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Based on record review and interviews, the hospital failed to ensure staff personnel records contained documentation that demonstrated Patient Rights competencies had been successfully completed during orientation for 1 (S4NP) of 5 ( S4NP, S5RT, S6Tech, S7RD, S8RN) hospital staff reviewed for Patient Rights training.
Findings:

Review of S4NP's personnel record failed to reveal Patient Rights training and competency was successfully completed initially during orientation.

In an interview on 07/11/2023 at 2:08 p.m., S1DON confirmed that S4NP was hired in 2022 as a contracted provider and did not go through the hospital employee Patient Rights training.

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care for each patient. This deficient practice is evidenced by:
1) failing to provide an accurate nursing assessment on Patient #1 on admit.
2) failing to ensure the physician was notified of abnormal vital signs per hospital policy and physician orders.
3) failing to follow physician orders for wound care in 1 (#1) of 3 (#1, #3 and #5) patients sampled for wound care.
4) failing to ensure each patient received daily hygiene care as per hospital policy and physician orders in 5 (#1-#5) of 5 (#1-#5) patients sampled for hygiene care.
Findings:

1) Failing to provide an accurate nursing assessment on Patient #1 on admit.
A review of hospital policy titled "Patient Assessment/Reassessment" revealed, in part: The initial patient assessment performed by nursing will include, but not be limited to, the following information: Pressure injury risk assessment. Wound assessment, in part: 2. All pressure injuries will be assessed, measured and staged by an RN or other qualified healthcare personnel within 24 hours of admission. Patient Reassessment, in part: A reassessment of the patient shall be performed at least every shift by nursing staff. The reassessment performed by nursing will include, but not be limited to, the following information, in part: Skin (integument).

A review of Patient #1's medical record revealed an Altered Skin Integrity assessment dated 01/18/2023 at 9:15 a.m. revealed multiple wounds assessed to left heel, ankle, foot, lower leg, and arm. Further review revealed multiple wounds assessed to right lower leg and knee. Continued review failed to reveal an assessment of the right heel.

A review of Skin assessment dated 02/08/2023 revealed Patient #1's right heel with ulcer (first assessment). 2 cm in length, 4 cm in width. 0.2 cm dept. full thickness tissue loss. Base covered by slough and/or eschar in the wound bed.

In an interview on 07/10/2023 at 2:45 p.m., S1DON confirmed the wound to the right heel was missed during the initial assessment and nursing assessments on following days until 02/08/2023 when it was noticed.

2) Failing to ensure the patient's physician was notified of abnormal vital signs per hospital policy and physician orders.
A review of hospital policy titled "Vital Signs" revealed, in part: Procedure, in part: Report any abnormal findings to the Charge Nurse. Collaborate with the Charge Nurse to determine if the physician should be notified.

A review of hospital policy titled "Patient Assessment/Reassessment" revealed, in part: Patient Reassessment, in part: Any significant change in the patient's condition should elicit a reassessment of the patient (documented in the narrative notes) within one hour. The registered nurse is responsible for ensuring that the physician is notified of all significant changes in the patient's condition.

A review of Patient #2's physician orders dated 06/23/2023 revealed, in part: Cardiac Monitoring, in part: Notify physician if: Question: HR>then 120/min.

A review of Patient #2's medical record revealed this 18-year-old female patient was admitted to the hospital on 06/23/2023 with diagnoses of Chronic Respiratory Failure second to Viral Encephalitis, Craniotomy, tracheostomy on ventilator with PEG tube.

Review of the Graphic/I&O Sheet dated 07/08/2023 revealed heart rate was documented as 122-130 from 3:49 p.m. to 4:50 p.m.

Further review of Patient #2's medical record failed to reveal charge nurse or physician was notified of heart rate being greater than 120 (122-130 BPM) on 07/08/2023 for 1 hour (3:49 p.m.-4:50 p.m.) as ordered by the physician. Continued review failed to reveal a nurse assessment pertaining to the sustained tachycardia.

In an interview on 07/10/2023 at 11:07 a.m., S1DON confirmed that the charge nurse or physician was not notified of sustained heart rated between 122-130 for 1 hour (3:49 p.m.-4:50 p.m.) as ordered by the physician. S1DON further stated that nursing documentation should have included an assessment of this patient with sustained heart rate greater than 120.

3) Failing to follow physician orders for wound care in 1 (#1) of 3 (#1, #3 and #5) patients sampled for wound care.
A review of hospital policy titled "Braden Scale Flor Predicting Pressure Ulcer Risk" revealed, in part: Protect heels and bony prominences. For individuals in bed, positioning devices such as pillows or foam wedges should be used to keep bony prominences (such as knees, heels or ankles) from direct contact with one another. Mange friction and shear, in part: Protect elbows and heels as indicated.

