to 10/22/24 were reviewed. Mgr 6 stated no "PO" for restraint renewal was ordered for 10/21/24. Mgr 6 stated LN documentation on Pt 24's "RMF" indicated, Pt 24 was in non violent physical restraints continuously and monitored from 10/20/24 at 11:15 a.m. to 10/22/24 at 3:35 p.m. Mgr 6 stated Pt 24 should have had a "PO" for restraint renewal on 10/21/24. Mgr 6 stated Pt 24's restraint order must be renewed every calendar day if the patient remained in restraints. Mgr 6 stated patients should not be in restraints without a "PO".

During an interview on 10/29/24 at 11:28 a.m. with the CNO, the CNO stated her expectation was for LNs to contact the physician and get an order to renew restraints every day when patients were in restraints. The CNO stated her expectation was for LNs to follow P&P.

During a review of the hospital's P&P titled, "Restraint & Seclusion," dated 11/9/23, indicated " ...Restraint and Seclusion [the involuntary confinement of a patient alone in a room or an area from which the patient is physically prevented from leaving] require an order from a physician or other authorized Licensed Practitioner responsible for the care of the Patient. The order must include reason for Restraint or Seclusion, type of Restraint, and duration of Restraint or Seclusion ... Staff must discontinue Restraint ... at the earliest possible time, regardless of the scheduled expiration order ... Staff will initiate or continue Restraint or Seclusion only upon the order of a physician or authorized Licensed Practitioner following the guidelines ... Trial releases are not permitted as the release of the patient is considered a
discontinuation of the Restraint order. If Restraint or Seclusion is discontinued prior to order expiration, a new order must be obtained prior to reinitiating the use of Restraint or Seclusion ... Orders for Restraints based on medical needs/ behaviors must be renewed daily ..."

Based on observation, interview and record review, the facility failed to ensure all licensed nurses (LNs) adhered to the hospital's policies and procedures (P&P), when:

1. LNs did not perform quality control (QC- a system of maintaining standards, glucometers- a device for measuring the concentration of glucose in the blood, control Solutions-solution use to test the functionality of meter and strips) checks on One of two glucometers (a small, portable device that measures the amount of glucose, or sugar, in a person's blood) in the Progressive Care Unit (PCU-a hospital area that provides intermediate care for patients who need more care than a general ward but less than intensive care) according to the facility's P&P titled, "Blood Glucose (the main sugar found in your blood) Monitoring Using [Brand Name of glucometer] Inform II System".

This failure placed patients at risk for inadequate blood glucose monitoring and management.

2. LNs did not administer phenobarbital (a medication used to control seizures, relieve anxiety and to prevent withdrawal symptoms) for one of one patient (Pt 1) according to the physician's order.

This failure resulted in Pt 1 receiving phenobarbital when it was not indicated and had the potential for drowsiness and sedation.

3. LNs did not adhere to the hospital's P&P "Pain Management Policy" for two of six patients (Pt 1 and Pt 18). LNs did not assess pain, reassess pain after administration of pain medication, and did not complete a level of sedation assessment according to hospital policy.

These failures placed Pt 1 and Pt 18 at risk for inadequate pain management or oversedation and could negatively affect the physical, emotional, and psychosocial (the influence of both physical and social factors on an individual) well-being of patients.

4. LNs did not complete a skin assessment (a physical examination that involves inspecting and palpating (a method of feeling with the fingers or hands) the skin to evaluate its health) for one of one patient (Pt 1) after Pt 1 had a fall and when Pt 1 was transferred to a different unit according to the facility's P&P titled, "Standard for Impaired Skin Integrity (Potential/Actual)."

This failure resulted in Pt 1's skin assessment to not be completed which had the potential for any changes to go undetected.

5. LNs did not accurately complete a Physician Certification for Transfer and Patient Acknowledgement/Consent for one of one patient (Pt 1) when Pt 1 was transferred from the facility to another facility according to the facility's P&P titled, "Transfer of Patients to Other Medical Facilities."

This failure resulted in incomplete transfer forms and had the potential for miscommunication on Pt 1's condition.

6. LNs did not rotate injection sites for heparin (an anticoagulant you take to prevent blood clots or keep an existing clot from getting worse) administration for two of two patients (Pt 16 and Pt 18) according to nursing standards of practice.

This failure had the potential for Pt 18 and Pt 16 to have tissue damage to the injection site and ineffective medication absorption.

7. One of five LNs (RN 16) did not complete the annual fit testing (a procedure to ensure that a respirator is comfortable and provides the expected level of protection to the wearer) according to the facility's P&P titled, "Saccharin Solution Qualitative Fit Test."

This failure resulted in RN 16 being overdue on her annual fit testing and the potential for inaccurate mask fitting.

8. LNs did not adhere to hospital P&P "Standard for Impaired Skin Integrity [the health of the skin, or whether it is intact, unbroken, and undamaged] Potential/Actual" for three of four patients (Pt 21, Pt 22, and Pt 23). LNs did not document turning/repositioning patients every two hours per physician order.

These failures had the potential to result in harm to Pt 21, Pt 22, and Pt 23 by increasing likelihood of skin breakdown and development of pressure injuries (PI- localized damage to the skin and/or underlying soft tissue, usually over a bony area or related to medical or other device damage to the skin and underlying tissue caused by prolonged pressure).

Findings:

1. During a concurrent observation and interview on 10/22/24 at 3:40 p.m. with the Director of Critical Care (DCC) and Registered Nurse (RN) 15 in the PCU medication room, a glucometer case had two vials of glucose control solution (solution used to test the functionality of meter and strips) with no opened date written on the vials. RN 15 stated inaccurate results can occur if expired glucose control solutions were used. RN 15 stated the night shift charge nurse was responsible to perform the QC on the glucometers. The DCC stated she expected LNs to label the glucose control solution vial with the expiration date after opening. The DCC stated the glucose control solution vials were good for three months after opening or until the expiration date on the bottle.

During an interview on 10/29/24 at 11:25 a.m. with the Chief Nursing Officer (CNO), the CNO stated LNs should be labeling the glucose control solution with the expiration date. The CNO stated she expected LNs to follow the hospital policy.

During a review of the facilities P&P titled, "Blood Glucose Monitoring Using [Brand Name of glucometer] Inform II System," dated 5/17/24, the P&P indicated " ...QUALITY CONTROL TESTING OF [Brand Name] INFORM SYSTEM ...To insure the [brand name] Inform II meter is functioning properly, Quality Control (QC) are required every 24 hours. Both a level 1 test and a level 2 test will need to be done prior to continuing use of the meter. The meter will lock out until QC has been completed. Quality control should be performed: Once per 24 hours with each [brand name] Inform II monitor in routine use and when prompted ...Each time a new vial or new lot number of strips is utilize ...Whenever a vial of strips has been left uncapped ...If the monitor has been dropped ...Whenever test results disagree with clinical symptoms ...To recertify an operator ...Glucose control solutions (Level 1 and Level 2), for use with the [brand name] Inform II. Date control solution vials with open expiration date. The controls are good for 3 months after opening or until expiration date from manufacturer, whichever comes first ...If either Level 1 or Level 2 Control Test FAIL, chose appropriate comment and repeat the failed test. If one or both tests FAIL again, Check the expiration date of the strips and control solutions, Open fresh controls and repeat the test ..."

2. During a review of Pt 1's "History and Physical (H &P-an assessment from physician including medical history and exam)," dated 8/22/24, the H&P indicated " ...[Pt 1] [with] untreated depression [a serious mental health condition that can impact how a person feels, thinks, and functions in daily life] /anxiety [a feeling of fear, dread, and uneasiness] and polysubstance [the use of more than one drug] use disorder presents due to 2 [days] of alcohol withdrawal sxs [symptoms] ..."

During a concurrent interview and record review on 10/24/24 at 10:15 a.m. with Manager (Mgr) 4, Pt 1's "Provider Order (PO)," dated 8/22/24, "CIWA [Clinical Institute Withdrawal Assessment for Alcohol-an instrument used by medical professionals to assess and diagnose the severity of alcohol withdrawal] > [less than] 8 ..." flowsheet, dated 8/23/24 to 8/25/24 and "Medication Administration Record (MAR- a record of drugs administered to a patient)," dated 8/23/24 to 8/25/24 were reviewed. the PO indicated, " ...Order: PHENobarbital ... Order Start Date/Time: 8/22/2024 [12:55 p.m.] ... Order Details: 130 mg [milligrams-unit of measure] = 1 mL (milliliter-unit of measure] ... IV Push [IVP-injecting a medication or fluid into a patient's bloodstream through an intravenous (into a vein) line], Q2h [every 2 hours] Awake x 8 per day PRN [as needed] ... Order Comment: PRN CIWA ..." The CIWA on 8/23/24 at 8:30 a.m. indicated Pt 1 had a CIWA score of three (Scores of less than 8 to 10 indicate minimal to mild withdrawal. Scores of 8 to 15 indicate moderate withdrawal; and scores of 15 or more indicate severe withdrawal). The MAR on 8/23/24 at 8:44 a.m. indicated Pt 1 received phenobarbital 130 mg IVP. Mgr 4 stated Pt 1 should not have been administered phenobarbital when the CIWA score was less than eight. The CIWA on 8/23/24 at 5 p.m. indicated Pt 1 had a CIWA score of five. The MAR on 8/23/24 at 5:35 p.m. indicated Pt 1 received phenobarbital 130 mg IVP. Mgr 4 stated Pt 1 should not have been administered phenobarbital when the CIWA score was less than eight. The CIWA on 8/24/24 at 3 p.m. indicated Pt 1 had a CIWA score of two. The MAR on 8/24/24 at 7:45 p.m. indicated Pt 1 received phenobarbital 130 mg IVP. Mgr 4 stated Pt 1 should have had a CIWA completed before receiving phenobarbital. The CIWA on 8/25/24 at 4:45 p.m. indicated Pt 1 had a CIWA score of zero. The MAR on 8/25/24 at 4:57 p.m. indicated Pt 1 received phenobarbital 130 mg IVP. Mgr 4 stated Pt 1 should not have been administered phenobarbital when the CIWA score was less than eight. Mgr 4 stated sedation was a concern when phenobarbital was administered with a CIWA score of zero. Mgr 4 stated LNs were not following the physician's order when phenobarbital was administered with a CIWA score less than 8. Mgr 4 stated the phenobarbital order indicated it was to be administered when a CIWA score was less than eight. Mgr 4 stated she expected LNs to follow physician's orders.

During an interview on 10/29/24 at 11:25 a.m. with the CNO, the CNO stated she expected LNs to follow the physician's order when administering phenobarbital.

During a review of the facility's document, untitled, undated, the document indicated, " ...Alcohol withdrawal syndrome (AWS) involves a group of select symptoms that develop several hours to a few days after an individual with a history of prolonged and heavy alcohol use (e.g., more than eight drinks per day on a daily basis for multiple days) stops or reduces alcohol intake ... Implement appropriate assessments, reassessments, treatments, and other interventions to target alcohol withdrawal symptoms per the practitioner's orders ..."

3. During a review of Pt 1's "H&P," dated 8/22/24, the H&P indicated "[Pt 1] [with] untreated depression/anxiety and polysubstance use disorder presents due to 2 [days] of alcohol withdrawal sxs [symptoms] ..."

During a review of Pt 1's "Provider Order (PO)," dated 8/22/24, the PO indicated, " ...acetaminophen [treats minor aches and pains, and reduces fever] ... Order Details: 650 mg [milligrams-unit of measure] = 2 tab [tablet] ... Oral, Q4hr [every 4 hours] PRN [as needed] For: Pain Mild ..."

During a concurrent interview and record review on 10/24/24 at 10:15 a.m. with Mgr 4, Pt 1's "Pain Assessment Flowsheet (PAF)", dated 8/23/24 and "MAR," dated 8/23/24 were reviewed. Mgr 4 stated the PAF indicated no pain assessment was done prior to pain medication administration and after. The MAR at 4 p.m. indicated Pt 1 was administered acetaminophen 650 mg. Mgr 4 stated the PAF indicated Pt 1 did not have a pain reassessment until 8 p.m. (a lapse of 4 hours and 19 minutes). Mgr 4 stated Pt 1 should have had his pain assessed before a pain medication was administered and reassessed within an hour after. Mgr 4 stated it was important to assess a patient's pain before a pain medication administration to determine which pain medication should be given. Mgr 4 stated it was important to reassess a patient's pain to make sure the patient was comfortable and assess the effectiveness of the pain medication. Mgr 4 stated the policy stated to reassess pain within one hour of pain medication administration. Mgr 4 stated she expected LNs to assess and reassess a patient's pain.

During a review of Pt 1's "PO," dated 8/22/24, the PO indicated, " ...oxycodone [a narcotic (a drug that relieves pain and induces drowsiness) used to treat moderate to severe pain] ... Order Details: 5 mg = 1 tab ... Oral, Q4hr PRN For: Pain Moderate ..."