A review of hospital policy titled: The Nursing Process-Care Planning" revealed, in part: Steps in the nursing process, in part: Implementation. Putting the plan of care into action to alleviate or reduce problems and promote health. Implementation occurs when: A. Physician's orders are carried out.

A review of hospital policy titled "Patient Assessment/Reassessment" revealed, in part: Patient Reassessment, in part: A reassessment of the patient shall be performed at least every shift by nursing staff. The reassessment performed by nursing will include, but not be limited to, the following information, in part: Skin (integument). Wound reassessment: 1. At a minimum, all wounds/pressure injuries or wound dressings will be reassessed each shift.

A review of Patient #1's medical record revealed a 61-year-old male admitted on 01/17/2023 with Chronic hypoxic respiratory failure second to COVID and End Stage Renal Disease on Hemodialysis, ventilator dependent with PEG tube.

Further review of Patient #1's medical record revealed wound care orders dated 02/08/2023 stating wedge pillow and heel lift boots daily until specified. Review of orders dated 03/08/2023 revealed Left heel-wound care clean with normal saline apply betadine cover with foam border change MWF. Right heel-Wound care clean with normal saline apply aquacel ag cover with foam border change MWF and PRN.

Observation of Patient #1 at 11:25 a.m. on 07/11/2023, revealed a bed bound patient with tracheostomy on the ventilator. Able to communicate well by mouthing words and nodding head. The dressings on both heels were disarranged with drainage noted to the pads. The patient had socks on over dressing and his heels were in direct contact with mattress, not floated. Observation of Patient #1 failed to reveal heel boots.

In an interview on 07/11/2023 at 11:35 a.m., S2RN stated he did not know if the patient was supposed to be in heel boots or if his heels were to be floated. S2RN stated Patient #1 did not have heel boots on when he started his shift. S2RN further stated he did not change the dressing because the wound care nurse changes the dressing on MWF. He was not aware if he could change the dressing PRN if the dressing was disarranged or with drainage.

In an interview on 07/11/2023 at 11:40 a.m., S3WC reported he saw Patient #1 this morning and he had heel boots on. He did not change his dressing because the orders are to change the dressing every other day and he changed it yesterday. S3WC stated that Patient #1's heels should always be floated when he does not have the heel boots on.

4) Failing to ensure each patient received daily hygiene care as per hospital policy and physician orders in 5 (#1-#5) of 5 (#1-#5) patients sampled for hygiene care.
A review of hospital policy titled "Patient Hygiene" revealed, in part: Policy: Patient hygiene will be provided daily and as needed. Procedure, in part: Routine hygiene will include, in part: Complete bath or shower as applicable, daily. Hair grooming daily, complete linen change daily, Peri-care twice daily, and oral care twice per day and as needed.

Patient #1
A review of medical record failed to reveal Patient #1 was provided a documented complete bath on 23 days (01/18/2023, 01/19/2023, 01/20/2023, 01/21/2023, 01/22/2023, 01/23/2023, 01/24/2023, 01/25/2023, 01/26/2023, 01/27/2023, 01/28/2023, 01/29/2023, 01/30/2023, 01/31/2023, 02/03/2023, 02/07/2023, 02/09/2023, 02/10/2023, 02/11/2023, 02/12/2023, 02/13/2023, 02/14/2023, and 02/17/2023) of 30 days reviewed for complete bath.

In an interview on 07/10/2023 at 4:30 p.m., S1DON confirmed that Patient #1 did not have a daily complete bath as per hospital policy on 23 of 30 days reviewed for a complete bath. S1DON further stated that nursing staff should have documented a reason why Patient #1 did not have a complete bath on these days.

Patient #2
A review of medical record failed to reveal Patient #2 was provided a documented complete bath 06/26/2023, 06/27/2023, 06/28/2023, 06/29/2023, 06/30/2023, 07/04/2023, 07/05/2023, 07/06/2023, and 07/09/2023.

In an interview on 07/10/2023 at 9:40 a.m., S1DON confirmed that Patient #2 did not have a daily complete bath as per hospital policy on 06/26/2023, 06/27/2023, 06/28/2023, 06/29/2023, 06/30/2023, 07/04/2023, 07/05/2023, 07/06/2023, and 07/09/2023. S1DON further stated that nursing staff should have documented a reason why Patient #2 did not have a bath on these days.

Patient #3
A review of medical record failed to reveal Patient #3 was provided a documented complete bath every day per hospital policy between 06/19/2023 and 07/09/2023.