During a concurrent interview and record review on 10/24/24 at 10:20 a.m. with M gr 4, Pt 1's "PAF", dated 8/25/24 and "MAR," dated 8/25/24 were reviewed. The PAF at 5:17 a.m. indicated Pt 1 had a pain score of 5 (moderate) out of 10 (Mild Pain=score of 1-3, Moderate Pain=score of 4-6, Severe Pain=score of 7-10). The MAR at 5:17 a.m. indicated Pt 1 was administered oxycodone 5 mg. Mgr 4 stated the PAF indicated Pt 1 did not have a pain reassessment until 7:54 a.m. (a lapse of 2 hours and 37 minutes). Mgr 4 stated Pt 1's pain should have been reassessed within an hour after receiving oxycodone. Mgr 4 stated the PAF indicated Pt 1 did not have a level of sedation assessment completed before and after oxycodone was administered.

During a concurrent interview and record review on 10/25/24 at 10:33 a.m. with Mgr 4, Pt 1's "PAF", dated 8/24/24 and "MAR," dated 8/24/24 were reviewed. The MAR at 7:45 p.m. indicated Pt 1 was administered oxycodone 5 mg. Mgr 4 stated the PAF indicated Pt 1 did not have a level of sedation assessment completed before and after oxycodone was administered. Mgr 4 stated LNs were expected to complete a level of sedation assessment before and after a narcotic was administered. Mgr 4 stated LNs should have completed a level of sedation assessment each time a narcotic was administered to Pt 1. Mgr 4 stated LNs should have followed the policy.

During a review of Pt 18's "H&P," dated 10/10/24, the H&P indicated, " ...[Pt 18] with past medical history for pulmonary hypertension [a serious condition that occurs when the blood pressure in the lungs is abnormally high], CAD [Coronary Artery Disease-a condition in which the arteries that supply blood to the heart become narrowed or blocked] ..., hypertension [when the pressure in your blood vessels is too high], ... diabetes type 2 [a long-term condition in which the body has trouble controlling blood sugar and using it for energy] ... presented to the ER [emergency room] from [physician's name] office for possible left foot debridement [a medical procedure that removes dead, damaged, or infected tissue from a wound to help the healthy tissue heal] ..."

During a concurrent interview and record review on 10/25/24 at 11:03 a.m. with Mgr 4, Pt 18's "PAF", dated 10/19/24 to 10/20/24 and "MAR," dated 10/19/24 to 10/20/24 were reviewed. The PAF on 10/19/24 at 6:18 a.m. indicated Pt 18 had a pain score of 5 (moderate) out of 10 and no level of sedation was completed. The MAR on 10/19/24 at 6:18 a.m. indicated Pt 18 was administered acetaminophen 325 mg - hydrocodone 5 mg. Mgr 4 stated Pt 18's level of sedation should have been completed prior to receiving a narcotic. Mgr 4 stated the PAF indicated Pt 18 did not have a pain reassessment until 10:34 a.m. (a lapse of 4 hours and 16 minutes). Mgr 4 stated Pt 18 should have had a pain reassessment within one hour after pain medication was administered. The PAF on 10/19/24 at 5:10 p.m. indicated Pt 18 had a pain score of 9 (severe) out of 10 and no level of sedation was completed. The MAR on 10/19/24 at 5:10 p.m. indicated Pt 18 was administered acetaminophen 325 mg - hydrocodone 10 mg. Mgr 4 stated the PAF indicated Pt 18 did not have a pain reassessment until 9:20 p.m. (a lapse of 4 hours and 10 minutes). The PAF on 10/20/24 at 2:26 p.m. indicated Pt 18 had a pain score of 6 (moderate) out of 10 and no level of sedation was completed. The MAR on 10/20/24 at 2:26 p.m. indicated Pt 18 was administered acetaminophen 325 mg - hydrocodone 5 mg. Mgr 4 stated the PAF indicated Pt 18 did not have a pain reassessment until 6:12 p.m. (a lapse of 3 hours and 46 minutes).

During an interview on 10/29/24 at 11:25 a.m. with the CNO, the CNO stated LNs should be assessing pain and reassessing pain after administering a pain medication. The CNO stated the patient's level of sedation should be assessed since it was part of the pain assessment and reassessment process. The CNO stated LNs should have followed the pain management policy.

During a review of the facility's P&P titled, "Pain Management," dated 9/23/24, the P&P indicated, " ...POLICY ...All patients have a right to appropriate assessment and management of pain ... PROCEDURE ...The pain intensity and pain relief, as reported by patient will be assessed and documented: 1. On admission, 2. After any known pain-producing event, 3. With each new report of pain, 4. With vital signs, 5. A reassessment within one hour of intervention or less as appropriate, 6. When medications are administered, 7. Assess the patient's level of sedation before and after administering narcotic medication that could be potentially sedating. If the patient becomes over sedated or experiences respiratory depression, following any intervention intended to lessen the patient's pain- notify the provider and document the measures taken ..."

4. During a review of Pt 1's "H&P," dated 8/22/24, the H&P indicated " ... [Pt 1] with untreated depression/anxiety and polysubstance use disorder presents due to 2 [days] of alcohol withdrawal sxs [symptoms] ..."

During a review of Pt 1's "Electronic Medical Record (EMR-an electronic record of health-related information on an individual)," dated 8/22/24 to 8/27/24, the EMR indicated Pt 1 had a "Skin Assessment Form #3443 (SAF)" completed on 8/22/24 and 8/25/24. The SAF indicated " ...Fill out a new form on admission, each time patient transfer to a different floor, and each time there is a significant change in patient condition (e.g. intubation ... change to constant observer) ..."

During a concurrent interview and record review on 10/24/24 at 10:15 a.m. with Mgr 4, Pt 1's "EMR," dated 8/27/24 and "System Review (SR)" flowsheet, dated 8/27/24 were reviewed. Mgr 4 stated the EMR indicated Pt 1 had a fall around 1:45 p.m. Mgr 4 stated the SR indicated Pt 1 did not have a skin assessment completed after the fall. Mgr 4 stated Pt 1's last skin assessment was completed at 8:58 a.m. The EMR indicated Pt 1 was transferred to the Critical Care Unit (CCU- a hospital department that provides specialized care for patients with life-threatening illnesses or injuries) at 6:20 p.m. Mgr 4 stated Pt 1 did not have a skin assessment completed when transferred to a different unit and it should have been completed. Mgr 4 stated it was important to complete a skin assessment when transferred to obtain a baseline (a starting point used for comparisons) of the patient.

During a concurrent interview and record review on 10/24/24 at 1:35 p.m. with RN 7, Pt 1's "SR" flowsheet, dated 8/27/24 was reviewed. RN 7 stated he cared for Pt 1 on the day of the fall. RN 7 stated the SR indicated there was no documentation a skin assessment was completed after Pt 1's fall. RN 7 stated he should have completed and documented a skin assessment after Pt 1 fell. RN 7 stated he did not complete a skin assessment form.

During a phone interview on 10/25/24 at 9:15 a.m. with RN 8, RN 8 stated he cared for Pt 1 when Pt 1 was transferred into the CCU after sustaining a fall. RN 8 stated a skin assessment should have been completed and documented when a patient was transferred to the unit. RN 8 stated he did not complete a skin assessment form. RN 8 stated it was important to assess a patient to establish a baseline when you received the patient. RN 8 stated a patient could change from the baseline and would want to notify the physician if changes occurred.

During a concurrent interview and record review on 10/25/24 at 2:28 p.m. with the Director of Critical Care (DCC), the facility's P&P titled, "Standard for Impaired Skin Integrity (Potential/Actual)," dated 7/22/24 was reviewed. The P&P indicated, " ...PROCEDURE ... A. Preventative interventions: Guidelines for potential or actual impairment of skin integrity. 1. Two (2) RNs/ LVNs will do a generalized skin inspection, especially of bony prominences, and complete the Braden Scale Risk Assessment in the EMR and Skin Assessment Form #3443 (man sheet). Patients will receive this assessment: a. At the time of admission. b. At the time of transfer to a different floor, fill out a new Skin Assessment Form #3443 (man sheet). c. At the time of a significant change in patient's condition (eg: intubation, beginning vasopressors or addition of another vasopressor, change to constant observer, significant change in LOC, in the event of a patient fall ...) fill out a new Skin Assessment Form #3443 (man sheet). d. Every shift, EMR documentation only, unless new skin issues are present ... f. If there are no skin integrity issues at the time of admission, transfer, or change in condition, the Skin Assessment Form #3443 (man sheet) will still be filled out, and the lack of skin issues will be noted on the diagram by writing "Skin Within Normal Limits" ..." The DCC stated RN 8 should have completed and documented a full skin assessment when Pt 1 was transferred to the CCU. The DCC stated RN 8 should have completed the skin assessment form according to the policy.

During a concurrent interview and record review on 10/28/24 at 2:10 p.m. with Mgr 4, Pt 1's EMR, dated 8/22/24 to 8/27/24 were reviewed. Mgr 4 stated Pt 1 had a SAF completed on 8/22/24 and 8/25/24. Mgr 4 stated a SAF was not completed after Pt 1 had a fall and when Pt 1 was transferred to the CCU. Mgr 4 stated a SAF should have been completed after Pt 1 fell to identify changes from Pt 1's baseline.

During an interview on 10/29/24 at 11:25 a.m. with the CNO, the CNO stated LNs should be following the policy for skin assessment to get an accurate view of the patient.

5. During a review of Pt 1's "H&P," dated 8/22/24, the H&P indicated " ... [Pt 1] [with] untreated depression/anxiety and polysubstance use disorder presents due to 2 [days] of alcohol withdrawal sxs [symptoms] ..."

During a concurrent interview and record review on 10/24/24 at 10:15 a.m. with Mgr 4, Pt 1's "Physician Certification for Transfer and Patient Acknowledgement/Consent (Transfer Form), Section II," dated 8/27/24 was reviewed. Mgr 4 stated the Transfer Form, Section II was signed by Pt 1's mother. Mgr 4 stated the witness line had no signature. Mgr 4 stated the person who had the mother sign the Transfer Form, Section II should have signed the form as well.

During a phone interview on 10/25/24 at 9:15 a.m. with RN 8, RN 8 stated he cared for Pt 1 when Pt 1 was transferred into the CCU after sustaining a fall. RN 8 could not recall if he went over the Transfer Form with Pt 1 and Pt 1's family. RN 8 stated there should be a witness signature if the form was signed by someone other than the patient.

During a concurrent interview and record review on 10/25/24 at 2:15 p.m. with RN 9 and the DCC, the facility's P&P titled, "Transfer of Patients to Other Medical Facilities," dated 6/5/24, was reviewed. Pt 1's "Transfer Form, Section I," undated and "Transfer Form, Section II," dated 8/27/24 were reviewed. The P&P indicated, " ...PURPOSE: To provide guidelines to facilitate a safe and appropriate transfer of patients in compliance with EMTALA [Emergency Medical Treatment and Labor Act is a federal law that ensures patients receive emergency care without regard to their ability to pay or insurance status] and California requirements ... Transfer of the stable patient: 1. If the Medical Screening Exam (MSE) establishes that no Emergency Medical Condition exists, the following steps should be taken: a. The medical record must reflect that the patient does not have an Emergency Medical Condition. b. The patient may be admitted, discharged, or transferred, as medically appropriate ... 2. If an Emergency Medical Condition was found to exist, but the physician determines that the patient's medical condition is stabilized, the patient may be transferred when the following criteria have been met: a. Treatment to stabilize the patient must be administered within the capabilities of [name of hospital] available staff and services. 3. Physician Certification for Transfer and Patient Acknowledgment/Consent, Section I ...The physician should complete and sign prior to transfer. (Check box pertaining to stable patient.) The patient should sign the acknowledgment/consent prior to transfer. 4. Physician Certification for Transfer and Patient Acknowledgment/Consent, Section II: Patient Transfer Acknowledgment/Consent ...Should be completed to document acknowledgment of notification of the transfer by the patient or their legal representative ... D. Preparation steps prior to transfer: 1. Transferring Physician's duties ...Complete Physician Certification for Transfer and Patient Acknowledgement/Consent ... 2. Nurse's duties: ... Complete Physician Certification for Transfer and Patient Acknowledgement/Consent ... 4. Charge Nurse duties: ... Must review all paperwork ... DOCUMENTATION, A. All forms to be complete (no blank lines) ..." RN 9 stated the Transfer Form, Section I did not have an updated status of the patient's condition. RN 9 stated the Transfer Form, Section I did not have a date and time of when the physician signed the form. RN 9 stated it was not a complete Transfer Form. RN 9 stated the physician should have completed the update on the patient's condition on the Transfer Form, Section I. RN 9 stated the physician should have written the date and time of when the physician completed and signed the Transfer Form, Section I. RN 9 stated she gave the Transfer Form, Section II to RN 8 to get the patient and/or family consent and signature. RN 9 stated she did not witness the mother's signature on the Transfer Form, Section II. RN 9 stated the LN who witnessed the mother's signature should have signed the witness line on the Transfer Form, Section II. RN 9 stated it was her responsibility to review the Transfer Form for accuracy to ensure the safety of the patient's care.

During an interview on 10/25/24 at 2:28 p.m. with the DCC, the DCC stated the Transfer Form was incomplete. The DCC stated the primary RN should complete the first check for accuracy then the charge RN double checks to ensure accuracy and completeness. The DCC stated LNs should have checked the Transfer Form to ensure it was accurately completed. The DCC stated she expected LNs to sign the witness line to validate it was the patient or family's signature.