In an interview on 07/11/2023 at 10:04 a.m., S1DON confirmed that Patient #3 did not have a daily complete bath as per hospital policy between 06/19/2023 and 07/09/2023.

Patient #4
A review of medical record failed to reveal Patient #4 was provided a documented complete bath every day per hospital policy on 05/03/203, 05/04/2023, 05/08/2023, 05/09/2023, 05/10/2023, 05/14/2023, 05/15/2023, 05/16/2023, 05/17/2023, 05/19/2023, 05/23/2023, 05/25/2023, 05/27/2023, 06/09/2023, 06/14/2023, 06/15/2023, 07/02/2023, 07/05/2023 and 07/06/2023.

In an interview on 07/11/2023 at 2:20 p.m., S1DON confirmed that Patient #4 did not have a daily complete bath as per hospital policy on 05/03/203, 05/04/2023, 05/08/2023, 05/09/2023, 05/10/2023y, 05/14/2023, 05/15/2023, 05/16/2023, 05/17/2023, 05/19/2023, 05/23/2023, 05/25/2023, 05/27/2023, 06/09/2023, 06/14/2023, 06/15/2023, 07/02/2023, 07/05/2023 and 07/06/2023.

Patient #5
A review of medical record failed to reveal Patient #5 was provided a documented complete bath every day per hospital policy from 02/10/2023-04/01/2023.

On 07/11/2023 at 10:25 a.m., S1DON confirmed that there was no documentation that daily hygiene care was provided per policy while patient was admitted.

Based on record review and interview the hospital failed to ensure each patient had their nutritional needs met. This deficient practice is evidenced by failing to follow hospital policy and physician orders for strict monitoring of intake and output every shift in 2 (#1 and #4) of 5 (#1-#5) patients sampled.
Findings:

A review of hospital policy titled "Nasogastric/Enteral Tubes/Feedings" revealed, in part: Patients receiving tube feedings shall have documented assessment of gastrointestinal function with intake and output recorded every twelve (12) hours in the medical record.

Patient#1
A review of Patient #1's medical record revealed a 61-year-old male admitted on 01/17/2023 with Chronic hypoxic respiratory failure second to COVID and End Stage Renal Disease on Hemodialysis, ventilator dependent with PEG tube.

Further review of Patient #1's medical record revealed physician orders dated 01/17/2023 for strict intake and output every shift and indicated by hospital policy.

A review of Patient #1's medical record dated 01/17/2023-07/11/2023 failed to reveal documented tube feeding intakes on every shift as ordered by the physician.

In an interview on 07/11/2023 at 2:40 p.m., S1DON confirmed the medical record failed to reveal documented tube-feeding intakes on every shift for Patient #1 as ordered by the physician.

Patient #4
A review of Patient #4's medical record revealed a 72-year-old male admitted on 05/02/2023 with Respiratory Failure with hypoxia s/p AAA with left frontal intracerebral hemorrhage, ventilator dependent with PEG tube.

Further review of Patient #4's medical record revealed physician orders dated 05/02/2023 for strict intake and output every shift.

A review of Patient #4's medical record dated 05/02/2023-07/11/2023 failed to reveal documented tube feeding intakes on every shift as ordered by the physician.

In an interview on 07/11/2023 at 2:40 p.m., S1DON confirmed the medical record failed to reveal documented tube-feeding intakes on every shift for Patient #4 as ordered by the physician.

Based on record review and interview, the hospital failed to ensure respiratory services were administered in accordance with hospital policy as evidenced by failure to document respiratory care for 2 (#1 and #4) of 5 (#1-#5) patients' medical records reviewed.
Findings:

A review of hospital job discription titled "Respiratory Therapist" revealed, in part: Oversees the documentation of all pertinent data on the respiratory therapy progress notes with each visit.

A review of hospital policy titled "Documentation Guidelines" revealed, in part: Documentation of interventions based on physician orders and/or on unit standards of care or approved protocols. Documentaion of independent discipline specific care provided.

Patient #1
A review of Patient #1's medical record revealed admission on 01/17/2023 with a diagnosis of chronic hypoxic respiratory failure second to COVID. Further review failed to reveal documented respiratory treatments for 03/25/2023 and 04/09/2023.

In an interview on 07/10/2023 at 4:40 p.m., S1DON confirmed that the respiratory assessments were not documented in the medical record by the therapist on a daily basis for Patient #1.

Patient #4
A review of Patient #4's medical record revealed admission on 05/02/2023 with a diagnosis of Respiratory Failure with Hypoxia. Further review failed to reveal documented respiratory treatment for 07/06/2023.

In an interview on 07/10/2023 at 4:40 p.m., S1DON confirmed that the respiratory assessments were not documented in the medical record by the therapist on a daily basis for Patient #4.