During an interview on 10/29/24 at 11:25 a.m. with the CNO, the CNO stated she expected transfer forms completed and filled out correctly.

6. During a review of Pt 18's "H&P," dated 10/10/24, the H&P indicated, " ... [Pt 18] with past medical history for pulmonary hypertension, CAD ... hypertension ... diabetes type 2 ... presented to the ER from [physician's name] office for possible left foot debridement ..."
During a review of Pt 18's "PO," dated 10/14/24, the PO indicated, " ...heparin ... 5,000 Unit (s) [unit of measure], 1 mL ... Injection ... Route of administration Subcut [subcutaneous- the injection is given in the fatty tissue, just under the skin] ... Frequency Q12hr ..."

During a concurrent interview and record review on 10/25/24 at 11:03 a.m. with Mgr 4, Pt 18's "MAR," dated 10/15/24 to 10/17/24 were reviewed. The MAR indicated Pt 18 had heparin administered to his lower left abdomen on 10/15/25 at 9:09 a.m., 9:36 p.m., 10/16/24 at 8:51 a.m., 8:10 p.m., and 10/17/24 at 9:43 a.m. Mgr 4 stated the injection sites were not rotated. Mgr 4 stated it was important to rotate sites, so the patient does not bruise, and to allow for the absorption of the medication. Mgr 4 stated it could cause trauma to the skin, such as tissue damage. Mgr 4 stated LNs are expected to rotate injection sites. Mgr 4 stated LNs should have utilized the facility's nursing skill platform on how to administer subcutaneous injections. Mgr 4 stated there was an icon on every desktop with the nursing skill platform which was accessible to all LNs.

During a review of Pt 16's "H&P," dated 8/29/24, the H&P indicated, " ... [Pt 18] transferred to our facility ... for a second opinion surgical consult. He has a complicated history of ... C1-C2 fracture [a break in the C1 or C2 vertebrae, which are located at the top of the neck and connect the head to the spine], quadriplegia [paralysis of all four limbs], trach [tracheostomy-a surgical procedure that creates an opening in the neck to provide an airway and help with breathing] ... history of hypertension, depression, anxiety, chronic pain ... deep tissue injuries [damage to the soft tissue beneath the skin caused by pressure or shear forces] ... Patient previously had a G-tube [gastrostomy tube-a small, flexible tube that is surgically inserted through the abdominal wall and into the stomach to provide nutrition and fluids], it was removed several weeks ago ... Since then he has a nonclosing gastric fistula [an abnormal opening in the stomach or intestines that allows the contents to leak to another part of the body] ..."

During a review of Pt 16's "PO," dated 9/2/24, the PO indicated, " ...heparin ... 5,000 Unit (s), 1 mL ... Injection ... Route of administration Subcut ... Frequency Q8hr ..."

During a concurrent interview and record review on 10/25/24 at 1:38 p.m. with Mgr 4, Pt 16's "MAR," dated 10/19/24 to 10/24/24 were reviewed. The MAR indicated Pt 16 had heparin administered to his left lower abdomen on 10/19/24 at 2:38 p.m. and 10:15 p.m. The MAR indicated Pt 16 had heparin administered to his left lower abdomen on 10/20/24 at 2:21 p.m. and 10:17 p.m. The MAR indicated Pt 16 had heparin administered to his left lower abdomen on 10/22/24 at 5:50 a.m. and 2:33 p.m. The MAR indicated Pt 16 had heparin administered to his right lower abdomen on 10/23/24 at 2:25 p.m. and 9:18 p.m. The MAR indicated Pt 16 had heparin administered to his left lower abdomen on 10/24/24 at 5:39 a.m. and 1:57 p.m. Mgr 4 stated the injection site should have been rotated if the previous one was given in the same site.

During an interview on 10/29/24 at 11:25 a.m. with the Chief Nursing Officer (CNO), the CNO stated LNs are expected to rotate injection sites. The CNO stated there could be harm to the patient if LNs are not rotating the injection sites.

During a review of the facility's document , untitled, undated, the document indicated, " ...ALERT ... Do not administer the medication into the injection site if the skin is damaged, burned, bruised, hard, inflamed, or swollen ... Select an appropriate injection site based on the subcutaneous tissue mass, medication volume, and the required absorption rate. Inspect the skin surface for bruises, inflammation, or edema. Do not use an area that is bruised or has signs associated with infection. a. When administering heparin, use abdominal injection sites ... c. When administering insulin, systematically rotate the injection site within the same anatomic area (e.g., abdomen).

During a professional reference review titled, "Injection Technique 2: Administering Drugs via the Subcutaneous Route," dated 8/28/18, retrieved from https://www.nursingtimes.net/assessment-skills/injection-technique-2-administering-drugs-via-the-subcutaneous-route-28-08-2018/, the reference indicated, " ...Complications associated with subcutaneous injections include abscesses and, in patients who require frequent injections, there is a risk of lipohypertrophy [a lump of fatty tissue under your skin caused by repeated injections in the same place]; this is characterized by an accumulation of fat under the skin. Lipohypertrophy occurs when multiple injections are repeatedly administered into the same area of skin. It can be painful and unsightly, and affect drug absorption, but can be prevented by rotating injection sites ..."

7. During a concurrent interview and record review on 10/29/24 at 10:45 a.m. with the Chief Human Resources Officer (CHRO) and the Director of Education (DE), Registered Nurse (RN) 16's "Personnel File (PF)," undated was reviewed. The DE stated the PF indicated RN 16's last fit testing was completed on 9/12/23. The DE stated facility staff were responsible to complete a fit testing within 12 months of the previous one. The DE stated facility staff performed the fit testing course on the facility's learning platform and should complete the courses by the due date.

During an interview on 10/29/24 at 11:25 a.m. with the CNO, the CNO stated the facility staff should follow the policy on fit testing.

During a review of the facility's P&P titled, "Saccharin Solution Qualitative Fit Test," dated 5/22/18, the P&P indicated, " ...PURPOSE: While caring for patients with actual or suspected mycobacterium tuberculosis disease, each employee will be

Based on observation, interview, and record review, the facility failed to ensure medications were securely stored from unauthorized staff when medications were left unsecured in a bin on top of the locked medication refrigerator in the patient care area of the Post Anesthesia Care Unit (PACU- the treatment a patient will receive in a nursing facility while recovering from an illness or surgery).

These failures resulted in the availability of medications to be diverted by unauthorized staff, patients and visitors.

Findings:

1. During an observation and interview on 10/23/24, at 10:30 a.m., with Registered Nurse (RN18), in the PACU, next to the nurse's station, on top of the medication refrigerator, there was an unlocked bin with medications. The bin was labeled, "Return Medications to Pharmacy." RN 18 stated, she was the charge nurse for the area and there were three medications in the return bin. RN 18 stated, medications should be secured from those who are not authorized to access medications as for example, environmental services. RN 18 stated, medications should be secured at all times, and they will have to come up with a different solution to ensure the medications were secure.

During interview on 10/28/24, at 11:15 a.m., with the Pharmacy Director (PD), PD stated, medications should be kept secure and medications in the return bin in the open area of the PACU was not secure. PD stated unauthorized staff had access to the medications by having the return bin unsecured on top of the medication refrigerator. PD stated, they corrected the situation to follow the hospital's policy.

During a review facility's policy and procedure (P&P) titled, "Storage of Medications in Patient Care Areas," dated 7/26/24. The P&P indicated "... PURPOSE ... To ensure the safe and secure handling and storage of medications on patient care units, including the storage of medication ... All medications are stored in a secure environment that limits access to authorized personnel as defined by hospital policy. ... Categories of personnel are authorized access to secure medication areas based on the organization's need for the individual to perform their assigned duties and in accordance with federal, state and local regulations. ... Medications that are not securely locked must be under constant surveillance ..."

Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment to avoid sources and transmission of infection when:

1. Fourteen of fourteen expired microbiology swabs (a collection and transport system used for culture testing) were found in the Progressive Care Unit's (PCU-a hospital area that provides intermediate care for patients who need more care than a general ward but less than intensive care) medication room according to the facility's policy and procedure (P&P) titled, "Procurement and Supply Chain (PSC) Management,"

This failure had the potential to result in inaccurate results which could lead to ineffective treatment.

2. Hospital Staff did not adhere to the standard of care for patient hygiene or hospital job descriptions for one of three patients (Pt 22) when Pt 22 was observed to have a brown substance under the fingernails of his left hand.

This failure had the potential for Pt 22 to have cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) from the substance under his fingernails to get into his mouth or onto the open wound on his right hand which could lead to infection.

3. Two of two Licensed Nurses (LNs) (Registered Nurse (RN) 10 and the Wound Nurse (WN)) failed to follow facility P&P titled, "Hand Hygiene" and "Transmission-Based Precautions" for one of two patients (Pt 5) when LNs were observed not performing hand hygiene (practice of cleaning hands to remove germs, dirt, or other harmful substances) and/or performing it incorrectly, before putting on non-sterile gloves, after taking off non-sterile gloves, and after touching the patient. LNs applied personal protective equipment (PPE - protective clothing designed to protect the wearers body from injury or infection) incorrectly when entering isolation rooms (room requiring PPE to prevent the spread of infection). LNs touched Pt 5's bed side rails, bedside table, room curtain, the translator tablet, and LN face with contaminated gloves.

These failures placed Pt 5, all patients being cared for by RN 10 and the WN, and staff were at risk for transmission of infections (an infectious agent is transferred from a reservoir to a susceptible host), cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and increased the potential for hospital acquired infections and illnesses.

Findings:

1. During a concurrent observation and interview on 10/22/24 at 3:40 p.m. with the Director of Critical Care (DCC) and Registered Nurse (RN) 15, in the PCU medication room, 24 microbiology swabs were expired. The DCC stated there were three microbiology swabs with an expiration date of 9/18/24, seven with an expiration date of 10/12/24, ten with an expiration date of 10/14/24, and four with an expiration date of 10/17/24. The DCC stated the microbiology swabs were used to swab a wound, tissue, or eye for culture testing. The DCC stated the microbiology swab was also used to test for methicillin-resistant staphylococcus aureus (MRSA-a bacteria that causes infections in different parts of the body). RN 15 stated if an expired microbiology swab was used to collect a sample, it would give an inaccurate result which would lead to an inaccurate diagnosis. RN 15 stated laboratory staff stocked the unit with the microbiology swabs. The DCC stated she expected LNs to dispose of the microbiology swabs when it expired. The DCC stated it was every one's responsibility to check for expiration dates.

During an interview on 10/28/24 at 1:46 p.m. with the Infection Preventionist (IP), the IP stated expired items should not be on the units. The IP stated the staff who delivered the items to the unit should have checked for expiration dates when coming to the unit to restock. The IP stated LNs check should check for expiration dates on items before using it. The IP stated an inaccurate result could occur if the item was expired.

During an interview on 10/29/24 at 11:25 a.m. with the Chief Nursing Officer (CNO), the CNO stated LNs should look at an item's expiration date and remove it if it was expired.

During a review of the facility's P&P titled, "Procurement and Supply Chain (PSC) Management," dated 5/20/22, the P&P indicated, " ...All manufactured sterile supply items maintained in the Bulk Storage, Central Service, and Par Level areas will be reviewed weekly and upon issuance in respect to the expiration date of the product. A. All manufactured sterile supply items maintained in the inventory control system will be reviewed weekly and upon issuance in respect to expiration dates. B. All expired items shall be immediately removed from the storage area and proper disposition be made of the items ... D. It is the responsibility of each individual department within the hospital to ensure that all manufactured sterile items that are maintained and used within the department are reviewed in respect to the expiration date of the item prior to using. Further, ii is the responsibility of each department to periodically review all manufactured sterile items maintained within the department for expiration dates ..."

2. During a concurrent interview and record review on 10/24/24 at 10:50 a.m. with Manager (Mgr) 6, Pt 22's "History and Physical (H &P-an assessment from physician including medical history and exam)," dated 9/17/24 was reviewed. The "H&P" indicated, Pt 22 had a Past Medical History (PMH) of left-sided craniotomy (a surgical procedure that involves removing a section of the skull to access the brain), behavioral issues secondary to traumatic brain injury (TBI- a brain injury caused by an external force, such as a blow to the head. TBIs can range from mild to severe, and can affect how a person thinks, feels, acts, and moves), seizure disorder (a chronic brain condition that causes recurring seizures [a temporary episode of abnormal electrical activity in the brain that causes sudden change of behavior, movement, or consciousness]), due to TBI, and high blood pressure. Pt 22's "H&P" indicated, " ... presented to the ER [Emergency Room] on 9/5/24 for a 5150 hold [a California law that allows for the involuntary psychiatric detention of a person for up to 72 hours] ... Patient has been in the ER close to 2 weeks, been trying to get placement ...". Pt 22 was moved to the inpatient Medical Surgical (MS) Unit on 9/17/24 at 6:55 p.m.

During an interview on 10/25/24 at 1:10 p.m. with Family Member (FM) 2 on the telephone, FM 2 stated she was unhappy with the care her father was receiving from LNs at the hospital. FM 2 stated Pt 22's room had an odor and Pt 22 had body odor. FM 2 stated Pt 22 had only been showered one time since his arrival to the hospital on 9/4/24. FM 2 stated Pt 22 was only able to use his left hand for eating and brushing his teeth and his hand was dirty. FM 2 stated Pt 22 "had a bunch of poop inside his nails" FM 2 stated she told staff about Pt 22's dirty nails on 10/23/24 and asked for a file or something to clean out under his nails and was told the hospital did not have anything.

During a review of Pt 22's "physician order (PO)", dated 10/4/24, the "PO" indicated Pt 22 was on contact isolation precautions (set of safety measures used to prevent spread of infection through direct or indirect contact) for Methicillin-resistant Staphylococcus aureus (MRSA - a type of bacteria that has become resistant to many antibiotics, can spread in hospitals) in his urine.

During a concurrent observation and interview on 10/25/24 at 2:50 p.m. with the Director of Medical Surgical (DMS) in Pt 22's hospital room, Pt 22 was observed lying in his hospital bed on his back with his eyes open. Pt 22's hospital room had isolation gowns and gloves outside the door. Pt 22's hospital room had a contact isolation sign posted. Pt 22 was lying with his left hand on his chest close to his throat. Pt 22's fingernails on his left hand were to the tips of his fingers. Pt 22 had a dark brown substance under the first, second, and third fingernails of his left hand. Pt 22's right hand was flat on the hospital bed and had a quarter sized open wound to the top of his thumb knuckle. Pt 22's right hand fingernails were clean. Pt 22's room had no odor. Pt 22's gown and bed linens were clean. The DMS stated Pt 22 should have clean hands and should not have brown substances under his fingernails. The DMS stated Pt 22's hands should be clean; Pt 22 was non ambulatory and depended on hospital staff to ensure hand hygiene was done. The DMS stated risk of infection increased when patients were not kept clean.

During a concurrent interview and record review on 10/28/24 at 11:25 a.m. with Manager (Mgr) 4, Pt 22's "Electronic Medical Record" was reviewed. Mgr 4 stated Pt 22 was bathed every day using the chlorhexidine gluconate (CHG- antiseptic-germ killing) bath wipes. Mgr 4 stated Pt 22 was incontinent of stool (inability to control bowel movements) but not incontinent (inability to control) of urine. Mgr 4 stated Pt 22's nails should have been cleaned by staff when he was bathed, before eating, or when visibly dirty. Mgr 4 stated her expectation was for staff to keep patients clean, to reduce risk of infection.

During an interview on 10/28/24 at 1:17 p.m. with Patient Care Technician (PCT)1, PCT 1 stated her role was to provide baths, oral care, hair washing, showers, and toileting (changing) patients. PCT 1 stated baths with the CHG wipes were done once per day unless the patient refused. PCT 1 stated showers needed a physician order. PCT 1 stated if a patient was very dirty, she would use a basin with water to clean the patient. PCT 1 stated Pt 22 required help to set up his food but he fed himself. PCT 1 stated Pt 22 required help with his oral care. PCT 1 stated Pt 22 required assistance to get into his wheelchair. PCT 1 stated Pt 22 required changing when he had a bowel movement because he was incontinent of stool. PCT 1 stated Pt 22 required assistance to clean his hands because he did not walk. PCT 1 stated PCTs received training during the orientation period how to bathe patients. PCT 1 stated Pt 22 should have his hands cleaned because infections could happen if feces was left under the fingernails.

During a review of hospital hand out "CHG: Bathing with Chlorhexidine Gluconate Wipes Patient Education," dated 5/17, the "hand out" indicated, " ... CHG wipes are antiseptic (germ-killing) cloths used to wash the skin. The living skin is a constant source of germs. CHG kills 99% of the germs on the skin to help to prevent germs from getting into an open wound or your bloodstream causing serious infection ..."

During a review of "Unit Tech-PCT [Patient Care Technician] Licensed [job description]," dated 4/3/19, the "Job Description" indicated, " ...The Nursing Assistant [NA] performs duties under the direction of the Registered Nurse [RN] ... Responsible for providing high quality basic care activities ... assistance with activities of daily living, such as bathing, feeding, ambulating, toileting ... Provides for the hygiene of the assigned patient population ... Gives all types of baths personal hygiene ..."

During a review of professional reference titled, "Assisting Patients with Personal Hygiene," (retrieved from https://www.ncbi.nlm.nih.gov/books/NBK563155/) dated 9/26/22, the professional reference indicated, " ... Preventing the spread of contamination from the medical provider to the patient and vice versa is essential ... A lack of hygiene can result in many adverse effects, such as hospital-acquired infections ... Basic adult hygiene includes oral hygiene, bathing, eliminating, shaving, brushing, and styling hair ... These may seem like basic procedures but are vital to maintaining the patient's health ... The inability to properly maintain hygienic conditions for patients can lead to many adverse effects ... Bathing patients regularly, particularly those in the intensive care unit, can help prevent ... infections ... Bathing helps the patient feel clean and gain a sense of normalcy, removes dirt, perspiration, bacteria, and dead skin, and promotes blood circulation ... Regular nail care can remove bacteria underneath the fingernails to help prevent infections ..."

3. During a review of Pt 5's H&P, dated 10/22/24, the "H&P" indicated Pt 5 had a PMH of severe alcohol use disorder and he presented to the ED due to right lower extremity (leg) popliteal (the hollow at the back of the knee) lesion (wound) that was worsening and painful. Pt 5 was admitted to the hospital as an inpatient on 10/22/24 for sepsis (serious infection that can lead to lead to tissue damage organ failure or death).

During a concurrent observation and interview on 10/23/24 at 11:29 a.m. with the WN and RN 10 in Pt 5's hospital room, Pt 5 was sitting up in his hospital bed at a 90-degree angle with his legs on a disposable pad. The WN was at the foot of the patient bed communicating with Pt 5 using the interpreter tablet at Pt 5's bedside. Pt 5's privacy curtain was closed. Pt 5 was in a contact isolation room, and the WN was wearing a yellow isolation gown and blue non-sterile gloves. Pt 5's bedside table was at the foot of the bed with wound supplies sitting on it. Pt 5 had a golf ball sized purulent (pus) draining wound to the back of his right knee. The wound appeared red and swollen. Pt 5 stated it hurt when the LNs pushed on the area. The WN failed to complete hand hygiene a total of five separate times in a 15 minute span, after removing Pt 5's old dressing and putting the dressing into the red biohazard bag, after cleaning the wound, after obtaining a doppler pulse (a handheld tool commonly used in healthcare settings to monitor blood flow in vessels), after measuring the wound, and after obtaining a wound culture sample (a small amount of fluid, tissue, or cells from a wound that is used to test for the presence of bacteria, viruses, or fungi that may be causing an infection). The WN changed gloves between each task but did not perform hand hygiene. The WN also touched Pt 5's siderail, bedside table, and the privacy curtain with contaminated gloves.

During an observation on 10/23/24 at 11:33 a.m. in Pt 5's hospital room, RN 10 was observed assisting the WN with Pt 5's dressing change. RN 10 was observed putting on a pair of non-sterile gloves first and then the isolation gown by pushing her thumbs through the sleeves to create a hole near the cuff of the gown. RN 10 had the cuff of the isolation gown across the palm and back of the hand (to mid hand) of the non-sterile gloves. RN 10 put on a second pair of gloves over the first. RN 10 would remove the second pair of gloves and use hand sanitizer over the first set of gloves whenever changing gloves between tasks. RN 10 washed Pt 5's legs with a washcloth, took photos of wound, retrieved more supplies, applied ointment to legs, and retrieved the doppler. RN 10 removed second gloves and sanitized the first a total of 5 times. RN 10's isolation gown would have hand sanitizer across the palm and inside cuff of the isolation gown each time the gloves were sanitized. RN 10 eventually removed the second set of gloves, did not put on a new second pair then assisted the WN to collect a wound culture sample, and held up Pt 5's leg with the isolation gown across the palm of the glove. RN 10 then touched her face with the back of her contaminated gloved hand. RN 10 also touched Pt 5's privacy curtain, the bedside table, and the interpreter tablet with contaminated gloves. The camera used to take photos of the wound was set on the bedside table next to the used washcloths and was not wiped with disinfecting wipes.

During an interview on 10/23/24 at 12:15 p.m. the WN, the WN stated she washed her hands before she started a dressing change and after. The WN stated her practice was not to perform hand hygiene between glove changes. The WN stated she washed her hands between patients and dressing changes were performed with the clean technique (a procedure that involves reducing the risk of spreading microorganisms by using clean gloves, sterile instruments, and a clean environment) to reduce infection.

During an interview on 10/23/24 at 12:20 p.m. with RN 10, RN 10 stated she should not have worn the isolation gown on top of her non-sterile gloves. RN 10 stated her isolation gown should be under the gloves. RN 10 stated clean hands were important to patient safety, and nurses should perform hand hygiene between glove changes. RN 10 stated having the isolation gown on the outside palm of gloves could cause cross contamination.

During an interview on 10/24/24 at 2:35 p.m. with the DCC, the DCC stated her expectation was for staff to follow the P&P for hand hygiene. The DCC stated LNs should complete hand hygiene between glove changes, after touching a patient and when entering and exiting a room. The DCC stated if the hands were visibly soiled LNs should use soap and water. The DCC stated LNs should wear PPE correctly and not put holes in the sleeves. The DCC stated LNs should not have isolation gowns over gloves because it could cause cross contamination. The DCC stated isolation gowns should be discarded if they become wet or soiled. The DCC stated LNs and should not use hand sanitizer on the gloves because it may break down the glove material making them less effective. The DCC stated LNs should avoid touching areas around the patient room with soiled gloves. The DCC stated LNs could pass bacteria to other rooms on their clothing by not using PPE correctly and by touching areas around the room with contaminated gloves.

During an interview on 10/29/24 at 11:37 a.m. with the CNO, the CNO stated her expectation was for LNs to perform hand hygiene according to hospital policy. The CNO stated her expectation was for LNs to not touch their face with contaminated gloves.
During a review of the hospital's P&P titled, "Hand Hygiene," dated 40/20/18, indicated, " ... Indications for hand washing and hand antisepsis ... before touching a patient ... On entering the patient zone ... Before performing a clean/aseptic procedure ... If moving from a contaminated body site to a clean body site during patient care ... After body fluid exposure risk ... After removing gloves ... After contact with body fluids ... or wound dressings ... After touching a patient ... After contact with inanimate objects ... in the immediate vicinity of the patient ... For example ... monitoring alarm, holding a bed rail, clearing the bedside table ... Ensure that healthcare personnel perform hand hygiene with soap and water when hands are visibly soiled ... Hand hygiene technique ... when decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers until hands are dry ..."

During a review of the hospital's P&P titled, "Transmission-Based Precautions," dated 5/22/23, indicated, " ...Transmission-Based Precautions are designed to reduce the transmission of pathogens [an organism that can cause disease in a host] by ... contact route ... During patient care, change gloves after having contact with infective material that may contain high concentrations of microorganisms [living things too small to see with naked eye] (e.g. if you needed to wear gloves to perform the task, you need to perform hand hygiene when the task ends) ... Remove gloves and perform hand hygiene ... Gown ... Wear a gown when entering room if you are within 3 feet of the patient ... Remove gown and observe hand hygiene before leaving patient's environment ... After gown removal, ensure that clothing and skin do not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other patients or environments ... Patient-Care Equipment ... If use of common equipment or items is unavoidable, then adequately clean and disinfect them before use for another patient.

During a review of a professional reference from the Centers for Disease Control ( CDC) titled, "The Basics of Standard Precautions", dated 2007, the professional reference indicated " ... Perform hand hygiene after PPE removal ... Wear gloves when anticipating contact with a patient's ... blood or body substance ... Mucous membranes (nasal, oral, genital area) ... Non-intact skin ... Extend to cover wrist, over isolation gown if worn ... Sequence of PPE donning [putting on] ... gloves are often the last item to be put on ... gloves are usually the first item to be removed ... A gown should not be worn in hallways or corridors ..."

During a review of professional reference from the CDC titled, "Clinical Safety: Hand Hygiene for Healthcare Workers, dated 2/27/24, the professional reference indicated, " ... Hand hygiene protects both healthcare personnel and patients. Hand hygiene means cleaning your hands with Handwashing with water and soap (e.g., plain soap or with an antiseptic). Antiseptic hand rub (alcohol-based foam or gel hand sanitizer) ... Cleaning your hands reduces: The potential spread of deadly germs to patients. The spread of germs, including those resistant to antibiotics ... Know when to clean your hands ... Immediately before touching a patient ... Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices ... Before moving from work on a soiled body site to a clean body site on the same patient ... After touching a patient or patient's surroundings ... After contact with blood, body fluids, or contaminated surfaces ... Immediately after glove removal ...".
During a review of professional reference from the World Health Organization (WHO) titled, "Glove Use Information Leaflet", August 2009, the professional reference indicated, " ... As medical gloves are single-use items, glove decontamination ...are not recommended and should be avoided ...







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